A week or so ago my son and I had a vigorous debate about the DSM. And as I listened to him, I realized he believed that those categories carried meaning in a very different way from the way I see them. I remember when I was in graduate school and learning the rudiments of being a therapist how eager I was to find recipes and prescriptions of treatments, because somewhere inside I knew I didn't really know anything. Structure, in the form of techniques, diagnostic frameworks, anything that brought order for me I grabbed onto for dear life so that I could figure out how to actually *be* a therapist. And I'm pretty sure, even if he might not admit it, that's where he is too. For him, determining a diagnosis is critical. So to him, that new diagnoses will be added in the DSM V is a good thing.
Now that I have been doing this work for a long time, the diagnosis, a la the DSM, doesn't seem very important to me. My task is to respond to the person sitting opposite me and as I listen to him or her, try to hear what is being said, where the sore places are, what this person's story is. I am listening to stories of lives.
Is the person who comes to see me after having had several relationship failures mentally ill? Really? Because in the mainstream mental health system, if insurance is to pay, he or she must be diagnosed with a mental illness to warrant treatment. But is that kind of unhappiness in life indicative of illness? Or the man who has lost his job and feel useless and afraid? That doesn't seem like mental illness to me. Or the woman wanting to make sense of her fears and to understand her dreams? Or the couple who seem to have forgotten how and why they fell love with each other? Or the woman who is lonely and isn't sure how to make friends? I have seen people like this again and again over the last 35 years. None of them were mentally ill. All of them were experiencing problems in finding the life they wanted.
When I was in college, I took a couple of courses from a brilliant and somewhat eccentric psychologist, Irwin Kremen, I remember his saying that from the moment of conception we are subject to a wide variety of noxious influences. Some of them leave long lasting effects, some do not. But no one is without blemish.
Someone is likely to come along and comment that I don't understand how terrible schizophrenia or major depression is. But I do. And it seems to me there is something different about what we call major mental illness from what I see day to day in my practice. As much as anything, this may be because I am a psychologist and not a psychiatrist. But the people who come to see me, with but a few exceptions over these many years, have been people who are able to work and have functioning lives. They suffer, often terribly from unhappiness and problems in their lives, but they are not incapacitated.
Maybe one of the reasons for depressed morale among psychiatrists, as noted in Ars Psychiatrica, is the whole muddle of what is mental illness. As therapists also struggle with changes in the climate for mental health treatment and the strictures of third party payments, maybe we all need to be willing to step back and see what we are about really. Maybe only some of what we do belongs under the umbrella of the medical model while much of what we see and do in psychotherapy, regardless of the training of the therapist, belongs someplace else. Consider that the word psychotherapy is from the Greek words psychē, meaning breath, spirit, or soul and therapeia or therapeuein, to nurse or cure. Does the care of the soul really belong in the medical model?