Can DSM Diagnoses Be Other Than Pejorative?
Name calling. Cursing. Yelling when a calmer tone could deliver the same message. Who of us at times doesn’t act outside the boundaries of civility and compassion?
The material world often gets the brunt of such outbursts. My earlier work writing computer programs in Fortran left me with a childish wish to inflict pain on computers when they failed to do what I expected. If cursing them didn’t seem to work, I sometimes flipped off the power. Yeah, I showed them who was boss.
I know I am not the only one who so pointlessly loses their cool. How many of us let the expletives rip when house repairs turn towards the incomprehensible? Ever put together a propane grill, or prefab bookcases, whose screws seem stripped before they even leave their sealed plastic pouches? Not a pretty sight.
Such object-focused rants seem like emotional outtakes, but they are also signs of a lack of curiosity about the world and a need for control. These verbal assaults would be fairly harmless if not for the sometimes blurry line existing between how we anthropomorphize our possessions and how we objectify fellow humans. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a reliable resource if objectifying someone is the goal. “He’s such a narcissist.” “She’s so borderline.” “I can’t talk to him; he’s totally bipolar.” Diagnoses are useful when there is a desire for distance and control, but perhaps more significantly, they protect oneself from feelings of vulnerability. No wonder many of us “diagnose” people close to us when relationships are precarious or we find ourselves in the wake of a break up. Yet such name-calling is a flimsy defense against heartbreak and the inevitable feelings of loss, or even grief, that emerge when people disappointment or hurt us.
By virtue of how psychiatric diagnoses are increasingly used by both professionals and laypersons, they are now largely empty speech that lack worth — what Jungian analyst Russell Lockhart called words without souls. For a word to have soul it must imply something about the nature of a person’s being, although not of a general sort that applies to anyone who meets certain diagnostic criteria. Rather, words with soul speak to what is unique about somebody and in ways that draw us closer through a feeling tone, thus creating an emotional bond that validates uniqueness rather than effacing a person’s individuality.
The DSM is the preeminent diagnostic guide for the mental health field, which, of course, includes the practice of psychotherapy. “Psychotherapy” gets its meaning from two ancient Greek words, psyche, which means soul, and therapia, which means healing. Thus, psychotherapy is the practice of healing the soul, or tending the soul of someone in the process of healing and returning to growth. To tend to a soul involves caring about speech, listening to someone’s distinctive story, hearing the worth of a word, witnessing how a phrase or gesture carries individuality — that is to say, the act of finding soul in speech and soma. How odd that the DSM, a most impersonal tome, would be produced in a field that started with psychotherapy as such a personal relationship.
The DSM originated through a power struggle between two competing perspectives on the nature of mental illness, if not what it means to be human. The DSM codified two general divisions into the mental health field between so-called Axis I and Axis II disorders, reflecting the split between biomedical psychiatry (Axis I) that originated with the work of Emil Kraepelin, and psychoanalysis (Axis II), which started with the work of Sigmund Freud. Along Axis I are mental disorders depicted as synonymous with chronic diseases of the body, such as diabetes. In contrast, Axis II disorders emphasize the role of a person’s character, temperament, and early life conditioning. Disorders along both axes carry the implicit belief that a diagnosis is likely a lifelong condition, which through psychotherapy or drugs (or both) is altered, but perhaps never completely escaped. Both risk producing calcified souls that are manageable and predictable and not enlivened and full of possibility as real people are.
Perhaps a diagnosis can feel like relief from the sense of alienation and shame that often are part of feeling mentally ill. As one woman emphatically stated, I am not crazy, or bad, or lacking in faith or in discipline. I have a disease. It’s called depression. Often such an interpretation becomes a defense against the threat of emotional chaos, feelings of alienation, and intense self-doubt that are the subtext of most mental disorders. Yet psychiatric diagnoses also limit opportunities for growth and connection. Old problems have a way of resurfacing for all of us. Change is often a slow process. With a diagnosis life’s seemingly terminable repetitions are recast as “symptoms” of a disorder, distancing the fear of being overwhelmed once again, although not necessarily changing the conditions that support their reoccurrence.
These names we call ourselves and others — diagnosing failures, anticipating compulsive repetitions — lack depth and are hollow places to hide our fears. And fear may be the reason psychiatric diagnoses have become part of our vernacular. For instance, despite that having a temperature is more accurately described by the medical term “febrile,” or a heart attack is technically called a “myocardial infarction,” we don’t use those words because a) people might not know what we are taking about, but more importantly, b) they make the sick body sound even sicker — and thus scarier. This seems the opposite effect that diagnoses in the DSM sometimes have. Granted, for some people, it can be scary to think of someone having schizophrenia — and thus a very different mental map than the so-called ‘normal’ person. But mostly we use these diagnoses as slang because through them we distance another person — and potentially gain power over them and the feelings they evoke. These terms lack soul and their nature is to de-soul, which is why they become so versatile when there is a desire to scapegoat someone, or avoid the pain of a broken heart, or simply vent anger. With a diagnosis on the tip of the tongue, the speaker grows larger while his object becomes stuck in the smallness of an ill-fitting label. Apathy or even repulsion replace fear. Some may say sympathy is also a potential outcome, yet it is often mixed with pity that has a way of infantilizing persons diagnosed with mental disorders, diminishing their social standing if not personhood. With diagnoses, psychological banishment also becomes a very real possibility — a dehumanizing defense that may seem increasingly attractive on a crowded planet of 7 billion people (and rapidly continuing to grow).
Certainly we need a language to understand how we suffer (and make others suffer) that can help us transcend old patterns of being and relating. But do we really need the DSM? And what, if anything, should replace it?
Reading Russell Lockart’s Words as Eggs, I am beginning to consider the DSM as a lot like Humpty Dumpty. As Lockart writes, when Alice (of Wonderland) met Humpty, he made a bold statement about his ability to control words: “When I use a word, it means just what I choose it mean — neither more nor less.” Humpty Dumpty really liked adjectives, because he had more control over them (like when we call someone a name). But Humpty wasn’t so crazy about verbs: “They’ve a temper, some of them — particularly verbs: they’re the proudest — adjectives you can do anything with, but not verbs.” Verbs, Lockart observed, “are words whose sole function it is to say that something exists, that it has being, that it lives, that it moves, that something has taken place.” Reconfigured as verbs, diagnostic categories become strategies for living and not defenses against people (including oneself) when life is hurtful or uncontrollable. By becoming verbs, diagnoses become more soulful and more open to growth and change, including outgrowing a mental disorder. Diagnoses would still point to how we hurt and repeatedly make the same mistakes as well as expose us to our blind spots. But diagnoses would also be a lot safer, since they would tell us what we are doing rather than creating fixed references for who we are. As verbs, diagnoses might also contribute to growth and change in unimagined ways, which is how soulful people like to live — full of possibility.
I suggest doing away with diagnoses that cannot be verbs. Rid them from your vocabulary if they fail to make space for growth and uniqueness. All of us “narcissus” at times. Put any of us in a toxic work environment (or society), and we will definitely “schizophrenic” now and again. And granted, some people “borderline” more than others when the end of a relationship is on the horizon — that is, until they don’t, and they do something else (such as house repairs), in which case another verb can reveal their soul-filled efforts at growth, love, and self-discovery.
Cronkite, Kathy. 1994. On the Edge of Darkness. New York: Delta Publishing.
Lockhart, Russell. 1983. Words As Eggs: Psyche in Language and Clinic. New York: Spring Publications.
© 2014 Laura K Kerr, PhD. All rights reserved.