Medicalizing Difference: A Study in Oppressive Language

I was perusing the asexual blogosphere the other day and ran across this fairly disturbing post that looked at an abnormal psych paper. This paper was proposing a potential new diagnosis to be added to the DSM, which they term “Nonsexual Personality Disorder”. While this is the first I’ve heard of someone literally terming asexuality as a disease, it is not uncommon for people to medicalize it or treat it as something which needs to be fixed.

I’ve spent a fair amount of time with DSM definitions and looked at a lot of problems with the ways we currently define mental illness, but even one glance at what this person proposes as the definition of Nonsexual Personality Disorder tells me that this is a horrible definition for many reasons. At its root, it says that this is different from normal and thus it’s bad without actually taking into consideration whether or not the difference is harmful to anyone. This is the same thing that happens to people who are gay, people who are extremely sexual or kinky, or all sorts of things that constitute “different”, generally from the privileged and well off majority.

Looking closely at the definition, we can pull apart what’s wrong with it and see how medical language is often used to oppress difference. This particular case is a doozy as it manages to pack in all kinds of oppressive tendencies that happen to many different people, so this should be fun.

Let’s start at the beginning shall we?

“A.  A marked inability to experience sexual attraction, beginning in early adulthood and indicated by 5 or more:”

As far as I’m aware there is no other diagnosis in the DSM that hinges exclusively on the lack of one experience. Oftentimes an inability to feel certain things are part of a diagnosis, but rarely are they the whole diagnosis because the whole point of the diagnoses in the DSM is to have a way to treat something that is causing harm or lack of functioning in someone’s life. There is no need for sexuality to be able to live a happy and fulfilled life and this whole diagnosis rests on the idea that if you do not have sexuality in your life then there is something empty or unhappy about your life.

Moving on:

“Inability to interpret sexual signals”

Now there are all kinds of symptoms listed in the DSM that people who are not mentally ill have but that only become signs of mental illness when they move into a realm where they seriously inhibit someone’s functioning or lead to high distress. Now I can imagine how you might get into some awkward situations if you can’t interpret sexual signals, but overall it doesn’t seem like the sort of thing that should be medicalized: it’s pretty damn normal and unless the other party involved also has some difficulties with reading emotions it should just mean that you don’t get into sexual situations. Oh no. How horrible.

Another way this sort of symptom was used in the past was in medicalizing lesbians. If you can’t interpret or don’t respond to a romantic overture, there’s something wrong with you. If you can’t follow the scripts that have been laid down, there’s something wrong with you, something that needs to be treated. In reality, it may simply be that you follow your own script or no script at all and that’s totally ok.

“Uncomfortable in intimate situations with a partner”

So I have a serious problem with this particular criterion because this whole disorder is circulated around an inability to feel sexual attraction. That implies that the intimate situation here is sexual. That’s a whole lot of assuming that the only intimate situations you’d ever be in would be sexual. There are all sorts of intimacies and personally I think it’s a bit gross to eliminate them all because SEX. There are also many, many people who are uncomfortable in sexual situations with partners for a variety of reasons and this criteria doesn’t touch on ANY of them (including abuse, PTSD, different priorities, etc). It also doesn’t specify frequency of discomfort, which seems important as probably everyone has felt uncomfortable in intimate situations at one point or another.

Generally discomfort at a situation is only diagnosable when you need to be able to function in that situation in order to have a complete and fulfilled life. I think there are many people out there who could attest that sex is not necessary for a complete and fulfilled life with intimate relationships, which makes this criterion really bizarre. There’s really nothing wrong about having discomfort or preferences against some stuff, and saying that we all need to be comfortable in the same settings is really a set up to oppress some people. Yes, being uncomfortable in all social settings or all settings outside of the house might be something that really interferes with your life, but sexual situations are specific, private, intimate, and unnecessary for day to day functioning.

If you’re really not interested in something and another person tries to get you to do it, it is 100% reasonable to feel uncomfortable. Generally we only want to label something as mental illness if the emotions or reactions are far outside of reasonable or logical.

“Avoidance of situations in which sexual activity may occur”

Um…so if you’re a priest you have symptoms of mental illness? If you choose to be celibate? Lots of people can make it through their lives without sexual activity. In other news, not feeling sexual attraction does not imply that you have to avoid sex. Unrelated! Crazy! Throwing these symptoms together is just illustrating a complete misunderstanding of what it’s like to be asexual.

