Last fall, at the beginning of a large online, undergraduate course in abnormal psychology, I was warned that after reading the textbook I should not attempt to diagnose mental disorders in friends, family, myself, or anyone else.
I immediately thought about a friend who had recently lamented to me that a dating relationship of hers had ended because she had discovered that the man was narcissistic, and maybe mildly autistic, too. She was not as certain on the latter part, because, she assured me, it might take more medical assessment to know that. I was transfixed by her use of the word “more.” Was her perusal and interpretation of MedWeb articles, I wondered, sufficient medical assessment for a diagnosis of narcissistic personality disorder? I realize now that as I stared at her with wide eyes I was beginning to formulate a question—reaching well beyond the personal opinion I surely also had of her at the time—a question that already had a deep yearning in me: I wanted to know what institutional and cultural trends in personality theory had led us as a society to treat the self so casually that a supposedly significantly disruptive pattern in personality function could be correctly perceived, labeled, and pathologized as readily as a common cold.
Let me pause a moment.
What exactly is “wrong” with his/my personality anyway?
And take a breath. A deep breath.
My great discomfort in moments like this one with my friend in which I am told in all seriousness--and much clearly stated fear and pity—that so-and-so has blank personality disorder or is mentally unstable, psychotic, or completely nuts, is symptomatic of a personal trigger--MY trigger. I hate the idea of being “that crazy girl” so much that one of the first things I often tell people about myself when we get close is that I might be the sanest person they’ve met—and then I do my damnedest to prove it. Internalized sexism much? In that trigger is also a projection and a judgment. Parts of me actually want to both distance myself from and better understand people who toss terms like narcissist and borderline into friendly conversation, because some part of me also thinks there’s something important in understanding how and why we aren’t better at talking about personality. I might call this something like “personality THEORY disorder.”
Personality theory disorder is something we’re all going through, as a society, on our own and together. It’s the natural outcome of being violently assaulted by large-scale social and economic forces that don’t care for the people being most affected. Because of this assault, we’re desperate for a theory of mental illness that helps people, but that same desperation is disorienting and distracting us from understanding how to help well. We want to put people first, but we keep putting applications first, thinking that we have to, that we don’t have the means to actually put people first. But we think that we don’t have the means, because we’ve internalized powerful messages that say caring about whole, integrated people requires limitless resources and there just isn’t enough time, love, money, food, counseling, you name it available for everyone. This is just a simple acknowledgment of a history—our history—of plunder and brutality, a history with long arms that keeps sending these messages out, actively and passively. Generations of trauma and disenfranchisement contribute to the ongoing stealing of power from our best intentions to help ourselves, let alone each other. You can see the great loss in this personal and interpersonal ransacking of hope in the huge fights among scientists, researchers, and theorists about impossible problems—an academic stance of powerlessness and a truly disordered approach to personality.
But we can change that; we can put people first again.
At the time of my friend’s lament, it seemed clear to me that she might have an easier time grappling with a failed love connection if there was a sure reason outside herself that the other person was simply too “damaged” or “dysfunctional” to be in a good relationship. There may actually be some utility to this line of thinking. Framing the other person as clinically maladaptive provides an escape from owning our own vulnerability or working on own shortcomings first—and that may be a necessary defense for her. Moreover, calling this sort of escapism out in others, as well as in myself, has certainly contributed to the work I’ve done in community and on myself over the past half decade to create access points to more personal power, and to more skillfully sharing power.
But what do clinicians do on the ground to accurately and compassionately understand, evaluate, and treat for better mental health outcomes in a way that puts the person first?
To be sure, as I work with more people in clinical settings on their relationships, on love and intimacy, on connection and partnership, and on community and cooperation, I will need a more coordinated, strategic approach, based in science and ethics, in order to answer that question, as well as to be with people, non-reactively, seeing clearly the context of popular beliefs about mental illness that may arise, uniquely, in each client’s narratives and dynamics as well. I will likely also need to keep revisiting my own judgments and gaps in understanding as to how and why lay diagnoses occur in the ways they do, including understanding the larger historical context of how personality has been understood, codified, and policed in our country as ill versus healthy. In other words, I will need to confront my own personality theory disordering, and I will need to pay attention to opportunities for healing and liberation.
