It wasn’t until 1987 that homosexuality ceased being categorized as a disease in the DSM (the Diagnostic and Statistical Manual of Mental Disorders). Used as the premiere diagnostic bible by mental health professionals and insurance companies worldwide, the DSM has been predominately responsible for the labeling of an individual’s behavior as regards whether it falls within the range of agreed-upon norms. As such, it’s been both praised and reviled over the years. Praised because of its concise descriptions and categorizations of behavioral symptoms, and reviled because of its reinforcement of stigmatizing attitudes towards those whose behavioral is deemed “abnormal.”
In fact, there’s an old joke about how clinicians use diagnostic labels to interpret their patients’ behavior. If the patient arrives early for his therapy appointment, he’s anxious. If he’s late, he’s resistant. And if he’s on time, he’s compulsive.
Nowadays, however, it’s becoming clear that the joke may be on us. Due to the influence of both broadcast media and the Internet, diagnostic labels are thrown around quite casually by people who ought to know better (shrinks on TV news programs) as well as by people who usually don’t (hosts of TV talk shows, Internet podcasts and innumerable blogs). Moreover, like many cultural phenomena, the ascribing of diagnostic labels follows the dictates of trends. Remember how every other child was diagnosed with ADHD (Attention Deficit Hyperactivity Disorder)? Now the “hot” new label is bipolar disorder (what used to be called manic-depression). Lately, you’re not cool if you’re not bipolar.
To be fair, there’s some good that has resulted from this expanding conversation about diagnostic labels. Case in point: I was recently on a panel with a successful businesswoman who claimed that until she’d been diagnosed with bipolar disorder, she didn’t have a frame of reference for her inexplicably erratic and self-destructive behaviors. Further, she felt that having the diagnosis, and receiving the appropriate treatment to address it, was what saved her life.
I completely understand her position. I myself have patients who are calmed and even reassured by a diagnosis that aligns them with others suffering the same symptoms. They feel less alone, less alienated from how “normal” people behave. In other words, they have a “handle” on it.
However, my concern is not with how these patients see themselves. It’s with how clinicians see their patients. How so many mental health professionals use diagnostic labels to both distance themselves from patients and reduce them to a set of conventionally agreed-upon symptoms. (At a clinical conference years ago, a colleague, describing his practice, said, “It’s a nice balance. I have three bipolars, a number of major depressives, and only one borderline. Thank God.”) Obviously he didn’t see these folks as patients. Hell, he didn’t see them as people. He saw them solely in terms of their clinical diagnoses.
Now I suspect (and greatly hope) that this particular therapist’s attitude isn’t shared by most of his colleagues. Yet his comment goes directly to my point. Namely, that while I don’t exactly revile the DSM, I view its contents (and the thinking behind it) with a great deal of skepticism. Not that there’s anything wrong, per se, with labels. Nor with the idea of a common vocabulary so that all us clinical geniuses can communicate with each other. It’s just that, if we’re speaking honestly, diagnostic labels exist for the convenience of the labelers. Which is fine, as far as it goes. But how far is too far?
In my opinion, “too far” is when labeling ventures into the arena of individual freedom; i.e., when it threatens the concept of equality. How does it do this? By giving clinicians the language to reinforce the views of the dominant culture.
To me, equality means just that: all people are equal under the law, and in relation to each other. Regardless---as the saying goes---of race, creed, or color. To which I’d add sexual orientation, political beliefs, gender identification, and choice of living singly or with a partner. (This last point is crucial. One of the dominant culture’s norms is that healthy people are in a relationship, or, if not, yearn to be. And that preferring to live alone, or under the same roof with others but without romantic attachment, is a sign of psychological disturbance.)
Equality means the right to be what the British lovingly refer to as “eccentric.” Equality means that thinking and living differently than how most others do is not a manifestation of anti-social behavior. Nor is it a silent condemnation of those living a more conventional life. In simplest terms, I’m saying that true equality means that a hermit living in a cabin in the woods is not necessarily suffering from a mental disorder (i.e., schizoid personality, with paranoid features). I’m not claiming he or she is not burdened by psychological distress. I’m just saying that such a lifestyle choice doesn’t in and of itself indicate a disorder. No more than it would a long-distance trucker who prefers his or her own company for weeks at a time.
If we’re to truly support and encourage equality, then we have to be skeptical of our inclination to label. And it’s not just mental health professionals who fall prey to this. We all do, to some extent. If a family member isn’t as ambitious as we think he or she should be, we label it laziness. If a friend finds the holidays so disturbing and anxiety-producing he spends each Christmas season in a tent out in the desert, we label him weird. I’ve even heard couples who choose not to have children labeled as selfish.
