I recently began thinking about the DSM-5 and the language we use in my NYC therapy practice after listening to a Philosophy Bites podcast with Dr. Steven E. Hyman. In the podcast, Hyman discusses the limitations he sees in the “rigid and arbitrary” boundaries set up in the DSM between what is considered “healthy” or normal and what is a mental illness.
In oncology, for example, the line between stage 3 and stage 4 cancer may have some wiggle room. However, the significance of both the distinction between one stage and another is grounded in research relative to both the progression of the disease and how that is known to produce one outcome versus another.
This distinction is not as easy in psychotherapy
Where I deviate in my NYC therapy practice from what I understand Hyman’s position to be on the podcast is that while I agree that the arbitrary nature of these distinctions in the DSM is problematic, I’m not sure it can be solved. I don’t believe that medicine or psychology–with any amount of research–will ever be able to draw the line between, for example as Hyman notes, ordinary sadness and depression that isn’t arbitrary. The definition of this phenomena is so culturally grounded, so complicated by language, so subjective how it is experienced that the desire to formulate some set of conditions against which the standard of where the line is drawn or upheld (some quantifiable measure of validity) is only going to create the illusion of a rational and reliable, objective standard.
So what do we do? Well, obviously as a psychotherapist who treats depression (and confronts a good deal of ordinary sadness), I’m not proposing that we give up treating these issues, that we abandon the word depression or the insurance companies no longer pay for services that do that. Nor do I think we should stop finding ways as practitioners to develop and share ways to help people in emotional pain.
Let’s look at how we talk in therapy
I think we need to create new ways of talking about these experiences that aren’t constrained by the formal language of medicine (assessment, diagnosis, research-based intervention). We need to appreciate that emotional experiences are fundamentally different from medical phenomena.
One of the biggest challenges to the field of psychotherapy becoming more relevant to people who are in pain or looking to grow emotionally is the attachment so many practitioners have to lofty language. If you look at the history of class, language is so much the currency of sophistication. In medieval times, there was the matter of reading Greek and Latin; in Elizabethan England (and really still today), various dialects so easily demarcated class and education. In post-war United States, there was the SAT, which functioned as a sort of gatekeeper to Ivy-League colleges that couldn’t justify a quota system any longer so the test was only accessible to those who attended prep school and were exposed to the sort of privileged vocabulary necessary to do well on the SAT.
Psychology and psychotherapy’s linguistic inferiority complex
Both the academic discipline of psychology and the professional practice of psychotherapy are relatively new compared with the so-called hard sciences and medicine, so they’ve always had a sort of inferiority complex. The relevant challenge is that while medicine and physics have an entire body of language that necessarily isn’t much like the way ordinary people speak (quarks and ventricles), psychology and psychotherapy haven’t cornered the market, so to speak, on talking about why people do what they do, how people are put together emotionally, and sorting out how to help people who are in pain or working to have a better life. Priests, teachers, lawyers, moms, dads, friends, sisters, co-workers and television personalities all have lots of relevant things to say about grief and sadness, anger and joy, relationship conflicts and striving to have a better life. Psychotherapy trades professionally in a space where many, many others (really everyone) have lots to say.
But psychotherapists and academic psychologists crave their own set of linguistic barriers to entry–so to speak–and diagnosis is what’s available. In a sense, the question Hyman engages around lines of demarcation between, depression and sadness, for example, isn’t so much a scientific one but one of ego. Therapists want to believe that they have a special understanding of sadness, as well as a unique capacity to treat depression so as to separate themselves from everyone else who treads in this domain. At the end of the day, this line of demarcation couldn’t possibly have any bearing on the health and happiness of someone who is stuck in sadness. They just want to feel better.
Embrace both everyday emotional and diagnostic language
People in pain have so much to offer the process of finding ways out of that pain. Millions of people help themselves and one another with emotional challenges every day without a therapist in sight. I don’t think we need to invent new ways of talking out of this air. Human beings have been talking about emotional experiences since the first words were uttered by humans millennia ago. Lots of people have lots of ways of talking about emotional experiences. When they get stuck and do seek the help of a therapist, it doesn’t make it easy if we refuse to speak the same language.
In my conversations with my patients and the other therapists in my NYC practice, we find ways of talking where we stay connected to the limitations of certain ways of speaking–both everyday language and diagnostic speak. I work hard not to “truth talk”–not to get sucked into the idea that however I’m talking about something is the “right way.”
Often in these conversations, both sorts of languages are helpful. With a patient, I might say, “This is an element of X diagnosis.” We might even look at the DSM itself to open up a dialogue. Often diagnostic language is helpful but sometimes, we might also use slang, metaphors or quotes from books or movies. I don't so much want to privilege everyday language over formal diagnostic language as I want to invite people into conversations where we can use any words that are helpful to us to understand their experience in the world.
