Does the DSM System Perpetuate the Stigma of Mental Illness?

In a recent conversation with a group of pediatrician colleagues, we bemoaned the lack of access to good therapy for our child patients and their families. One wisely observed that until we integrate mental health care into primary care , we will continue to have this problem. He went on to point out how the direct result of this lack of access to care is prescribing of medication to children without offering opportunity for listening and understanding. I agreed wholeheartedly, calling attention, as I do in my forthcoming book, to the way vast income disparity for professionals who offer this kind of listening has a big role to play in perpetuating this shortage of quality care.

But he went on to say that, as part of the solution, we should view DSM defined mental disorders as medical problems that are no different from any other medical problems.

Here I identified a paradox. On the one hand, we are calling for time and space for listening, for healing through human relationships that good therapy can offer. But the DSM 5 gives the illusion that mental health problems are, in the words of Andrew Solomon in his book The Noonday Demon, "single-effect illnesses." None of the named DSM disorders are known specific biological processes, but rather represent collections of "symptoms" or behaviors that tend to go together. 

I would argue that under the influence of the health insurance and pharmaceutical industries, DSM 5 is part of the problem, rather than the solution.   The DSM 5 can have the opposite effect of what we are calling for, because a single effect illness can be treated with a drug alone. By emphasizing the value of listening in healing, we are calling for recognition of the intricate interplay of biology and environment, and the complex relationship among brain, mind, feelings, and behavior. 

When we invoke the DSM 5 in this way, it is with well-meaning effort both to de-stigmatize mental illness and to obtain parity, or equal pay, for mental health care. But we may inadvertently be getting in our own way with this approach. When we compare, for example, depression and diabetes, we may in fact devalue the complexity of human experience. Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. Unlike the brain, the pancreas has no corresponding mind with thoughts and feelings. The pancreas does not love. It does not grieve, nor does it produce great literature.

A recent study identifying the important role of psychotherapy in treatment of schizophrenia, one that received great media attention, seemed to give an infusion of life to the notion that listening is healing. However, as psychoanalyst Todd Essig points out in his Forbes article on the subject, the stigma of talk therapy is prominent both in the media coverage and in the study itself. He writes:

Therefore, it was a big media surprise that people who suffer a psychotic illness benefit from the support and hope that comes from a therapeutic relationship with a knowledgeable, non-judgmental and empathic other. What’s tragic is we needed to spend millions of dollars on an NIMH study to re-discover this. It should have remained clinical common sense.

Before we look to the DSM, and rush to equate of “mental illness” with “physical illness” we as a culture must first and foremost return to a recognition of the healing power of human connection. We need to value -both culturally and monetarily- time spent listening. If this step does not come first, we may be sabotaging our own efforts.

In another conversation with a colleague who is a family practitioner, she spoke of the need for this kind of listening for all of her patients, including those who present with what is thought to be a purely “physical” illness. Underlying these symptoms is often complex emotional pain that can only be healed when we offer time to hear the full story.

Maybe what is called for is the mirror image of what my pediatrician colleague expressed. Perhaps rather than equating mental illness with physical illness, we need to recognize that all suffering has some emotional basis, and that relationships are central to all healing.

The DSM system may have some role to play. It offers clinicians opportunity to communicate, to know that they are talking about similar sets of behaviors. But in our current system of health care, without renewed value placed on listening, using it to equate physical and mental illness may serve only to stigmatize our humanity.