Diffing the DSM
Is talk therapy on the “right side of history”?
Imagine that it’s 1980, and you find out hysteria has been finally removed from the DSM (The Diagnostic Statistical Manual, i.e., the tome psychiatrists use to determine what is and isn’t a disorder). You high-five your friend and say, “At last, this sexist stigma has been banished from the psychiatric canon.” (“hysteria” comes from the Greek word “hystera” or uterus.) “Finally, therapy is out of the dark ages.”
Ten years later, in 1990, you find out that homosexuality has been removed from the ICD (The International Classification of Diseases, a tome maintained by the World Health Organization). You high-five your friend and say, “Finally, therapy is out of the dark ages.”
Ten years later, in 2000, some U.S. states legalize marijuana, and it occurs to you that attitudes around drugs have relaxed in recent years, a far cry from the days when “reefer madness” would land you a referral to a therapist. Once again, you celebrate, “Finally, therapy is out of the dark ages.”
If you saw a psychiatrist today, how would you know if you weren’t being explicitly or implicitly labeled with something that will become society’s next “hysteria”? Fortunately, the consequences of getting it wrong are a far cry from the early 1900s. (Look up the sad story of Rosemary Kennedy, JFK’s sister, who, if you read between the lines, was probably diagnosed with female “hysteria.”) But the safety issues are still real since most prescribed psychoactive drugs today, as well as modern electro-shock therapy, carry significant risks of suicide.
Unfortunately, this ironical process becomes less discernible the closer we get to the present. Furthermore, if norm violations are a big part of why people seek therapy in the first place (i.e., “not fitting in”), then not only are you possibly tripping over a blind spot, but also falling down a rabbit hole and breaking your back.
I’ll note, though, that I’m an advocate of talk therapy. I wasn’t at first, but after some hard work, I found a therapist I love (I’ll share some best practices at the end). In the meantime, I cannot emphasize enough how irresponsibly society is navigating when it comes to mental health.
I initially started my inquiry by trying to “diff” the DSM, which is a programmer term for conducting a line-by-line comparison between revisions (the APA actually maintains a change summary). Instead, in just thirty minutes of online research, I discovered at least four areas that could become retroactive historical regrets:
Overdiagnosis of ADHD
The War on Boys came up in my search right away, but I discovered that the underlying issue, which is the overdiagnosis of ADHD, has been wrapped in culture war rhetoric. The subtitle of the book, after all, is “How Misguided Feminism Is Harming Our Young Men.” But, in flipping through the contents, I found the author’s tone more neutral. Something tells me that her publishers pushed for a politicized title and marketing campaign as a necessary evil to grab attention.
76% of therapists are women. Even suggesting that this is — or isn’t — an issue seems to ignite a culture war. But the problem cuts both ways. A common issue that men discuss in therapy is doubts about their sexuality. And a common issue that women discuss in therapy is domestic abuse. Having a female therapist address the former or a male therapist address the latter has inherent challenges, no how much value bracketing the therapist does.
Dealing with trans teens
There are at least four ways that the current approach to trans issues could be problematic. We’re either over- or under-suggesting that trans teens undergo transition therapy, and we may be erroneously urging them toward or away from their gender identity. In other words, we don’t know what we don’t know, but even inaction could be problematic. Again, like the other two, this subject is a culture war issue.
We only recently seem to be figuring out that intervention is sometimes more harmful than no intervention. For example, in 2013, researchers discovered that psychological debriefing after trauma leads to an increased risk of PTSD. I also learned this term “medicalizing distress” from this paper, and I’ll just quote it here because it’s so well-said:
Psychiatry has blurred the disease-illness divide, subcategorized clinical presentations, lowered the thresholds for diagnosis and introduced many new psychiatric “disorders.” Its phenomenological approach to diagnosis and classification employs symptom checklists and symptom counts sans context. The medicalization of distress is supported by the capitalistic project and the current political economy of health, fits in well with neoliberalism and allows the free market to expand its business interests. This essay contends that social and economic correlates of depression, anxiety and common mental disorders, despite robust evidence, are not emphasized.
If we didn’t have outlets for some emotions, would we have those emotions in the first place?
If I’m ultimately in favor of therapy, then what am I against exactly? I’m against “present-exceptionalism bias,” which is the urge to think we’re on the right side of history. Whenever we have the thought, “everything is fine now,” we should remind ourselves that every generation before us has said the same damn thing.
Appendix: Tips for Patients
Everybody should see either two therapists or none, but never one. Seeing one therapist can lead to thinking that all therapists are the same. Since you’d get a second opinion before getting back surgery, shouldn’t you also get multiple perspectives from a professional operating on your mind?
Also, it might be taboo to say this, but the more expensive the therapist, the better. Therapy often isn’t covered by health insurance, and therapists are usually booked on a recurring basis, unlike surgeons, so you could see how the free market would distort the field. My anecdotal experience confirms this (I’ve had introductory sessions with six therapists). I’ve even found that the ones that don’t accept insurance are better.
Calling a prospective therapist is a pain. Firstly, you will always get voicemail since they’ll be either with a client or off work. But you have to leave a message. I know it’s extremely difficult, especially when you’re in need of therapy, but they will call you back. Therapy is a matter of life or death, so therapists keep the numbers they post online accurate. I’ve had to call therapists on behalf of friends before, and every single message was returned.