Should Racism Be A Psychiatric Diagnosis?

I have written extensively about non-diagnostic therapy–one meaningful way of describing the sort of therapy we practice at our downtown NYC therapy center. The phrase is meant to contrast us with the model of how therapy is traditionally practiced wherein an assessment is made in the interest of producing a mental health diagnosis and then, that diagnosis determines the course of treatment based on prevailing standards of practice. This approach is standard in Western medicine and is so termed “the medical model.” Psychotherapy has historically fashioned itself in the image of medicine and therefore, the model in psychotherapy is to follow this same process of assessment, diagnosis and treatment.

And so it is with a full appreciation of the irony that several years ago, I was invited to teach a graduate course in clinical diagnostics at Hunter College School of Social Work. I am trained in diagnosis and was excited for the opportunity to teach the class. But I also hoped I could introduce students to the limitations of diagnosis. I wanted to show them the ways in which it empowers a very narrow class of people to define the scope and terms of emotional and psychological suffering for literally billions of people.

From the syllabus:

“Cognizant of the critical impact of culture, class, ethnicity, race, age, sexual orientation, spirituality, ability, and gender upon the process of diagnosis and social work practice interventions, the conceptual framework for this course is based upon a social work perspective of “normal” and “pathological” behavior including what we mean when we use these terms."

Could Racism Be A Mental Disorder?

With those intentions laid out, the first exercise I asked students to do was to form small groups and–following the format of the DSM-IV (now the DSM-5 aka “the diagnostic bible” published by the American Psychiatric Association)–create a new diagnosis for hypothetical submission to the DSM that constructed racism as a mental disorder.

For example, a diagnosis of Racism Superiority Delusional Disorder might look a little something like this:

Racial Superiority Delusional Disorder 608.23 (F71.8)

Diagnostic Criteria

A belief of superiority over members of another racial group by virtue of membership or perceived membership. Superiority may include, but is not limited to: intelligence, moral superiority, physical attractiveness and entitlement to special privileges based solely on membership in a particular racial grouping.

At least two of the following:

A pattern of discriminatory practices based on race or perceived race in one of the following: hiring, the leasing of housing or commercial property or service.

A persistent belief that an individual has insight into the criminal background, criminal intentions, culinary preferences, habits of self-care or related characteristics of an individual member of a racial group or a racial group as a whole.

Verbalization of frustration or disagreement at least once per week at the presence of members of a racial grouping requesting compensation for discriminatory practices and/or asserting that racial bias exists in a given community.

Specify Current Severity
Mild: An average of 1-3 incidences of verbal or physical or racial aggression per week.
Moderate: An average of 4-6 incidences of verbal or physical or racial aggression per week.
Severe: An average of 6-9 incidences of verbal or physical or racial aggression per week.
Extreme: An average of 9 or more incidences of verbal or physical or racial aggression per week.

Differential Diagnosis

A clinician should assess for Racial Superiority Delusional Disorder in contrast to the following based on predominance and specify:
Religious Intolerance Disorder
Misogynic Delusional Disorder (with or without sexual aggression)
Homophobia

While it seems like an unexpected if provocative exercise, I wanted to encourage students to recognize that the DSM is constructed just as they were constructing their own hypothetical diagnosis for the purposes of this assignment. Like the students, people in a room sat down and made up the words in the DSM. Of course, the DSM is based on research and expertise but many students in that room were bona fide experts, too, in the etiology and treatment, so to speak, of racism. There were a number of students of color in the course, but it was also clear that the white students were also conscious of racism and had some awareness of their own participation in it. The very act of sitting together and discussing these experiences in the context of the assignment was meaningful research.

So they were experts too, who thoughtfully constructed the definition of a phenomenon with serious societal and emotional consequences, that clearly impaired functioning in the individuals both who suffer from it and who are affected by the dangerous behavior of those who suffer from it. This is not so different from the sorts of concerns about anxiety or psychotic disorders that compels the APA to include these disorders in the DSM.

“Hey…Wait…Why isn’t this in the DSM?”

In the three years that I taught the course, it was remarkable just how well suited racism appeared to be for the DSM–how easy it was for students to formulate the diagnostic criteria and how consistent it was with the disorders that were included. The question students asked, which the exercise was designed to elicit, was, “Hey, wait…seriously…I know we’re just playing here but why isn’t this in the DSM? What is the difference?” Many left outraged and puzzled. That is the mindset I wanted them to to have before going home and reading the first assignment of some clinical text about Disorders of Childhood or some other diagnoses.

I wanted them to ask the same questions of these diagnostic texts. How do we–as a society, as therapists, as social workers–decide who is sick and who isn’t, what behaviors are of clinical concern versus some other sort of concern? Homosexuality was included in the DSM as a psychiatric disorder as recently as the 1970s. “Gender Identity Disorder” is listed in the current iteration of the DSM–why? What are the social implications of what gets included and what doesn’t? What sort of authority does this book have in shaping not just the nature of the services individuals receive (and have funded), but also how we understand the significance of these distinctions in the media or in everyday conversation? Does including something in the DSM make it more “real”? How does that construct it as a particular sort of problem? What are the consequences on a micro and macro level of these distinctions?

The lines are, in fact, much more arbitrary than we imagine them to be. Adding a new disorder to the DSM just can’t possibly be the same as adding a new liver disorder to the ICD-10. But most of the public (and I would argue most psychotherapists and psychologists) relate to these as equivalent. I think that has serious consequences that need to be looked at.

What does this mean in our NYC therapy practice?

Our rejection of the medical model is not intended as a rejection of research and theory in the practice of psychotherapy but rather, an appreciation of how deeply limiting this approach is in co-creating meaningful growth in the lives of the bright, committed people that seek help in our NYC therapy office.

This also doesn’t mean diagnosis is never at play in our NYC therapy practice. However, we never take diagnostic language so seriously. If it’s helpful, we talk about it.  But we don’t act as if we are expressing some special medical insight. We approach the DSM and diagnostic language as being useful rather than being a singular truth.

We also don’t limit the practice of diagnosing to those diagnoses officially recognized by the authors of the DSM. We can construct our own language and our own diagnoses if and when they add value to our work. We make the questions of “What’s going on with me” one to which the possible answers are much more vast than what the DSM includes, but also one that the patient and therapist can answer together. This allows for a more collaborative process rather than insisting that the therapist alone, by virtue of some training, knowledge or licensure, only has this power.

Simply put, we make stuff up. And in doing this, we drop the conceit that some made-up stuff (such as DSM diagnoses) is necessarily more powerful than other made-up stuff like the meaningful words we discover together in therapy that we decide have significance in helping a client understand and grow his or her life.