The Diagnostic and Statistical Manual is the primary reference catalog for mental health illnesses.
In the hit musical Next to Normal, a climactic scene portrays Diana Goodman, the lead female character, throwing out her bipolar medications, singing “I miss the mountains.”
The lyrics, written by Brian Yorkey for music by Tom Kitt, continue:
I miss the highs and lows,
All the climbing, all the falling,
All the while the wild wind blows,
Stinging you with snow
And soaking you with rain.
I miss the mountains,
I miss the pain.
I encourage you to find the song and listen, because it conveys—emotionally and intellectually—two powerful points.
First, it conveys the tragic bind many people with mental “disorders” face (you’ll see why I use scare quotes). Someone may be so troubled that they need to do something about it—it’s driving them to self-harm, damaging relationships, or even generating delusions. Yet the medications or other remedies that confront them dampen a genuine part of themselves, aspects of themselves they sometimes love. So do I medicate, or flush my pills down the toilet?
Second, the song—in the context of the musical as a whole—conveys the ominous homogenization within society that psychiatric medicine promotes. Do you get sadder than most people? Depressed. Do you make choices more spontaneously? Impulsive. Do you like your place exceptionally clean? OCD. To put the point starkly: the DSM is implicitly and by opposition an instruction manual for how to be “normal,” backed by the bewildering authority of “science” and the intimidating stare of men in white coats.
Psychiatrists, the DSM, and medications train us to be “normal” (or next to normal), just like everyone else. What is “normal” like? The song continues:
Everything is balanced here
And on an even keel.
Everything is perfect.
I want to focus on this second point—homogenization—and relate it to the idea of defining a mental “disorder” at all.
There are, broadly speaking, two aspects of the definition of any mental “disorder.” There is a descriptive aspect and a normative aspect.
The descriptive aspect identifies a psychological phenomenon. The idea of psychological phenomenon is broad, and many psychological phenomena are healthy and great. Others are neutral. An appetite for food is a psychological phenomenon, as is dreaming, as is seeing what’s in front of you. Psychological phenomena can be widespread or individual. They may be events in the mind, or pathways from causes in the environment to behaviors. Naturally, definitions of “disorders” should identify real psychological phenomena, as opposed to bogus ones. Otherwise put, being a psychological phenomenon is a necessary condition on being a disorder. Importantly, however, the notion of a psychological phenomenon by itself is non-judgmental.
But being a real psychological phenomenon is not sufficient for counting as a “disorder.” There also needs to be something wrong with the psychological phenomenon. This is the normative aspect. And this is where a major problem with definitions arises. By what standard should we adjudicate a psychological phenomenon—occurring in, say, you—as having something wrong with it?
John, Ken, and Jerome Wakefield explored two sorts of answer to this question in the show.
One sort of answer was social. For a psychological phenomenon to have something wrong with it, on this view, means that it is contrary to norms of society. This way of looking at the normative aspect of disorder, however, is disastrous, as John pointed out. It is perfectly possible for a society at a time and place to regard some mental phenomenon as “wrong” that is harmless and maybe even valuable to the individual. Being homosexual, highly creative, transgender, emotionally expressive and male, etc. have all been looked down upon by one or another society. Tying the notion of “disorder” to social norms simply gives an illusory appearance of scientific legitimacy to such judgmentalism.
But—to the present point—the social approach to defining the normative aspect of mental “disorders” also gives rise in spades to ominous homogenization. It says, in effect, you have a disorder if you’re mentally different. Or at least, if you’re different enough from what society expects. That’s a recipe for homogenization.
The other sort of answer was evolutionary. A psychological phenomenon has something wrong with it if it’s contrary to what’s evolutionarily adaptive—if it’s dysfunctional in the evolutionary sense of “function.” But this approach too leads to troubling consequences. That which is evolutionarily maladaptive may be what makes someone interesting, or even able to flourish in her present environment. Furthermore, if we tether our definitions of right and wrong, healthy and unhealthy, to evolutionary adaptation, we’ll tend to end up applying the same standards to all of us, thereby contributing (again) to homogenization.
Is there a better approach? I think there is.
Each individual has preferences, desires, goals, hopes, and dreams. But certain psychological phenomena within an individual may systematically undermine what she at a more fundamental level longs for. Obsessions and compulsions may undermine goals at work. Sadness may hinder relationships and thereby lead to a downward spiral of further sadness. Compulsive fears may undermine the social contact a person craves. And so on.
Importantly, such cases are cases where a psychological phenomenon does damage from the individual’s point of view.
Thus, we can approach defining the normative element of a “disorder” by taking the individual’s needs and interests as a starting point. This is a way of avoiding the problem of homogenization, since as we know, people are various in their needs and interests. It would also turn the DSM into a hypothetical set of “disorders,” scientifically valid (we hope!) on the descriptive aspect, but merely provisional on the normative, conditional on whether the individual is plagued given her own needs. Of course, an individual may need help seeing that she is in fact plagued, but that’s consistent with this approach.
An individual-relative approach would allow for more quirks and variations to be accepted in society. It would maybe allow for a few more mountains too.