And you may ask yourself, well, how did I get here?
In 1980, at the same time that David Byrne asked the world to consider the existential nature of standard American success, Reagan defeated Carter, Lennon was shot dead in New York City, and a Norwegian polio survivor gave birth to a girl in Chapel Hill, North Carolina, and named her Anna. Fifteen years later, threading her career through the independent living movement across the American South, my mother hired me one summer to enter data for her from a massive well-being survey into a database at the Missouri Institute on Mental Health. Has car, has food, feels happy, feels sad—I ticked off a long list of self-reported indicators that seemed both profound and meaningless on the computer screen, and I wondered how in the world this information could be used. How could this litany of survey questions make up the whole picture of a person’s well-being?
From my vantage today, this memory is not surprising. From 1980 to 1995—my whole life at that point—not much had changed in the official method of the American Psychiatric Association for assessing mental health. But before 1980 things looked much different.
For more than sixty years, the Diagnostic and Statistical Manual of Mental Health (DSM) has been a main site of power in articulating and enacting theories of “personality illness” across our institutions and woven through our culture in the United States. How the DSM defines disordered and medically significant personality deviation is still being heatedly argued about today and provides an important anchor for understanding how personality has become typed and treated as ill, even beyond the overtly therapeutic setting. The history of the DSM is also an incredible storyteller and reflection of the narrative of our shared personality theory disordering.
The first (1952) and second (1968) editions of the DSM, “reflected Sigmund Freud’s idea of psychodynamics: that mental illness is the product of conflict between internal drives” (Adam, 2013). According to Mayes and Horwitz, “these manuals conceived of symptoms as reflections of broad underlying dynamic conditions or as reactions to difficult life problems” (2005). But in the 1970s, for much good reason, Freud was being heavily criticized and challenged by multiple other schools of thought in psychology, including the humanists, the cognitive behaviorists, and even the human potential movement. With scathing critique form the new feminists and Freudian classical psychoanalysis in the doghouse (Robinson, 1993), the third (1980) and fourth (1994) editions of the DSM flipped the “dynamic” approach on its head, opting for a theory of discrete, categorical buckets designed to meet a supposed need for easily diagnosable, uniquely treatable, and statistically viable mental ills. The DSM-III’s categorical approach, which was billed as a clear and straightforward classification system, handily “imported another role model from central Europe: psychiatrist Emil Kraepelin” (Adam, 2013). Kraepelin was famous for saying that conditions had “unique sets of symptoms and presumably unique causes” (Adam, 2013). With Kraepelin, asserts Nature writer David Adam, the DSM-III erected “solid walls between conditions,” listing out symptoms, which writers like Ronald Levy coached a generation of clinicians to interpret and apply (2013; Levy, 1982).
“In a very short period of time,” write Mayes and Horwitz, “mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases” (emphasis added) (2005). Concurrently, “a descriptive approach” to the language was purposefully applied to provide “a medical nomenclature for clinicians and researchers” (psychiatry.org), making it easier for clinicians to diagnose and prescribe treatments, as well as for statisticians to collect data on diagnoses. Unfortunately, this shift toward increased diagnosis was “neither a product of growing scientific knowledge nor of increasing medicalization” (2005)—though it certainly led to increased medicalization.
It wasn’t just pressure to reject Freud either. Larger social and economic forces leading up to the 1980s contributed to this rapid and sweeping change in how personality theory and mental illness were forced into a new standardization. According to Mayes and Horwitz (2005),
"This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases."
Certainly public scandals like the Rosenhan experiment, published in 1975, in which “patients” who claimed to have a mental illness but did not were successfully admitted to an institution and kept there against their will contributed some pressure to the field of psychiatry to avoid improper diagnoses (Rosenhan, 1975). But shifting views of the legitimacy of psychiatry in the United States were more likely fundamentally affected by human rights challenges to mental “health” institutions that forcibly indentured populations, kept sick and healthy people locked up in unsanitary living conditions, and committed multiple forms of torture, some under the dubious banner of “science” (Deegan, 2011; Souder v. Brennan; ACLU, 2010). At the same time, as government and communities scrambled to treat people in the face of large-scale desinstitutionalization, the 1970s saw a surge in the influence of the health insurance industry, privatized care, and big pharma all of whom—watching their bottom lines—were making it increasingly important to neatly label and put patients into exact boxes or categories of mental health in order to medicalize and monetize the fields of psychiatry and clinical psychology (Lyons, 1984). By the time the Regan administration pulled the plug on funding state mental health care, clinicians had to follow along in order to get patients any kind of treatment at all (Torrey, 2013). By 1994, the DSM-IV “simply added and subtracted a few categories” to this picture.