“Lack of attraction to the opposite or same sex”

This is extremely sloppily written. What kind of attraction? What about non-binary people? Do friend urges count? If they don’t then we’re really looking at something far more akin to antisocial personality disorder. I think it’s implied that those are not the kinds of attraction that the author is thinking of but rather sexual attraction. What is wrong with not feeling sexual attraction if there’s nothing about it that hurts you or anyone else? It’s not like a lack of empathy that leads you to undertake cruel behaviors, it simply leads you to seek out different relationships for yourself. I’m really failing to see the problem.

At its heart this criterion says there’s one way to be human and that’s a sexual way, not because asexual people say they’re unhappy but because the author can’t imagine a different way. Why is this any less discriminatory than making it an illness to have a lack of attraction to the opposite sex?

“Complete lack of sexual thoughts”

My biggest problem with this is that I don’t think it exists unless you’ve got a hormonal imbalance, which is not related to mental illness but simple physical health. There are absolutely people that don’t feel sexual thoughts towards anyone or who rarely have sexual thoughts, but our bodies are filled with hormones that give us certain reactions and that doesn’t stop happening just because of your orientation. As an analogy, if a gay man is given a blowjob by a woman, oftentimes his body will react even if he doesn’t feel an attraction or particularly want the blowjob. It is possible to orgasm during rape. Our bodies react to things.

The other problem is that things like age can also play a role here. Hormones change with age, and some people’s testosterone and other happy sexy hormones just go down as they age. And then they stop thinking sexual things. It’s actually super normal and healthy. So why the compulsory sexuality?

“Touch aversion”

Ok so this is one of the criteria that I think has a little bit of merit in that there is a fair amount of research that shows that human contact is really good for your mental health. People who get hugs or hold hands or what have you tend to be happier. But there is also a lot of evidence that people simply exist on a spectrum of sensory sensitivity and for those who are extremely sensitive touch can be overwhelming. That’s a simple fact about the way their bodies process touch. Perhaps it has something to do with a medical condition (physical), but probably it’s just like different pain thresholds. We have them and for people with high pain thresholds it’s kind of a nuisance but you adapt.

I am one of those people who is fairly touch averse. I am not a hugging type person. I am not a kissing type person. I generally like my space. I cannot cuddle through the night (except with a cat). But that doesn’t mean that there aren’t times that I feel incredibly comforted by touch with someone I trust and care about. It doesn’t mean that I’m broken, just that I need touch in a different way. It really hasn’t been a big deal in a lot of my relationships except that I yell “STOP TICKLING ME!” fairly often when the other person is not intending to tickle me at all. People get their boundaries, move on.

“Inability to experience romantic relationships”

This is unrelated to sexual attraction. Sex and romance are not the same. Romantic relationships are possible without sex. Not feeling romance is also not a super big deal. Someone needs to read asexuality 101. I really have no more ways to say “it is possible to have a fulfilled and happy way full of great relationships without sex and romance”. These symptoms are basically saying “I prioritize romance so much that the only way I could imagine not having it is if I was crazy”.

“Social isolation”

Where did this come from?? Especially because later in the definition it specifies that you would be capable of holding down close personal relationships of a nonsexual or romantic nature, so it contradicts itself. Not dating is not the same as social isolation. Saying that it is is basically telling everyone there’s one way to have a family or be around other people and if you don’t do it that way you’re sick.

“Inability to become sexually aroused”

This is seriously not on par with nor related to a lack of sexual attraction. The symptoms that they give as evidence of “lack of sexual attraction” for the most part have nothing to do with sexual attraction. The ability to become aroused is 100% biological: does your body respond to certain stimuli. Attraction has to do with feelings towards someone. If you can’t become sexually aroused at all and you have a problem with it, it’s probably a question for your medical doctor not your psychologist. But of course none of these symptoms can be the result of something medical as per criterion b.

“It would manifest as something similar to schizoid PD, in which the individual is rather socially detached. However, unlike schizoid PD, this person would take enjoyment in other types of close relationships, such as with family or platonic friends. Additionally, they would not exhibit flattened affect, excepting in sexual situations. In this dimension, this individual does not possess the skills to understand or interpret social cues. A person may develop this due to either a predisposition to a schizotypal-like PD, lack or disregulation of hormones, or a lack of physical contact in childhood.”

