Diagnosis as Self-Understanding & Self-Alienation: what you need to know about your diagnosis

This article by Dr. Awais Aftab has been published on his Psychiatry at the Margins website. Although it’s very much open to question as to what extent the views expressed actually inform mainstream psychiatric practice, the article is nonetheless well worth reading. It begins:

“I have said before that almost everyone in the psy-disciplines (even psychiatry, yes) dislikes, disdains, disregards, or begrudgingly tolerates the DSM but they do so for wildly different reasons. This is understandable as different complaints exist in the context of different clinical, scientific, and social goals. One set of grievances that frequently comes up pertains to the allegedly pernicious influence of the DSM on how we relate to our own emotional lives. In particular, it is said to have alienated us from the nature of our psychological difficulties.

This line of thinking is expressed quite well by the psychoanalyst Nancy McWilliams in the article Diagnosis and Its Discontents: Reflections on Our Current Dilemma (2021):

“One interesting (and, to a therapist, somewhat disconcerting) side-effect of the 1980 change toward descriptive and categorical psychiatric diagnosis involves the ways people in Western cultures have begun talking about themselves since the DSM-III paradigm shift. It used to be that a socially avoidant woman would come for therapy saying something like, “I’m a painfully shy person, and I need help learning how to deal better with people in social situations.” Now a person with that concern is likely to tell me that she “has” social phobia – as if an alien affliction has invaded her otherwise problem-free subjective life. People talk about themselves in acronyms oddly dissociated from their lived experience: “my OCD,” “my eating disorder,” “my bipolar.” There is an odd estrangement from one’s sense of an agentic self, including one’s own behavior, body, emotional and spiritual life, and felt suffering, and consequently one’s possibilities for solving a problem. There is a passive quality in many individuals currently seeking therapy, as if they feel that the prototype for making an internal psychological change is to describe their symptoms to an expert and wait to be told what medicine to take, what exercises to do, or what self-help manual to read.

Mental health problems are listed in the DSM and similar classifications as if there is no narrative that holds together the kinds of difficulties a person reports. Experienced therapists tend to see connections between someone’s “having,” simultaneously, a personality disorder, a depression, an addiction, a post-traumatic symptom, and a self-harming behavior. Since we know from clinical experience and research on self-reflective function (e.g., Fonagy et al., 1991; Gabbard, 2005; Jurist & Slade, 2008; Müller et al., 2006) that the development of a personal narrative about the connections between one’s unique life experiences and one’s idiosyncratic psychology is a key element of mental health – so evident in its absence from the shattered mental life of many survivors of trauma – it is not hard to view our current psychiatric nomenclature as contributing to self-fragmentation rather than providing a means to heal it.”

I do think the phenomenon is real — this collective sense of estrangement, passivity, and hyponarrativity in the face of psychological afflictions. It would be, however, simplistic to lay the entire blame on the diagnostic manuals, tempting as it may be (not that McWilliams offers such a simplistic explanation). So what is going on here? …”

You can read more from here.

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