Gary Greenberg on the DSM and Its Woes

Gary Greenberg: Well, I actually didn't decide. I was happily ignoring the whole thing and knew what any person scanning The New York Times would have known until I got a phone call from Wired magazine asking me if there was something about the DSM that might be worth their while. At the time I was sort of aware that there was this rebellion at the top within the American Psychiatric Association—that the guys who had done the DSM-III and the DSM-IV were really unhappy about the DSM 5—and so I started looking into it and realized that their complaints were really about the nature of psychiatric diagnosis. That interested me and I told the magazine I would write the article. I've been thinking and living in this whole set of questions for many years, and it didn't seem all that remarkable to me, but the reaction I got from people who I thought would have also seen it as old hat was pretty strong, so the decision that I made wasn't to go out after the story, but having gone after the story I decided to feed the curiosity of the people who responded to it. In particular because everybody grouches about the DSM.

GG: Nobody likes the DSM, including, for the most part, the psychiatrists who author it—but also therapists, clinicians, researchers and academics too. And when you look into what people object to, a lot of their objections are—I don't want to sound haughty—but they're uninformed. There's an understandable, and for the most part accurate, instinctual objection to the whole idea of it. So I thought it would be interesting to do with the DSM something like what I did with Manufacturing Depression, which was to explore it as an instance of a problematic mental health culture.

GG: Whether it’s correct or not, in medicine real entities are those that have a biological basis, where you can find the causes and the boundaries of a disease through biochemical means, whether that's by culturing tissue, or looking under a microscope, or doing a blood test, or whatever it is you do. The problem with mental illness, or with psychological suffering in general, is that it's very difficult to come up with those biochemical assays. In fact, I shouldn't say, “very difficult,” but rather, “at this point, impossible.”

GG: Mostly because the brain is so seemingly infinitely complex and the tools that we have for understanding it are comparatively crude. And if you pay attention to neuroscience, the field changes dramatically all the time. It's a moving target.

So you don't really have the basis for understanding mental illness in terms of real entities in that respect. On the other hand, for many different reasons, there is a strong need to have those entities. From the political and ideological having to do with the authority of medicine, right to the most practical having to do with how society decides to ration its health care resources, and everything in between. The way that psychiatry has bridged that gap is by using the rhetoric of science to create a DSM without ever being able to say that those scientific sounding categories are truly scientific. In other words, you can create the construct and then build all sorts of science around it.

GG: Right. But so does schizophrenia. And this is a problem with all ideologies. If you accept their basic premise, then everything else makes sense. In scientific methodology this is known as the validity problem. None of the categories in the DSM are valid, and that becomes a problem particularly because once you use that rhetoric it is inevitable, inescapable, that the categories will become reified, meaning that people will take them as real, and they'll use them as real, and they will become the basis for all sorts of political, economic, and individual decisions based on their reality.

One of the things that you find when you talk to the people who make the DSM is they're all really smart—well most of them are really smart people—and they're quite capable of understanding and appreciating the problem that we're talking about. But they have trouble taking account of the fact that the reification is a problem for everyone, not just for the professionals.

GG: In other words, they're happy to say to you, “Yeah, I understand that. We all know these are just constructs,” as if their knowing it is enough. But what that really means is that they don't want everybody else to know.

GG: Right. It's the problem of the noble lie. Actually, I think that the best example isn't really the noble lie as Plato saw it, because that's a more complex topic. It’s more like what the Grand Inquisitor presents to Ivan Karamazov [from Dostoevsky's The Brothers Karamozov], which is that, “We in the Grand Inquisitors coterie, we know this stuff and nobody else needs to know, and in fact we're using our knowledge to help people.” That's exactly the pitch that the Grand Inquisitor uses to justify what he's doing to Ivan Karamazov.

GG: Of course. Power unquestioned is always a problem, and the problem is always damaging to the people that don't have it.

GG: I think that's an interesting point. I think that's true. I don't think any of that is particularly conscious. I imagine that’s why I chose these professions—they both try to unearth power relations in one way or another, and claim, anyway, that that's the truth that they're uncovering.