So basically nothing would be wrong with this person except that they don’t want to have sex. Oh no! How horrible! Their life must be empty! The basic take home message is that if someone is not feeling a desire for sex then they must be unhappy or wrong. This is a pretty common feeling among a lot of people: if you’re not having or wanting sex, there must be something wrong with you and you should probably fix it. But simply having different desires, priorities, ways of relating, or ways of expressing intimacy doesn’t mean anything about your ability to live a good life. Throughout history psychology and medicine have turned difference into illness so that they have a legitimate way of trying to eradicate it. You’re a woman who likes sex a lot? Medicate. You’re gay? Stamp it out, it’s a disease. You’re a kinkster? Better see your doc.

Many of the symptoms presented above boil down to “you don’t feel the way that I’m used to people feeling”, or tie together something painful but unrelated with the different way of feeling. Many of them point at things that are often a sign of illness (lack of sex drive) and say that they are ALWAYS a sign of illness. Together, these allow a doctor to say that difference is actually a problem because it causes unhappiness. In reality the unhappiness is more likely caused by stigma and oppression.

So if you’re thinking about introducing a new medical definition let’s think about whether the symptoms are actually causing pain in someone’s life rather than just are something that doesn’t make sense to you, shall we?

 

Falling Through the Cracks: When the DSM Can’t Find You

This week in my DBT group, we were talking about what Borderline Personality Disorder is and how it’s diagnosed (DBT was originally formulated for BPD). Essentially, there are nine traits that are used to diagnose BPD. If your diagnosing therapist sees five or more of them in you, then you are diagnosed with BPD. If you have less than five, but still have some, you are diagnosed with what’s called BPD Traits. I had never heard of BPD Traits before, and I don’t think most people have. Insurance is far less likely to cover something that sounds subclinical like that, and it’s far less likely to be understood by the general public. It simply sounds less severe, right?

 

Unfortunately, this system has a few major flaws, and it seems to me that these flaws are indicative of many of the problems with the DSM as a diagnostic manual. The main problem with this system of diagnosis is that many of the traits of BPD are things that everyone has to some extent or another (things like anger issue, or efforts to keep people from leaving you), and so they only become diagnosable when they seem to be excessive or problematic. This leaves a great deal up to the discretion of the diagnosing therapist. It also means that that therapist has to draw a hard line about what counts as problematic and what doesn’t, when in reality these traits exist on a spectrum. So you could be just over the line and counted as having the trait, or you could be so far over the line you can barely function on a day to day basis, and in the eyes of the diagnosis, you have the same trait.

 

This also means that the difference between BPD and BPD traits isn’t as clear cut as it might seem in the first place. For example, someone with BPD might be just over the line on five traits, but someone with BPD traits might be way, way over the line in four. Who’s to say which is more severe, or that one should receive a full diagnosis that allows them access to treatment, while the other receives a diagnosis that gets them almost nothing?

 

Overall, this illustrates something that is definitely wrong with the DSM: mental illness and mental traits all exist on spectrums. There is no on or off switch to depression, anxiety, paranoia, or any other problem that may be diagnosed as a mental illness (with the possible exception of hallucinations). However in order to diagnose someone (and particularly for that individual to gain coverage of treatment), symptoms are treated as present or not present. Occasionally we use modifiers like “severe” or “mild”, but more often than not it’s either there or it’s not.

 

This seems to be a recipe for disaster for people whose symptoms either don’t present as traditionally understood, who are barely subclinical, or who have an odd constellation of symptoms. I find that I often have this problem: I have lots of issues (oh LOTS and lots). I have bits of OCD, OCPD, ADD, BPD, depression, anxiety, bulimia, anorexia, and really probably a whole host of other things. But because many of them are subclinical, or I don’t have the right pairings to fit into a particular diagnosis, I have been left without any sort of personality disorder diagnosis, or larger diagnosis to fit it all together. Despite how severe my eating disorder was, I was lumped in the EDNOS category, which is far less often covered, and is often treated with less respect and as less severe than other eating disorders.