As a therapist in private practice for over 25 years, I’ve grown to appreciate the vast differences in temperament, relationship choices, communication styles and even prejudices of my patients. Which means I’ve been forced many times to challenge the orthodoxy of my own profession, and to pay attention to the potential inequality underlying certain therapeutic assumptions.
In the world outside my consulting room, it seems that the more lip-service is given to the notion of equality, the less actual practice of it there is. As a nation and as a global community, we’re more divided than ever. Our politics have become almost nothing but labeling, a divisiveness that strikes at the heart of equality. Sectarian violence around the world is a tangible result of one group of people denying the equality of another group. Rather than a reaffirmation of Buber’s “I and Thou”---a relationship that can only exist in a context of equality---people from all walks of life are asserting that their rights, opinions and beliefs have ascendance over those of others.
Put bluntly, to label is to divide. To divide is to upend equality. And without a basic sense of equality, there can never be the kind of social and cultural adhesion that ensures what our Founding Fathers called “domestic tranquility.” This is not to posit some Utopian love-fest among all peoples. That will never occur. But I’m thinking more in line with something that the late Martin Luther King said: “Peace is not the absence of conflict; it’s the presence of justice.”
If we as a people are to maintain the presence of justice in our society, then we have to view our differences through the lens of equality rather than that of labels. To label this individual as “bad” and some other individual as “good,” based on their respective beliefs, sexual orientation or lifestyles, is to render the former a non-person. And it is much easier to abuse, threaten, even kill a non-person than someone you feel has an equal right to exist.
Of course, reaffirming that all people are equal isn’t to say that all behaviors are equal. As a society, we have a right to label certain harmful or exploitive behaviors as unacceptable. Just as we have a right as a society to determine how to bring to justice those who exhibit those behaviors.
But what I’m referring to is something else. It’s the temptation each of us has to judge another, merely against the standards of conventional society or measured against our own idiosyncratic standards. To deny others’ equality as an existential right because we dislike their religious faith (or lack thereof), are offended by their choice of sexual partners, or reject their own stated gender identity.
As human beings with prejudices and insecurities (conscious or unconscious), we may be made uncomfortable by one or another of these life choices. We may even find them a sign that civilization is crumbling, or that every diverse or otherwise unconventional choice is an assault on “traditional values.” But that still does not rationalize inequality. Nothing does. Especially not knee-jerk appeals to religious freedom, patriotism and xenophobia.
Which brings me back to the DSM, and how stunningly reductionist it can be when it comes to providing diagnostic labels. The general public may be unaware of the fact that, prior to the publication of each new addition to the manual, mental health professionals can suggest new diagnostic categories to be added to the list. One of my recent favorite suggestions is quite in line with the constraints on freedom and equality that I’ve been addressing.
Called “Political Apathy Disorder,” this new diagnostic label was to be given to individuals lacking an appropriate sense of social justice. Among the criteria to be used when giving a patient this diagnosis are whether he or she lives in a gated community, fails to take into account the impact on the environment of a purchase, and refuses to vote in local elections. Believe me, I’m generally not a fan of people who exhibit these traits, but I’d never go so far as to label them evidence of a psychological disorder. To me, this is just labeling---or in this case, social engineering---to a disturbing degree.
In fact, a colleague of mine, Dr. David Levy, once wrote a satiric essay in which he proposed a new diagnostic category especially for mental health professionals. It was called “Pervasive Labeling Disorder.” I can think of at least a few fellow therapists who seem to suffer from it.
The sad fact is, I think we’re all guilty at times of “Pervasive Labeling Disorder.” As I mentioned above, it might even be woven into our very natures as humans. Regardless, labeling is a potential enemy of equality. And we do so at our peril.
As Benjamin Franklin once said, “Liberty is the one thing you cannot have without giving it to everyone else.”
(This essay appears in a new collection called EQUALITY, from Vine Leaf Press)
Formerly a Hollywood screenwriter (My Favorite Year; Welcome Back, Kotter, etc.), Dennis Palumbo is now a licensed psychotherapist and author of Writing From the Inside Out (John Wiley). His work has been profiled in The New York Times, The Los Angeles Times, GQ and other publications, as well as on CNN, NPR and PBS.
His mystery fiction has appeared in Ellery Queen’s Mystery Magazine, The Strand and elsewhere, and is collected in From Crime to Crime (Tallfellow Press). His acclaimed series of crime novels (Mirror Image, Fever Dream, Night Terrors and the latest, Phantom Limb) feature psychologist Daniel Rinaldi, a trauma expert who consults with the Pittsburgh Police. All are from Poisoned Pen Press.
For more info, please visit www.dennispalumbo.com