GG: In what way?

GG: Well, the only direct approach I make to that question is my critique of cognitive-behavioral therapy.

GG: Do I have to?

GG: Cognitive-behavioral therapy is an ideology of optimism that is used by therapists to induct people into a more genial understanding of their lives and their circumstances. It's in some ways the diabolical twin brother of Freudian psychoanalysis, in that it trades on optimism rather than pessimism. CBT believes in the perfectibility of the human as opposed to the depravity of the human. It posits, without saying so, a benevolent universe, which is the opposite of what Freud thought.

GG: Well, piety is a problem. Ask the people at Charlie Hebdo. If power is the general preoccupation of my books, piousness is the specific preoccupation. Unquestioned belief. For all of his problems at the granular level, at the macro level Freud was the master of ambivalence and uncertainty, and I think that there is a connection to be drawn between understanding life as infinitely uncertain—at least mental life—and the tragic sensibility. I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life. So, to get back to your original question, why do I go easy on psychotherapy? Well, this is one way that I don’t go easy on it and, as you and I both know, CBT is the dominant theme of psychotherapy in this country right now.

GG: It links in with the evidence based therapy thing, which bleeds over into my second criticism of psychotherapy, which is that we're way too tied in to medicine. Regardless of what we individually, or even as institutions, believe about psychiatric drugs, that's not the issue. The issue is how do we get paid and how do we get our status and authority in society? When I pick up the phone and I call somebody and then say, “Hey, this is Dr. Greenberg,” I get a different response than I would if I called up and said, “Hey, this is Gary Greenberg.” I'm not averse to using that power, but I'm implicated in a whole web that I shouldn't be. That critique shows up in both of my books, where I repeatedly question the whole business of psychotherapy.

GG: Well, you've got to make a living.

GG: We're all doing it. You make your accommodation with it however you can. The problem, when it comes to the DSM and to the medical-model aspect of our practice is that it is so at odds with what we purport to do. If you start your therapy by giving a person a diagnosis that you don't believe in, there's no way that you can't see that as a contradiction of the terms of psychotherapy, because it's dishonest.

GG: Well, I don't know about the DSM, but I do know about the larger rhetoric of mental illness. The DSM is just the most obvious example. I believe that as symptoms get more severe, and as impairments get more severe, the justification for using the rhetoric becomes greater, because it is a rhetoric that is quite effective. For instance, the rhetoric would say, “Schizophrenia is a biological brain-based illness that is just the luck of the draw. Maybe you had some stressors, but you definitely had this serious predisposition and your brain's all fucked up and now you're going to have to manage this all your life. And the best way to manage it is with Geodon.” Or you can go farther with that. You can say to somebody, “You have to take responsibility for you who you are, just like I do. And who you are happens to be somebody with this vulnerability, and that means keeping yourself in situations that aren't likely to kindle your psychosis. It means recognizing the prodromal nature of it. It means taking medications when it seems to be necessary to keep you and the people around you safe.”

That whole rhetoric is very helpful. I believe at some point it makes sense. And I even would go farther and say that there are some psychiatric illnesses, mood disorders, certainly the autism spectrum, that really are the luck of the draw, in the same sense that type 1 juvenile diabetes is. So the best we're going to do is help you cope. And I think that the rhetoric is useful there.

The problem is that that's the model for everybody, and we have no way of determining who it is that we should consider that way and who we shouldn't. It's like not knowing the difference between who's got type 1 diabetes and who should just eat less sugar, and just treating them all the same way. That's a problem. And it's not a problem that's been intentionally created by psychiatrists. I'm not a Scientologist. I don't believe that that's what's happened here. But I do think that because of its blindness to its power—and I do hold psychiatry more responsible than the rest of us because you and I are just living off of their crumbs when it comes to this stuff—psychiatrists have failed to make those distinctions, have failed to start with the assumption that only a small minority of people who are suffering with mental illness, even severe mental illness, have that classic disease structure. Now it’s reasonable to say, “Let’s err on the side of caution.” We’re talking about serious stuff here, and it's a useful model.