 

This is a serious problem if we want to provide proper services for those people suffering from mental health issues. We shouldn’t have to wait until a symptom is truly interfering with someone’s basic functions before we give them help. There are many problems with the DSM, and trying to posit a replacement for it is extremely difficult, but one element that really could use replacement is this all or nothing thinking. There is no “partially depressed” or “sort of ADD”. You either have it or you don’t. One improvement could be seeing mental health on a spectrum. We all have different traits, and many of those traits are spectrum style traits. Understanding that moving towards the extremes is always a problem is one great way to view mental health in a more understanding and helpful way, because it allows us to try to help everyone move towards a more balanced place, and could allow us to provide treatment for those who have not yet reached the critical zone.

 

Another issue with this system is the amount of discretion that it allows for the diagnosing clinician. Let’s look at a particular example. One of the criteria for diagnosing BPD is “inappropriate, intense anger or difficulty controlling anger”. This is fairly vague. What counts as inappropriate anger? How might things like race and gender fit into this (hint: black women will always be viewed as having inappropriate anger)? Shouldn’t there be specific examples of things that might constitute inappropriate anger, or the consequences in someone’s life for “difficulty controlling anger” or the number on an emotional scale of what constitutes “intense” anger? How often does one need to be intensely angry to get this trait? All of these things are left up to the discretion of the diagnosing clinician, and unfortunately this allows for a lot of bias.

 

There is a difficult balance here, because having that kind of specificity means that you could be very close to a diagnosis, but not quite reach the correct number of episodes, or the right “level” of anger to reach diagnosis. It seems to me that having these specific levels combined with a spectrum view of disorder would allow clinicians to have less individual discretion that can lead to variability in diagnosis, but would also allow more people to get the treatment that they need. It is widely recognized that we need some changes in the DSM, but these particular issues are ones that I have seen in action in myself and in people around me, and that seem as if they could be fixed without great difficulty. Get on that DSM.

Follow Up: Mandatory Mental Health

A couple of notes here: I’ve noticed that I’ve been posting a lot and then having more thoughts come to me immediately afterward I put something up. I think that what this means is that I need to spend more time with each post before I hit the publish button. I probably flood this blog anyway, so I’m going to cut down how much I’m posting so that I can devote more time and energy to editing and putting up quality rather than quantity. I will be posting a fair amount on Teen Skepchick this week, and I should have posts going up at The Fementalists and CFI On Campus as well, so never fear you will have your overdose of my writing. With that explanation, here is my single post for the day.

I recently posted that I thought it could be beneficial to institute mandatory mental health education in schools. In my initial post, I didn’t flesh out some of the serious benefits that we could see from instituting this kind of policy, and I didn’t really explore how we could implement it either, but rather focused on the first flash of an idea. In order for this idea to have any kind of impact, it needs to have some feet under it. I need to identify who it will benefit, how it will show benefits, and what might stand in its way. That’s what I intend to do here.

There are many practical benefits to adding a new . The first chunk of these benefits falls under the heading of “preventative treatments”. As it stands today, it is extremely difficult to get any kind of mental health treatment unless you are already overwhelmed or in a non-functioning state. We don’t hand out diagnoses to people who are showing signs of something and want help to keep those signs under control: we hand them out to people whose symptoms have gotten out of control. Unfortunately, a DSM diagnosis is the only way for many people to get help. By the time they get to this point, they’re often already in a state of crisis.

To take a stark contrast, we spend a great deal of time thinking about preventative measures in our physical health: we tell our children to wash their hands, to stay home if they’re contagious, to eat healthy and exercise, and to get vaccines. For some reason this logic isn’t extended to mental health even though there is a great deal of evidence for the biosocial theory of mental illness: we start with some predisposition that makes us vulnerable to mental illness, but our environment can either tip us into it or help us away from it. The messages that we are sent about our emotions and our worth make a huge difference in determining the severity of our emotional difficulties. Adding education to schools can help send positive messages to kids about accepting their emotions and about how to handle emotions. It reduces the stress level of the environment, or at the very least provides kids with some tools to diminish the stress levels in their personal environments.

