DSM-5: The new normal?

It’s the year 2063. A New Yorker article titled “The Last Normal Person in the United States” highlights the life of a certain E. Piphany. As far as experts know, she is the last living person not found to be diagnosable by the recently released DSM-9. Amazingly, she alone does not fall into one of the 5,146 conditions currently described in the DSM.¹ Which, ironically, makes her quite abnormal . . .

OK, I admit I’m being a bit snarky. No one, least of all thoughtful and caring psychiatrists, wants the trend of multiplying diagnoses to continue to this hypothetical endpoint. In fact, the fifth edition of the DSM unveiled last week contains a few less diagnoses than its predecessor. But the release of the DSM-5 after more than a decade of debates and revisions still pushes us to ask hard questions.

• Why are more and more people receiving psychiatric diagnoses?
• What is the best way to understand and classify disordered thoughts, emotions, and behaviors?
• Does having a diagnosis equate to a malfunctioning brain?
• How can we wisely and compassionately care for those who are truly suffering?

Even insiders within the psychiatric community have raised concerns about over-diagnosis and the way we classify mental disorders. See for example the recently released Saving Normal, by Dr. Allen Frances, who chaired the Task Force that created the DSM-IV. The subtitle says it all: “an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life.”

What I hope to do in this post is to briefly orient readers on how to think about psychiatric diagnoses and what role they should, and should not play, in biblical counseling.

DSM categories are descriptions not explanations

It’s important to remember that psychiatric diagnoses are descriptions of a struggling person’s thoughts, emotions, and behaviors; they are not explanations for them. They tell you what but not why. The DSM admits that. So what’s the problem? What’s wrong with giving a name to a set of symptoms? Isn’t that generally how the diagnostic system has historically evolved?

The problem is this: giving a summary label to a set of symptoms gives the appearance of explanation, particularly in our medicalized culture. It suggests that each diagnosis is a discrete and largely brain-determined entity, and there is simply little evidence for that except in the major psychiatric categories of schizophrenia, bipolar disorder, and severe depression. Even in these entities, we must realize the complex interaction of multiple factors.

Knowing that these categories are primarily descriptive (and not definitive explanations) should reduce any intimidation biblical counselors might feel about them. Don’t be scared off by a diagnosis! Don’t assume that you can’t provide what the person really needs. It may be important in certain cases to involve others, including psychiatrists, in the care of your counselees. But you can do the hard work of pressing beyond the symptoms to explore a variety of potential contributors to the person’s struggle. Spiritual, physical, relational, situational, and cultural factors are all important to probe and address. Doing so will help prevent the uniqueness of individuals from being swallowed up by a clinical description.

Descriptions can be helpful

On the other hand, do not simply dismiss the diagnostic entities in the DSM as invalid. Realize that they describe a subset of people who are struggling in real ways. Don’t allow a critique of the DSM to become a critique of the suffering people described in its pages! Rather, listen and learn—from your counselees—and from those in the psychiatric community who are “case-wise” and have devoted their lives to helping people who struggle in very particular ways.

But then, prayerfully seek to interpret people’s lives through the pages of Scripture. If it’s true that Jesus comes to make his blessings known “far as the curse is found,” then we need to wrestle with what the outworking of redemption looks like in concrete ways in the lives of those who struggle with psychiatric problems.

The current description-based system of psychiatric classification seems to be here to stay, at least for the foreseeable future. The DSM-5 gives no epiphanies from the secular mental health community, which is still at loggerheads regarding how best to classify psychiatric problems. We Christians must remain intent on faithfully and creatively bringing the riches of redemption in Christ to the people before us, whether diagnosable or not.