Against The Use of Psychiatric Diagnosis

While accepted definitions of “normal” behavior form the basis for most psychological treatment, a wider appreciation of individuality and creativity has always informed my practice. For nearly four decades, I have sat and listened as people present their life stories and still marvel at how unique are many of their problems and how well these problems also function as solutions. Those who come to therapy already have already changed in response to the many sharp turns and sudden twists that life delivers. Sometimes those adaptations are accompanied by unexpected guests – consequences in the form of a problem or symptom. The more I explore those problems to find how they function, the more originality I discover and the deeper is my conviction that the human mind possesses an extraordinary genius for creativity.

As I continue to teach and lecture among my colleagues around the world, I am profoundly aware that most psychotherapists still train and practice within a paradigm that sees patients’ problems as rooted in pathology. They look for how a symptom fits into a diagnostic category, then apply treatment methods according to specific guidelines. That neatly solves the problem for the therapists, but not for the patient.

My approach is less to diagnose and treat the problem than to identify, respect and even revere how it solves or rectifies life’s dilemmas. Whenever I am able to cast a so-called problem in a such positive light by uncovering its meaning and purpose, the person gains a reinforced respect for himself and for what he or she is seeking to achieve in maintaining the problem. Self-respect forms the platform from which we summon the imagination for creative alternatives for change.

When I can help patients find their way back to the original conflict that their problem solves, I can also help generate different options or solutions that have fewer emotional consequences, yet the same stabilizing results.

Efforts to standardize “normality’ have lead to the creation of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association’s (APA), imperial attempt to label and codify much of so-called dysfunctional behavior, clustering it into diagnostic categories in relation to agreed-upon definitions of “normal.” The newly published–and deeply conceptually flawed–DSM-V medicalizes problems or symptoms caught in its net, forcing clinicians to make distinctions that trivialize individuality and creativity and lead to unneeded treatments and drug prescriptions –a goldmine for pharmaceutical companies. It creates medical disorders based on questionable science.

Used by insurance companies to determine eligibility and therefore pervasive in its influence, the DSM-V serves more like a guide for therapeutic witch-hunts generated by an elite, powerful few seeking to shoehorn patients into cost-effective, “evidence-based” treatments. Diagnoses become life sentences, branded into the consciousness of patients and their families as well as medical and insurer data banks that follow them throughout their lives. Even so, some psychiatrists think the DSM has not gone far enough in considering the use of brain scans as a tool in determining the neurological and genetic sources for patients’ supposed mental illnesses. For them, all “dysfunctional” behavior is a function of chemical imbalances.

In response to the DSM-V, The British Psychological Society condemns its bias: “It is based largely on social norms, with ‘symptoms’ that all rely on subjective judgements… not value-free, but rather reflect[ing] current normative social expectations.”

These words echo my view. Definitions of “normality” should have no authority in psychological assessments because they create a dangerous standard by which to judge human behavior in and out of the consultation room Mental health professionals use it to pathologize, and religious leaders to demonize behavior outside the norm without consideration or respect for social and familial context, or how symptoms function as a creative solutions. A problem or symptom can only be understood and decoded within the context of the patient’s unique life experience.

Sexual behavior especially defies normalization. Every sexual experience is inherently different because it draws upon the individual and cultural history of the participants as well as how they come together at a particular moment in time. Yet, diagnostic categories for so-called “unhealthy”, “deviant” or “perverse” sexual behavior have been standardized in the DSM from its earliest publication.. These diagnosis have too often served as the justification for dangerous treatments such as Conversion Therapy in which homosexual patients are taught heterosexual behavior. Yet, what had been vigorously defended for decades as psychological “truth,” was later cast aside. In 1973 homosexuality was eliminated from the DSM; other categories of sexual behavior once considered deviant have undergone a similar fate as values and attitudes toward sex have changed. Still, the DSM-V continues to invent new sexual categories such as Hypoactive Sexual Disorder– the lack of sexual interest–a diagnosis for which pharmaceutical companies are racing to create medications that work to increase women’s sexual desire.

Though solid findings have shown that flagging sexual interests are more likely the result of long term monogamous relationship, many psychologists continue to promote the idea that women have lower sex drives because they are hardwired to want children and not necessarily sex. On the contrary, monogamous relationships act like “cultural cages” that confine natural sexual desire.

Even hormonal decreases during menopause can be overridden when a woman takes a new lover.

Is a diagnosis of Hypoactive Sexual Disorder the result of some bio/psychological indifference as the DSM-V proposes, or is it monogamy itself that results in the loss of sexual desire?

Even our sexual thoughts are not beyond professional judgment. Ideas about the role that sexual fantasies play in our lives have been intensely debated among psychologists. While sexual fantasies are now considered a universal experience, Freud and other early psychoanalysts believed that sexual fantasies resulted from feelings of deprivation in the absence of sexual satisfaction. Many experts still maintain this view, further reasoning that certain types of fantasies are signs of pathology. For them, fantasies involving a patient’s sexual submissiveness, for instance, are viewed as a deeper symptom of “masochism” because they are assumed to lower self-esteem.

Some psychotherapists and sexologists say sexual fantasies should never be acted out because such activity might serve as a stepping stone to further pathological, antisocial or even violent behavior. There is no evidence to support the notion that acting out fantasies will lead to violent behavior.

These views are less about understanding than policing sex. Along with religious fundaemntalists who preach that sexual fantasies are sinful and strictly prohibited by the bible, the field of psychology has contributed to forms of sexual oppression that have resulted in widespread feelings of shame and confusion.

Far from pathological, our deepest sexual desires reflect our unique histories and are as original and varied as we are as people. They represent subconscious attempts to resolve childhood conflicts or to satisfy unmet needs by turning painful feelings into pleasurable ones through eroticizing them. Our fantasies, whatever they may be, are windows into our deepest psyche. They have value and purpose that can safely and intelligently be used to create a gratifying and meaningful sexual life.

Sex can be hollow, repetitive, and preoccupy us just like many other life experiences–like unfulfilling work or meaningless relationships–especially when we have repressed or denied our deepest desires. Yet, running the work treadmill or following the daily rituals of marriage are considered necessary and normal parts of life; no diagnostic category exists for them. But when it comes to sex, we use pathologizing language like “sexual compulsive” and “sexual addict” to describe similar ritualized behavior.

The field of psychology has strayed far from its origins a little more than a century ago when extraordinarily creative thinkers developed theories and practices based on actual experience with patients rather than experiments run in universities by graduate students. There has been much lost to psychology by its attempts to legitimize itself through questionable scientific studies and speculation that reduces human behavior to codes and categories. It has taken on the job of modifying, medicalizing and erasing “deviant” behavior in the name of “health.”

Sexually speaking, we can reverse the corrosive influence of definitions of socially acceptable behavior by making a conscious attempt to understand accept and honor the true nature of our unique sexuality. If we can achieve authenticity by aligning our sexual behavior with our fantasies and desires, we can permanently change our relationship to ourselves and satisfy a host of deeper needs. We can reclaim rejected, repressed or abandoned parts of ourselves and integrate them into our essence, which is so crucial to our sense of well-being. By challenging socially constructed values of “normal,” we will arrive at our own set of moral values and obligations that derive from self-knowledge and self-acceptance. By honoring all of our desires, we do not demonize their difficult aspects. Rather, we instead accept ourselves in all our human complexity.