There are many people who could benefit from this kind of preventative care. First, those people who are vulnerable to mental illness need all the help they can get to build a healthy and safe environment for themselves. This NEEDS to start as a child. Much of the evidence about mental illness suggests that childhood is one of our most vulnerable times and it’s when we begin to develop our patterns and understandings of emotions. Providing some extra help to children could mean significantly fewer individuals who fall into diagnosable states as they grow older. While we can only do so much to provide kids with safe and happy family environments, schools do provide an ideal location to teach the skills to help handle less than ideal environments. Giving a vulnerable child the skills to not fall into the place of crisis that a diagnosis requires would be a huge improvement in quality of life.

In addition to those children who may at some point gain a diagnosis, or who need help to not fall into a diagnosis, there are also individuals who have serious struggles with their emotions and mental health but who will never have a DSM diagnosis. They’re hovering in the uncertain place where they’re not destroying themselves, but they’re certainly not healthy or happy. People with subclinical symptoms, or who might have a bad environment but higher tolerance. Oftentimes these individuals can’t afford therapy or simply don’t have very many resources to help them learn about emotional regulation. With some regular education and practice at emotional regulation, these kids could grow into much happier adults. They deserve help to flourish just as much as anyone else.

Finally, the general population of kids (and the adults that they become) could benefit from learning emotional skills. Obviously we all feel better when we can regulate our emotions and tolerate distress. But the most important section in my mind is learning about interpersonal relationships. If the bullying epidemic in this country tells us anything, it’s that we haven’t been stellar at teaching our kids about interpersonal relationships. We’re constantly talking about how to decrease bullying, and asking all children to learn how to get what they want and need in a more appropriate fashion can only help. In addition, as a recent college grad, I can promise you that 99% of the jobs that I’ve been looking at list “work well in a group” as one of their requirements. Our world is very much about connection right now: technology seems to be thriving on the concept of connecting. So giving our kids the skills to navigate the world of constant connection would be extremely helpful, both for their future work lives, and for their current personal lives.

So beyond helping our kids and future citizens be happier and healthier, what else do we get out of adding mental health education to our schools? I know that politics right now is about money, money, money, pragmatics, the economy…we can’t just go throwing money at things without some guarantee of a return on our dollar. But I have news: this will likely save us money. I don’t know if you’ve noticed, but mental healthcare is EXPENSIVE. My experience is primarily with eating disorder treatment, and I know that it’s come near to bankrupting a fair number of families. Most of the money for treatments is coming from insurers, and thus drives up the cost of insurance for everyone. Therapists are damn expensive, and once a mental illness becomes thoroughly entrenched it can take many, many years of therapy and work to get it under control. That’s a huge amount of expense both for individuals and for the community. If we can prevent some mental illnesses from ever occurring, we can save a great deal of money.

In addition to the cost of treatment, mental illness itself can be expensive, both individually and societally: individuals who are struggling can have a harder time getting and keeping work, or may spend money on things they don’t want (BPD can lead to excess shopping, addiction leads to money spend on substance of choice, BED means money on huge quantities of food). If someone is desperately fighting for their own mind, they’re likely not contributing as much to society as they could be (this is in no way meant to shame individuals with mental illness. Your job is to bring yourself back to health, not to contribute to society on a monetary level. If someone had a debilitating physical illness you wouldn’t shame them because they can’t work as many days. This is simply to say that when we’re very ill we’re not at our best). But if society wants its members to be as productive as possible, holding down jobs and putting money back into the economy, preventing mental illness is a really good way to do this.

But maybe money isn’t your thing. Maybe you’re more interested in the people than in the money. Well first of all go back and read the first few paragraphs about how we could make a lot of people happier and healthier. Still not enough? Ok, I’ve got another. The most immediate and concrete would likely be an improve in grades. Now I don’t know of any studies on the relationship between mental health treatment and grades, but I’m gonna go out on a limb here and say that when you’re fighting a mental illness or fighting to stay out of a mental illness, you’re more likely to struggle in school or at work. Now there are absolutely people who can keep up good grades while struggling. Some mental illnesses tend to push people towards perfectionism, and those individuals appear highly competent while in the throes of a mental illness. I myself managed to keep up above average grades through all of college while dealing with an eating disorder, depression, and generalized anxiety. But the worst grades of my life came at the time when my mental health was at its worst. This is not a coincidence. If we want our children to be well-educated and to be as successful as possible, we have to help them to be able to focus on school when they need to, and to have ways to deal with whatever else might be going on in their lives.

