Abnormal? Unusual? Who Decides?

By Christine LaCerva

There is a fight going on in psychology. And we — the staff of the Social Therapy Group —  want you to know about it.

I’m talking about the controversy surrounding diagnostic labeling of patients in the field of mental health. It’s a national fight, in response to “DSM-5,” the American Psychiatric Association’s upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, and it’s currently being fought by progressive practitioners and the various professional organizations they belong to.

DSM-5 is the official manual of characteristics used to define emotional illnesses and make the diagnoses that mental health practitioners must give patients in order to be reimbursed by insurance companies, and/or to prescribe the medications that you or your children might need. The new edition makes many changes to the criteria for various diagnoses, and there has been a level of professional and public reaction rarely seen in the hidden corridors of the mental health field.

This controversy is of great interest to us at the Social Therapy Group. As you may know, social therapy is a radically humanistic, non-diagnostic group therapy. Social therapy is explicitly pro-development and explicitly anti-label.  My close friend and colleague Lois Holzman, director of the East Side Institute, has written passionately and eloquently about these issues (click here for one of her blog posts on the subject). As Dr. Holzman points out, controlling and defining diagnosis is nothing less than a turf war, as official organizations fight for (more than) their slice of the treatment pie. It’s a big, lucrative pie, and getting bigger all the time as more and more people suffer the emotional ravages of living in a society that increasingly fails to provide for the needs of ordinary people.

For years, along with many other progressive practitioners and postmodern social scientists, the Social Therapy Group has spoken out against the inhumanity of diagnosis-driven mental health treatment, which we think is pseudo-scientific labeling that can greatly affect a patient‘s well-being. For children, there’s a particular danger — diagnostic labels can track them down a road that’s very difficult to reorganize. In social therapy our work with families and children has helped many children grow beyond their labels. But their families have to work incredibly hard to get them declassified — that is, out of special education and with the diagnosis removed. Many schools will not accept children with a prior diagnosis, regardless of any progress they have made!

But as disturbing as the impact of specific diagnoses can be, there’s an area of this controversy that’s even more important to me. In a recent article in the New York Times reporting on the fight around DSM-5, the author poses what he sees as the central question of this debate: “where to draw the line between unusual and abnormal.”

I find that question offensive. How did it become the question in the first place? What kind of descriptions of human beings are these?

For us at the Social Therapy Group, the central question is why diagnose at all?  I mean this in no way as a denial of mental illness — depression, anxiety and many other extreme and painful emotional experiences are real, and affect millions. But who benefits from diagnosing them?

Diagnostic categories are not benign. They have a long, turbulent and well-documented history in this country that exposes and clarifies the many ways in which diagnosis shapes our world. We can look back to the 1950s and ’60s, when large numbers of African American children were diagnosed as “mentally retarded” while their white, middle-class counterparts with the same challenges got the more acceptable diagnosis of being “learning disabled.” Today, many critics of DSM-5 point out that these categories that shape peoples’ lives are heavily over-determined by government funding and partnerships with pharmaceutical companies. No, diagnostic categories are not neutral. They are social/political phenomena and function as methods of social control, determining who receives benefits and who doesn’t; who gets the “socially acceptable” label and who doesn’t.

In my experience as a clinician, diagnoses can be stigmatizing; at the very least they over-determine how people feel about themselves. When I ask children I work with if they have been given a diagnosis (they often have) I ask what it is, and what they think it says about them. Often, in a variety of ways, they answer that their brain is broken. What follows, of course, is their understanding that only medication can impact on what is happening to them — whether it’s Attention Deficit Hyperactivity Disorder (ADHD) or Pervasive Developmental Delay, these children learn that they are helpless.

Abnormal? Unusual? Who gets to decide?

I think that rather than focusing on changes in definitions and spending untold millions of dollars coming up with the “right” kind of label, mental health professionals could  consider doing more of what the Social Therapy Group does: working together with diverse groupings of adults, families, therapists and young people themselves, to create new solutions that will help all of us — unusual and usual — to grow, create our lives, and develop as creative, productive citizens of our communities.

I want to know what you think about all this. The issue of diagnosis is a sensitive one. Many people have felt relieved to have a name given to their painful human experience. Others feel that getting help to grow and develop is what’s primary. We want to know what you think about this controversy and the questions we are raising. Let us know where you stand — we'd love to hear from you, so please leave a comment below.