The 1980s and 90s were terrible years for people with acute mental health problems. But it was also the proving ground for a new movement—bringing the DSM back from the grips of the categorical approach.
Fired up, ready to go!
The categorical approach clearly had some big problems. As David Adam writes, “even as walls between conditions were being cemented in the profession’s manual, they were breaking down in the clinic” (2013). People found that they needed a better way to understand how multiple diagnoses or intersecting diagnoses should be treated. Adam also notes that a persistent problem has been that “biologists have been unable to find any genetic or neuroscientific evidence to support the breakdown of complex mental disorders into separate categories” (2013). Professionals in the field were coming to understand with greater clarity that a different answer, a new proposal, was needed. The establishment considered what the reform movement came up with—a “dimensional” approach—to be dangerously radical.
But as gender studies, race studies, disability studies programs, and other interdisciplinary focuses flourished across institutions of higher learning, the idea of a spectrum of identity became increasingly popular in academic settings. And the idea that mental health might also exist on a spectrum, along with new science about the brain and human biology, became an exciting new area of research. This new approach to the DSM, combining a goal of accurate diagnosis with a throwback to the Freudian view of “dynamic” personality, was lauded for its unique inclusion of 21st-century research technologies, as well as leaving open questions that remain about what is know-able about a “spectrum of personality” (Adam, 2013).
Enter the DSM-5.
In 2009, Obama supporters were fired up and ready for the president to go to work on real progressive change—with great hope comes great reality checks? The Great Recession was in full swing and I had just moved to the Bay Area from Louisiana. And in 2009, Lisa Cosgrove, Ph.D., and Harold J. Bursztajn, M.D., noted that,
"the fact that 70% of the [DSM-5] task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."
Since the DSM-5 was published in 2013 it has received sweeping criticisms. Some say that it is not much different than the DSM-IV, that it didn’t do enough to change the categorical approach. But others, like Allen Frances who led the development of the DSM-IV felt dubious to say the least about the ambitions of the DSM-5, attacking the new edition in a Mother Jones interview as liable to cause new epidemics of over-diagnosing and over-prescribing (Mechanic, 2013). Today, the National Institute on Mental Health (NIMH) is apparently so discouraged with the whole DSM system that they have replaced it with something called Research Domain Criteria, an initiative aimed at being a biologically-valid framework for understanding mental illness:
RDoC research starts with basic mechanisms and studies dysfunctions in these systems as a way to understand homogeneous symptom sets that cut across multiple disorders, rather than starting with clinical symptoms and working backwards. (National Institute of Mental Health)
The NIMH has not given up on the dimensional approach, but it is clear that they believe more research is needed.
But maybe we’re still missing something big in the DSM-5 debacle, maybe “madness” doesn’t exist on a single-person spectrum either. As the Association of Humanistic Psychology asserts, it may be that “nourishing environments can make an important contribution to the development of healthy personalities” (2014). It may be that a nourishing clinical setting can make a contribution to how we grapple with our own and each other’s mental health and well-being. If that’s true, maybe what we need, along with brain science, advances in biological knowledge, and money pouring through pharma, insurance companies, and privatized care, is to develop a whole-person, whole-society spectrum approach to mental health, and to teach it widely to clinicians, as well as beyond the formal clinical setting. If we are paying attention, we might notice that there is a movement in our country right now that is already putting people first.
Complicate the narrative.
No matter the causes of the adoption of the categorical approach in the 1980s, it was misguided and inadequate, and it wreaked havoc on our ability as a people to care for each other. But a dimensional approach to diagnosing personality disorder, if it remains in the hands of “scientists,” may not do any better at helping our society treat people clinically, or at helping us treat each other better interpersonally—and that is a gamble we can’t make.