In addition, spending time with one’s own emotions can really help to create more empathy for others. Again, I am speaking from my own experience here, but I find that the more I learn about understanding where my own emotions come from, the more I find myself curious about why others are upset or struggling. If even half of the kids in these classes gained something, we would have a significantly more empathetic and supportive community for others who might still have difficulties. And if every child went through something very like therapy at a young age, we might be able to decrease some of the stigma against mental illness and against therapy.

Now obviously there would be a cost here. It’s not free to get a therapist into the schools, or to further educate our already over-burdened teachers to handle one more thing. But adding a single additional school therapist who did one hour of work per week with each classroom would not break the budget (possibly two for larger schools. Keeping therapy groups small is REALLY important), and it could lead to some serious improvements. Therapists are expensive, but if we get all of the benefits outlined above it seems that it would be well worthwhile.

The ideal way to do this seems to me to have one therapist who is entirely devoted to education and preventative work, who conducts classes with small groups of students to teach them different skills, check in about their week, and assign them a short piece of homework to practice an emotional skill during the week. This would be a highly demanding position for one therapist to build close relationships with a large number of kids, but if schools were capable they could add more therapists for more students. Even if it didn’t exactly mimic a traditional therapist/patient relationship, it could still be a useful way for kids to simply have a time to check in, learn how to talk about emotions, and get some emotional education. It absolutely seems to be a cost effective measure to improve grades across the board (because this seems to be a measure that would benefit all kinds of students, and engage those with some interest in psychology at an early age) and to prepare kids for jobs and life.

Now I am obviously not a school administrator or policy maker. I have never been in the position to create a budget for a school. So I would love to hear input from those people who might have more experience with these sorts of things: do you think it would be a cost effective measure? Could it help to lighten the load of some of the other school counselors to do some preventative measures? How could we try to push for this change to be made?

DSM V and Diagnostic Woes

THE NEW DSM IS OUT AND I HAVE A COPY OF IT! For those who don’t know, the DSM is the Diagnostic and Statistical Manual, essentially the bible of Psychology. It’s what’s most often used to diagnose someone, and if you want insurance to cover treatment you generally need a DSM diagnosis. They’ve been in the midst of some pretty contentious updates for a long time, but I now have my hands on the brand new copy of the DSM-V.  Mmmm, tasty.

 

Of course when I got ahold of it I spent a good half an hour paging through and self-diagnosing, but after that diversion, I moved over to the eating disorder section to see what updates had actually gotten through and how they had phrased them. I was happy to see the inclusion of Binge Eating Disorder, as well as Night Eating Disorder and Purging Disorder as new categories in the manual, but when I looked back at our old favorite anorexia I was…annoyed.

 

One of the most contentious points in the DSM IV was the weight criterion for anorexia. While this has been removed from the current version and replaced with the following: “a significantly low body weight in the context of age, sex, developmental trajectory and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected,” there is a scale to determine the severity of the disorder. This scale is entirely based on BMI, with the caveat that a psychologist can make adjustments if necessary. And I must say that the numbers listed on that scale are INSANE. To be considered a moderate case, your BMI needs to be between 16 and 17.  My BMI has never been even close to that. While I generally dislike numbers, and I am going to insert a HUGE TRIGGER WARNING right here, when I was at my worst I literally would go for a week without eating at times. I never ate two days in a row. I was seriously ill. However my body weight never dropped into what would be considered technically underweight by the BMI scale. I would have been considered a mild case, even if I had gained the diagnosis at all (as it stands I was diagnosed with EDNOS because of the weight criterion in the DSM IV).

 

We have gone over and over the harms that come from including weight as a criterion of an eating disorder. First and foremost, it keeps people from getting treatment until they’re already too sick, which is unhelpful to everyone involved. It ignores how different bodies react to starvation. It ignores that people’s weight can fluctuate throughout the disorder or treatment. It’s simply unrealistic. But more than anything, I feel like it shames those people who never get that diagnosis. It tells them that their pain and suffering wasn’t real unless they hit the magical BMI of 17 marker. And I am so disappointed in the writers of the DSM that they would ignore all of the feedback they’ve received from the eating disorder community and still include BMI criteria for anorexia. I’m so disappointed that after all the research and stories and experiences that people have shared that illustrate that an eating disorder is not about weight, we still have to reduce to such. And most of all I’m disappointed that until the next rewrite, more individuals will be stuck trying to navigate a system that reduces them to their weight, even as it’s trying to convince them that they should stop doing that.

