Next year the American Psychiatric Association will release the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnosis. The DSM 5, as it is to be known, has created an unprecedented amount of debate and controversy. And for the first time in the manual’s history, the debate over what to include and what to discard has been played out on the internet. Psychiatrists, public health advocates and consumers have all entered into the fray. Two of the most vocal critics of the new edition, Allen Frances and Robert Spitzer, have both been part of committees that have produced former editions. At stake is not only how we speak about and diagnose mental health problems, but also who receives government assistance. For the first time we’re talking widely about how we classify mental ill health. And for many of us, the question that grabs our attention the most is what the limits of normal really are.
Late one night a few years ago, a friend rang up with a revelation about her then husband. "He’s got an Obsessive-Compulsive Personality Disorder! He meets all the criteria." She was relieved and felt supported because someone out there had taken the time to describe what she was experiencing. The DSM IV had given her a language and a framework to make sense of her mate’s behaviour. He wasn’t simply more interested in folding towels than talking to her. She was no longer alone with a seemingly random set of observations. She had words.
We need to find part of ourselves in the outside world. If I can’t "language" myself, I can’t experience myself. This is the true joy of diagnosis. In the case of our experience of other people, diagnostic frameworks for so-called abnormal behaviour offer us support for our feelings — it’s not just me, someone else can confirm my experience. They give us a kind of expert back up for our relational puzzles.
Diagnostic labels entered the realm of interpersonal communication with the advent of psychoanalysis and we still incessantly diagnose behaviours in regular conversation. Our bosses are sociopaths; our friends are in denial, depressed or passive aggressive; our mothers are narcissistic. These labels can be useful catch-all containers for complex and painful events. Other people know what we mean, and we have some psychiatric backing for our discontent.
But with each diagnosis, lay or professional, we reinforce an idea of normality. With each label we are defining and reinforcing the notion of what normal is or should be. We do this mostly for ourselves. To understand our own reactions and to understand our place in the psychological world. We want to know what the limits of normal are and we want to know that we fall within them.
Unfortunately the limits of normal, whatever they are, seem to be rapidly shrinking. We are witnessing an unprecedented medicalisation of normal. Since it was first published in 1952, the disorders named in the DSM have tripled. More and more of us fall into disordered categories of experience and behaviour. Inescapable human pains like grief and bitterness are now more pathologised than ever before. And within this shrinking cage of normalcy we have begun to pace.
While we can be soothed and supported by having our psychological experiences labeled and categorised, the shrinking space allocated to what is normal has become terrifying, particularly when we are in crisis ourselves. Are we grieving correctly? When is it ok to be angry? Are we caring or codependent? Do we love red wine or are we alcoholic? Our everyday lives and human frailties become diseases, while our misfortunes become failures of character and upbringing.
At the same time, the enormous scope and variety of human experience has never been so accessible. In the early 80’s I went to a women’s music festival held over four long hot days. In a sea of 10,000 topless women, I realised for the first time that there is no such thing as a normal breast shape. Mine weren’t normal or abnormal, or even big or small, but part of such a wide variety of shapes, sizes and colours that they became once again my own, with no conceivable standard to compare them against. In a similar way, we are now exposed to a constant stream of experiential variety which challenges our personal and cultural ideas of what is acceptable. We have lost our benchmarks.
This means that we are simultaneously being told that what is normal fits only into an increasingly narrow band of experience and also that we are all very different and everything is okay. As the varieties of psychological experience we witness expands, we can become less and less secure about what is normal. This leaves us floating in a great sea of choice where the only anchors are attached to the smallest of boats.
One of the reasons people come to therapy is to make sense of their lives. To understand them and to find words to express their own internal histories. What we are witnessing in the storm of debate over the new edition of the DSM is nothing less than a battle for what’s left of our language to describe the inevitable features of our human condition. We all will be hurt, we will grieve, we will at some point become bitter for a time. We will suffer abuse and we will abuse others. Most of us will have some days in our lives when we contemplate ending them.
While we struggle to describe our experiences and to give them meaning, we need to be wary of searching for the moral certainty of psychiatric diagnosis. Because each time we reach for a diagnostic label we risk colonizing just that little bit more space from the wilderness of normality.
ABOUT THERAPY FOR NEWS JUNKIES: Why does the news make the news? Why do certain stories gain such traction? Therapy For News Junkies is a regular NM column which looks at why audiences react so vehemently to particular issues. Zoe Krupka is a psychotherapist who uses her knowledge about how we react as individuals to better understand collective responses to the events of the day.