In 2015, this too remains true: “no one has yet agreed on how best to define and diagnose mental illnesses” (Adam, 2013). But it seems clear and vital that we need to stop putting people in boxes—literally, our country needs to stop using prisons to throw people with mental illness away, and as a society we need to stop using any number of institutions to foster madness, both in a physiological and an emotional sense. We also need to think hard and take action so that we don’t let people succumb to “the hands of the drug companies” (Mechanic, 2014) or structural racism and other forms of oppression.
When Freud says that “we are confronted with the conclusion that there is indeed something congenital at the basis of perversions, but it is something which is congenital in all persons, which as a predisposition may fluctuate in intensity and is brought into prominence by influences of life” (1920, p.34), I hear in his insight an understanding of how we might pervert theory itself in our influence-able development as a relatively young society. We can ask specifically how we are raising our young people—what kind of nurturing do they receive? In 2015, young people still face industrialized schooling, a military industrial complex, a prison industrial complex, poverty, racism, gender oppression, and more—these are all things that no doubt contribute to a disordering of personality at a young age. But they are also things that might disorder a theory of personality, making it not that surprising that the DSM has been such a hot mess for so long. One might even joke that the DSM, with Freud in mind, has some daddy issues—and tragically not be so far off.
In Jung (1970) we find the seeds not just of the individual dynamic personality, but of the spectrum of collective experience:
"The dynamism of instinct is lodged as it were in the infra-red part of the spectrum, whereas the instinctual image lies in the ultra-violet part. . . . The realization and assimilation of instinct never take place at the red end, i.e., by absorption into the instinctual sphere, but only through integration of the image which signifies and at the same time evokes the instinct, although in a form quite different from the one we meet on the biological level."
What is the collective will of our society today? What are we creating? And what do we need to heal, together? Putting people in boxes and categories, making judgments based on some essential characteristic, using each other, making profit off the backs of some, slavery, hierarchy—these are all deep societal wounds that we are still waking up from. The categorical approach to the DSM may have been one cycle of unfolding consciousness in response to these woundings—but it was also a product of that same trauma. You can see this in its aim to regulate human experience and human bodies as much as it attempted and failed to regulate the actual care of humans by responding to human rights violations or by growing compassion, empathy, and equity in our society. The DSM-5, perhaps another botched attempt to change this, is another sign that personality theory and systems for understanding mental health in our country yearn for and need a lot of healing right now—healing and liberation.
Intersectionality, a word that hasn’t made it into the dictionaries yet, is a feminist concept that sees the study of intersecting identities as critical to social well-being. Intersectionality assumes that selves exist on a spectrum, that our various identities are dynamic and multi-storied. But it also tasks us with grappling with additional vectors—including each other, how we are viewed and affected by our social rank and our cultural backgrounds. In other words, maybe dimensionality doesn’t exist along a single spectrum—maybe the dimensionality of mental health is already a spectrum, one that includes race, gender, ability, etc. Every time you assess a person or a mental health concern on a spectrum, the act of connecting those dots already creates another spectrum of meaning. Another way to say this is that my being Jewish and a woman is uniquely meaningful to my sense of self and to my mental health. My “womanhood” exists on a spectrum and my “Jewishness” exists on a spectrum, and at the same time my social identities exist on yet another uber spectrum. And me being a Jewish woman married to a black man further complicates my narrative. And that’s exactly as it should be.
In 2014 when a white officer, David Ried, shot and killed Aura Rain Rosser, the media, in a too-familiar shock, took a breath to acknowledge “the deadly intersection of mental illness, race, class, and gender” (McCoy, 2015). But in January of 2013 when Ried was let off without any charges, #BlackLivesMatter did not shy away from the case or from making it a central party of their ongoing rallying cry (Adamopoulos, 2015). They did not say, no, we cannot stand up for this life—it is too insane, too black, too poor, and too female to matter. Instead, they took to the streets, only adding fuel to their cause.
The power of the #BlackLivesMatter movement is palpable, and that’s because they’re doing one thing absolutely right—they’re putting people first. With every protest step, they’re saying that what matters right now is the preciousness of life, and in the common refrain, “we’re sick and tired of being sick and tired” (and dying) because we’re black, they are literally saying life is what matters. And they’re saying, as one recent Twitter post that was retweeted over a thousands times states, “3 black women started #BlackLivesMatter. 1 is Nigerian-American, 2 are queer. Complicate the narrative… Because all #BlackLivesMatter.”