Frustrations with the DSM

I live in a very psych oriented world. I work for a nonprofit that provides services to kids with autism and developmental disabilities and general mental health problems. I spent at least five hours a week in therapy. I talk a lot about mental health, I care a lot about mental health, and a few of my friends and I just started throwing around the idea of creating a skepticism and psychology conference (SO EXCITED). So I’m thinking (as per usual) about mental health.

One of the talks at SkepTech (by the fabulous Stephanie Zvan) was about psychometrics, which is “The science of measuring mental capacities and processes.” She talked a fair amount about how we often define certain disorders based on our stereotypes: we view autism as a boy’s disorder, so the diagnostic criteria are slanted towards how autism presents in boys. I think this is a very important thing to address (especially in terms of race. UGH), and I think the place to start is with the DSM (the psychology diagnostic manual). The DSM is very much a quantitative measure. For eating disorders for example, it lists particular weights, numbers of binges and purges per week, and length of the persistence of the disorder as diagnostic criteria. In many ways, these concrete diagnostic tools are incredibly helpful: they allow insurance to see who to treat or not and they allow clinicians to have something more solid than personal judgment to use in their diagnoses. That’s important. We do need some element of consistency, we need some science in our diagnostic tools.

The problem shows up in the fact that many of these diagnoses are written around what is considered the typical case and doesn’t necessarily allow for any variation. It also doesn’t address the fact that many people have lots of symptoms that don’t quite fit into a neat diagnostic category. In many ways it’s far too rigid. Diagnoses that involve NOS (not otherwise specified) often aren’t covered by insurance, aren’t included in research, and aren’t afforded as much respect as serious problems by clinicians or the individuals diagnosed.

This is a really big deal because it limits who can access mental health care based upon demographic or personal variation. Males with depression generally exhibit it in very different ways from females, and they are not diagnosed as often because they aren’t viewed as the typical depression sufferers. People of color are not diagnosed with eating disorders nearly as often as white girls (particularly teens).

So how can we both create helpful categories AND capture the wild diversity of mental illness? How can we approach mental illness not as a checklist of symptoms that we address and move the individual back to the neurotypical end of the spectrum? First and foremost, insurance needs to NOT be tied to strict diagnosis. That is not fair to individuals who might need preventative therapy or interventions, or those who want to catch a disorder before it becomes so serious that it interferes with their life. It is also not fair to those individuals who have a serious mental illness that is wreaking havoc on them, but who don’t fall neatly into a category. But it’s also unfair to those who DO fall into the category, because it might ignore any other symptoms or problems that could be contributing to their diagnosis. OF COURSE labeling some patterns and similarities can be helpful because it allows us to conduct research and to develop treatments that work for people with similar issues. But these labels should not be considered so strict, should not be the only guide we have in treatment, should not have such harsh boundaries, and should allow more movement between diagnoses. They should be guidelines (the code is more like guidelines than actual rules).

There should also simply be more cross-cultural research. Right now we have very Western-centric views of psychology as well as very white, male views of psychology (thanks Freud). We need to focus on evidence based treatments, and we also need to simply be willing to have MANY types of treatment available for people who are exhibiting different symptoms because of their demographic. We need to have psychologists who are social justice aware: personally I think that sociology, women’s studies, and race studies classes should be required of every psychology major. It is SO important to improve our mental healthcare system, and the first place we need to turn is how we determine who needs mental healthcare.

If we’re being honest? EVERYONE. Mental healthcare isn’t about turning people into the neurotypical. It is about improving functioning. Everyone could use a mental health checkup, just like they have a physical health checkup to make sure they’re functioning like they should and to catch any worries or glitches before they turn into something serious. We need a paradigm shift that no longer sees diagnoses as identifying problematic difference to seeing diagnoses as identifying problems with functioning that require help.

NOTE: they are trying to adjust some of these problems in the latest update of the DSM, the DSM-V which is coming out in May.