“Don’t tell me what is going on with me, help me understand the how of me.” AJ, a 24 year old male.
With the release of the proposed draft revisions (version 5) to DSM disorders and criteria, new questions have arisen about psychiatric diagnosis. Articles like the very in-depth analysis by Louis Menand in The New Yorker wonder whether or not the classification of mental disorders doesn’t pathologize the vicissitudes of human emotional expression. Jonah Lehrer’s recent piece in the NYTimes adds another element to the discourse about what is diagnosis: what if mental illness, like depression, has value? I would like to suggest another angle to this over-due debate: Diagnosis is a process, a fluid and mutable motion between body, mind, other people, culture and the environment. A diagnosis should not be construed as a territory with fixed boundaries nor a rigid categorical definition. A viewing lens can assist in the identification of a Downey Woodpecker but you can’t learn anything about the creature until you observe it flying and interacting with the trees. A psychological enterprise should always engage with a person’s process, and should aim to assist a person in the discovery of how all the pieces of their life come together. This work relies on experience and training, as well as science and art. It also depends on a deep understanding of the natural, evolutionary world in which we are all embedded.
Human beings can’t survive without other people or the earth. There is a relational web between self and others that generates meaning systems shared by a group in a particular locality. Every person is born into a set of ideas and beliefs that shift according to the group processes that generated them. At the same time, every person has a body that is a unique combination of genes, neuro-transmitter activity, hormones and hard-wiring. Every personality is an individual expression of biology, mind, relationships, culture and the environment. Traditional psychiatric diagnosis relies on ideal types to differentiate the pathological from the ordinary. Since there are no real ideal types, everybody starts out as deviant. What concerns me is that when any analysis of people takes place without accounting for context it is impossible to adequately understand what is observed.
Yet, the lack of a standard human prototype doesn’t plunge the human condition into hapless relativism. Respecting the array of human difference doesn’t mean that there is no pain, sorrow, malfeasance, sadistic aggression, or glee, triumph and passion. Rather it suggests that supporting a person with mental anguish means teaching an understanding of the self in motion, as a constellation shifting across the night sky, as a rushing body of water, as a continually evolving mixture of body, other people and landscapes. Sometimes we can add chemicals to the mix, sometimes organic compounds and different food choices, sometimes words, sometimes physical movement and sometimes a walk in the woods.
To diagnose somebody according to a defined set of terms that are static and non-dimensional is to trap and contain someone. It serves the purpose of imprisonment and further leads to an ordering of human emotions according to a hierarchy of deviance. Ordinary feelings and states of being are mistaken for pathologies. Medications are prescribed when what is needed is love. Words are used when a person really needs a metabolic boost. No good really comes of confining people to a landscape whether it be geographic or ideational. I like what Chief Joseph is reputed to have said: “You might as well expect rivers to run backwards as any man born free to be contented penned up.”