book of insults

About three weeks ago, while I was listening to Sunday Night Safran (with John Safran and Father Bob Maguire, on Triple J), one of the guest speakers was Gary Greenberg, a psychotherapist, and author of The Book of Woe: The DSM and the Unmaking of Psychiatry.

During the interview, Greenberg referred to the DSM (The Diagnostic and Statistical Manual of Mental Disorders used by the American Psychiatric Association, and known throughout the world) as a 'book of insults', since many 'symptoms' listed therein could be considered negative ways of interpreting individual personality quirks and differences in perception and values. I found this description of the DSM amusing, because it briefly summed up one of the major impressions I had of it. If people are not conventionally confident, resilient or optimistic, there is an increasing pressure to accept it must be pathology - not that they could be exhibiting sane reactions to an insane world.

In 2010, I wrote this in an attempt to tackle some of the issues I saw with the DSM (specifically, the DSM IV), from the perspective of a person who had had trouble with the system. I appreciate Greenberg's efforts, and find that on a personal level, they contribute more pieces of the puzzle.

In 2012, Greenberg participated in the field trials for the DSM-5. He witnessed a lot of what went on behind the scenes, including the power and ego struggles, and the frustration of those who know the DSM is a flawed document, but have to use it anyway.

In order that insurance companies will pay, that people can be prescribed certain meds, that psychiatrists can charge for their services, we need something like the DSM to give professional validity to what psychiatrists do. However, the reality is that the practice of psychiatry is still pretty much hit or miss.

Psychiatry is not really scientific.

Some people, including so-called professionals, still persist in perpetuating the myth that there is something called a 'chemical imbalance' that results in various mental conditions, even though we have no actual proof that such imbalances exist, and we do not know what the 'correct' chemical balance is. We know that psychiatric meds work for some people, but not others. And when these meds 'work', what does that mean? Has a chemical balance changed, or has a person simply become more compliant with society's idea of someone who is more fun to be around (they complain less or are less 'awkward' or 'obnoxious'), so people like them better, they fit in better, and as a result they like themselves more?

All we have to go by is language when it comes to describing symptoms, and it is difficult to be objective, let alone scientific.

Greenberg states that neuroscience is an important field to research and that research in this area will eventually have useful results. But he also says that it just doesn't make sense that we can 'MRI our way to an understanding of mental illness and how to treat it'[...]

There is a lot of psychological suffering in the world. How do we identify it? How do we treat it? What resources are we willing to allocate to treating it? How do we put it all into terms that people can understand? How do we train people to treat these things? It's one thing to identify social problems, poverty and prejudice, but if we can't fix these things NOW, what do we do with all of those who have various psychological reactions to these conditions? Can all of these problems be addressed by simply medicating all need to question out of a person, or by cultivating a 'better attitude?'

Greenberg, in an interview for Guernica, with Katherine Rowland: Most of what I write about and criticize is not what I do. Part of therapy to me is orienting them away from diagnoses and toward the idea that whateverís happening has meaning. Itís not just electrochemical noise, and I have to do that because otherwise itís become a default. I still have people who think of themselves in overwhelmingly diagnostic terms - they think of themselves as having these mental disorders.

Although those in psychiatry know that the DSM is a flawed document, and mostly they 'hold their noses' while utilizing it such that they can prescribe meds and charge for their services, it still affects those who are treated in ways that go to the core of a person's identity. Those who are diagnosed may not only think of themselves as having 'mental disorders' (which btw have no basis in scientific fact!), their personal identity might also be based on a diagnosis which is mainly a means to an end.


In Sociology, master status is the social position which is the primary identifying characteristic of an individual. It is defined as "a status that has exceptional importance for social identity, often shaping a person's entire life."

The master status is often the most important constituent in the architecture of an individualís identity. Common master statuses are those of race or ethnicity, sex, sexual orientation, physical ability, age, economic standing, religion or spirituality, and education. Others include that of being a parent, child, or sibling; being employed or unemployed; and being disabled or mentally ill. It is not realistic to deny that as a society we label individuals based on their most prominent characteristic in this respect, such as the "old loon", the "blonde bimbo", etc.

In perception, an individualís master status supersedes her/his other identifying traits; for example, if a woman feels that her role as a mother is more important than her role as a woman, a daughter, a wife, an American, and a novelist, she is more likely to label herself first as a mother and to identify with other women who label themselves as such. Even more so, an individual's master status dominates her/his perception by others and their behaviour towards him/her. More than other aspects of the status set, the master status affects how the individual behaves and how others behave with respect to her or him in almost every given situation.

In an interview for the New York Times' Arts Beat, Greenberg said:

Psychotherapy, like psychiatric medications, and like much of medical treatment, works by the placebo effect. Thatís not what makes me skeptical, however. What makes me skeptical is the way psychotherapy has become medicalized. Therapy, or at least psychoanalysis, climbed into bed with medicine in the late 1920s, purely for mercenary reasons, and the D.S.M.-5 is only the latest offspring of that affair. I like the fact that I provide a placebo treatment. Placebo effect is just another way to say that the cure is, at least in part, in the relationship between the healer and the healed. What psychotherapy does for people is to provide them with a relationship in which they can feel cared for and challenged, encouraged to tell the truth and required to hear it, and which allows them to understand their suffering in the context of their lives. This can be pointless and ineffective, but it can also be transformative.

How many different types of problems does a patient have? Any physical illnesses or problems in addition to (or resulting in) the psychological distress? Is psychological distress related to money issues? Does a patient have enough money for meds or treatment? How easy is transportation to arrange? Does the person have adequate food and shelter? Does the person have a human support system/network outside of his or her therapist? How do the various issues interact with each other and affect the core problem? What is the core problem?

It seems to me that the relationship between patient and therapist is extremely important, but in addition we need to be able to identify different practical parts of the problem any individual is encountering. The DSM actually addresses this to some extent, but there seems to be little general consciousness of this sort of thing. If a person can't afford medication or psychotherapy, can't arrange transportation, can't afford to eat nutritional meals, or something along those lines, or the people he or she knows don't believe in or support therapy, or are extremely judgmental regarding the circumstances, a person's difficulties in utilizing psych resources really might not be about noncompliance, although they can actually be assessed as such. In addition to filling basic human needs, and accessing psychotherapy, human beings require support systems that involve input from other human beings: family, friends, colleagues, and they need to have realistic ways of contributing to and interacting with the world. This is not only about 'placebo' effect.

What I am getting at is the idea of measurement, and how at present it is not 'scientifically' possible to measure when it comes to assessing psychological obstacles (or efforts). At present, we are hindered by 'myths' and 'shoulds' that do not take into account how events really affect human beings. If a person has to face a certain amount of human foes in war, we can comprehend that it is 'courageous' to be outnumbered and persevere, even if that results in death or loss of limb or some disability (this is not to say that most people understand what soldiers go through - because the reality is that many people who serve their countries are not recognized afterward). But when it comes to psychological issues, it's difficult for us to comprehend that a person might have faced 100 'foes' bravely, and then had his 'leg' cut off by 'enemy' #101, such that he can't do what he used to do, exactly, and that when others expect him to be able to run the way he used to, it's really not simple, and he might be dismissed as someone who has a 'weak' character, or is a 'failure', when in actuality if the majority of the population had faced what he had faced they would not have been able to have 'walked' or 'crawled' as far.

->exile on meme st: a diary