GG: I just had a patient go into the hospital because she was sure that laser beams were doing something to her bones. She was a howling, psychotic mess. She's in the hospital and I'm really hoping that one of the psychiatric drugs that they throw at her will work, because her brain's on fire. It’s a useful way to look at it in this instance.

GG: Yes, but do we know when we should and when we shouldn't? Absolutely not. But to get back to your patient who came in with the bipolar diagnosis, you took out the DSM and then what? You never finished the story. Did you then get them to tell their history of manic episodes?

GG: Yes! Now was this bipolar 1 or bipolar 2?

GG: So my guess is, if somebody shows up in your office and they're basically okay, and they tell you they just got diagnosed with bipolar and you're thinking, “What?!” chances are that person is going to qualify for the bipolar 2 diagnosis.

GG: It only requires hypo-manic episodes. And so what you have there is the diagnostic creep that I just outlined. That diagnosis just arrived in 1994. I don't know how long you've been in practice, but I've been in practice for a long time and I remember when these people started showing up in my office with their diagnoses and their anti-psychotics and their stabilizing drugs. All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?” I think there's cases where that's a totally useful and justified approach, and I think there's cases where it isn't, and that's where all the trouble lies.

GG: It's not quite that conspiratorial. In the case of depression and antidepressants and neurotransmitters, it’s like strands of a braid that came together advantageously for some patients, and many doctors, and most of all for the pharmaceutical industry, which was brilliant, clever, and lucky.

I guess that's a little cynical. I have to be fair, the cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit. They knew that it was wrong, and then they did tone down the rhetoric to some extent in their advertising. The consumer advertising started right around the same time that scientifically the serotonin myth fell apart, the late 90s, but you wouldn't know that to look at the ads. That, to me, was their most egregious move.

GG: Exactly. They knew that if you could sell it as that kind of disease, it was so overdetermined that it would succeed and they could not resist it. You would have to be some kind of Boddhisattva of advertising to resist that temptation.

GG: Right. Now you say you just came across that. You're an intelligent, well-educated person with a PhD, right?

GG: There's two ways to look at that question of why. One of them is, do we know neurochemically what's going on and what, if any, deleterious consequences there are? And the answer to that question is no.

GG: We know that you're increasing the activity at certain receptor sites, including some of the serotonin receptor sites, although these drugs aren't as precise as they are sold as. And we know that serotonin appears to be associated with increase in neurogenesis. And we know that at really high doses you can see the axonal growth that appears to be the direct result of increased serotonin activity. So there's all these things that we know, but why that changes a person's mood...

GG: Right. In order to know that you would have to have an account of how the brain produces consciousness, and good luck with that, because that's just not going to happen. So what you're left with is to say, “Okay, well this drug makes me feel better.” And I don't mean that necessarily in the same way that smoking a joint or whatever makes you feel better. It just makes you feel better, and it works, and it doesn't hurt my life in any other way, and I'm going to take it. To me, anyway, the only problem I have with that approach is the same as with any drug. It's like, “Okay, well, am I hurting myself in any way?” It's the same question I have about vaporizing nicotine. Obviously, the reason that that's become controversial isn't because we know that it's bad for you.

GG: No, I think it's because we are an anti-drug society, and it just makes it really clear what's going on in smoking cigarettes. People don't smoke cigarettes to get cancer. They smoke cigarettes to get high, and the vaporizer just eliminates the middleman and delivers to people the drug that they want. And in our society, unless you're on antidepressants, or happen to be addicted to caffeine or alcohol, you can't just openly say, “I'm going to do this in order to change my consciousness.”

So I think that the controversy arises because of that, and then it is also true that we don't really know the long-term effects of using nicotine—although we know enough to know that it is not carcinogenic.

GG: Right.