As a clinician I will always have access to many tools: the DSM—all five versions, a sea of other publications and research in psychology and psychiatry, new technologies and new scientific discoveries, experts and veterans in the field, and even the insights and shortcomings of our global parents in the healing arts. I also have all of human experience, including art and social change activism, to bring to bear on my whole self as I work to have a healthy and empowered theory of personality. And I absolutely need all of me to do this work.
When my friend told me that her ex was narcissistic, I did not shut her down. I did not pathologize her experience by prescribing her a course of therapy that I wasn’t sure she needed, and I did not shame her for being exactly where she was in that moment in her own theory of personality. I took all of me and I gave it to her in that moment by getting really curious, listening to her, loving her, and making damn sure that I never lost track of her as a person first.
ACLU. (2010, September 1). “ACLU history: Mental institutions.” Retrieved from https://www.aclu.org/aclu-history-mental-institutions
Acton, G. S. (1998). “Classification of psychopathology: The nature of language.” The Journal of Mind and Behavior, 19: 243–256. Retrieved from http://www.personalityresearch.org/acton/language.html
Adam, D. (2013, April 24). “Mental Health: On the spectrum.” Nature. Retrieved from http://www.nature.com/news/mental-health-on-the-spectrum-1.12842
Adamopoulos, A. (2015, January 31). “Protesters march in Ann Arbor after prosecutor declines to press charges against officer.” The Michigan Daily. Retrieved from http://www.michigandaily.com/news/protesters-march-following-aura-rosser-decision
Association of Humanistic Psychology. (2014). “Humanistic Views & Methods.” http://www.ahpweb.org/about/what-is-humanistic-psychology/item/33-humanistic-view--methods.html
Cosgrove, L., Ph.D., & Regier, D. A., M.D., M.P.H. (2009, January 1). “Toward credible conflict of interest policies in clinical psychiatry.” Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/articles/toward-credible-conflict-interest-policies-clinical-psychiatry
Deegan, P. (2011, August 30). “Lead Shoes and Institutional Peonage.” Retrieved from https://www.patdeegan.com/blog/posts/lead-shoes-and-institutional-peonagewww.patdeegan.com/blog/posts/lead-shoes-and-institutional-peonage
Ebert, A., & Bär, K-J. (2010). “Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology.” Indian Journal of Psychiatry, 52(2): 191–192. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2927892/
Freud, S. (1920). “The sexual aberrations.” Three contributions to the theory of sex. Nervous and Mental Disease Publishing Co.: New York.
Jung, C. G. (1970). “On the nature of the psyche.” Retrieved from http://frithluton.com/articles/what-is-an-archetype/
Lyons, R. D. (1984, October 30). “How release of mental patients began.” The New York Times. Retrieved from http://www.nytimes.com/1984/10/30/science/how-release-of-mental-patients-began.html?pagewanted=1
McCoy, A. C. (2015). “Police brutality, mental illness, and race in the age of mass incarceration.” Nursing Clio. Retrieved from http://nursingclio.org/2015/06/30/police-brutality-mental-illness-and-race-in-the-age-of-mass-incarceration/
Mechanic, M. (2013, May 14). “Psychiatry’s New Diagnostic Manual: ‘Don’t by it. Don’t use it. Don’t teach it.’” MotherJones. Retrieved from http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances-saving-normal-dsm-5-controversy
Robinson, P. (1993). Freud and his critics. University of California Press: Berkeley, CA.
Rosenhan, D. L. (1975). On being sane in insane places. Retrieved from http://www.bonkersinstitute.org/rosenhan.html
Souder v. Brennan. (1973). Retrieved from http://www.leagle.com/decision/19731175367FSupp808_11075.xml/SOUDER%20v.%20BRENNAN
Torrey, E. F., Ph.D. (2013, September 29). “Ronald Regan’s shameful legacy: Violence, the homeless, mental illness.” Salon. Retrieved from http://www.salon.com/2013/09/29/ronald_reagans_shameful_legacy_violence_the_homeless_mental_illness/