GG: The way you do with anything that you're wondering about. You just take it as it is. You support it. “Okay. So, tell me about it.” Of course, people aren't stupid, and they tend to expect, particularly from me because of my relatively high profile, that I will disapprove. So I have to spend a little time reminding them that I really don't disapprove. If they actually read what I wrote, as opposed to listening to what people say about it, they would know that. You have to start by letting them know that, for the most part anyway, it's cool with me if this is what you decide to do. But one of the hallmarks of being mature and self-possessed is recognizing that you can't have it both ways. If you want to be on drugs, you've got be on drugs, and live with whatever that means to you and with whatever the implications are. And among the things that it means to be on antidepressants, particularly long-term, is struggling with the question of what's you and what's the drug. People have these severe doubts about their functioning and about their success. There's a whole version of the imposter syndrome that goes along with being on long term antidepressants.

GG: What does that mean?

GG: No, I’m saying that I’m sure there are situations, brains, people who certainly qualify. Let's say that the ability to feel depression as it's described in the DSM is heterogeneous—in other words, there are many ways to get there, both existentially and biochemically. I'm sure that's true. And let's say that some subgroup of people who qualify for the diagnosis—which is insanely broad—

GG: —nine symptoms, five of which qualify you; there's 125 different combinations to be depressed, just for starters. But let’s say some subgroup of the people that qualify are suffering from some identifiable biological fuck up, some hiccup somewhere. Or maybe more than one. And it wouldn't matter what their circumstances were, once the depression was kindled, they're screwed. Again, I don't know who they are. Nobody knows who those people are. In the meantime, the presumption is that everybody is. And that's the problem.

GG: Yes. And I also think that the question of, “Is it an illness? Is it real?” is, in some respects, a red herring. Because why are you asking the question? What is the importance of that question?

GG: Why does it matter to know that it is or it isn't?

GG: So the reason that you're asking the question is because you see certain shortcomings, at least potential shortcomings, to understanding it as an illness.

GG: The advantage of seeing it as an illness is that certain social resources become available to you if you see it that way. Drugs, medical care, sympathy, understanding, none of which is to be sneezed at. It's notable that one of the major ways of getting social resources in our society is to be sick.

But there are also disadvantages, as you just pointed out. If you see yourself as sick then you act sick, and if you're sick you're less empowered, maybe you're less active, maybe you take less responsibility for yourself. You cited an extraordinary example, but you're certainly not going to do that if what you decided to do is to live the life of a blind person. So, yes, there's something liberatory about it which is much more likely to be achieved if we understand illness as a contingence category as opposed to an absolute category. As something human-made as opposed to something scientific and medical.

GG: Well, I think to start with, there's lots of psychologists like yourself who are appalled at that outcome, so it's pretty clear that it's not a necessary outcome. There are even psychologists who don't buy Marty Seligman's self-serving excuses for his own implication in these things. That conference that I wrote about in Harper’s took place in 2009 and the issue was still alive at the time, and Seligman had some very greasy responses to those questions.

GG: But there are people who don't buy it and who are critical when these discoveries are made. But, having said that, I think your point is well taken. There is a kind of wish among all the medical health disciplines to be on the inside rather than on the outside. And whether you're on the inside by virtue of having a professional license or by virtue of having the authority to declare people mentally ill, or to get services for kids through special education, or to help the military figure out how to make soldiers resilient, I think this desire to be considered an insider can be problematic. And that in itself is complicated because sometimes it's simply wanting to make a living, or to make a decent living. Obviously, if we didn't have our professional licenses then we probably wouldn't make as much money as we do. If we didn't have our ability to bill insurance companies or, in my case, help people get reimbursed, then we would make less money. So some of it is just about that, but a lot of it is about wanting to be in the mainstream, because, like I said earlier, you can't have it both ways. If you're not in the mainstream, there are some severe prices to be paid.

GG: I have one foot in each world. Yes, I feel like an outsider in the sense that there's lots of things that I don't do that I would do if I wanted to be on the inside, like joining insurance panels and stuff like that. I probably feel better about that than I ought to though because it's not that important. It does restrict my access in some ways, but mostly what it does is restrict my income.

GG: Yes. But I'm clearly an insider in the sense that I described before. I pick up the phone and say, “This is Dr. Greenberg,” then I get somewhere on the phone tree.

GG: No. I do it totally straightforwardly, because I'm just trying to be effective and that is the way you're effective. These questions can come down to a kind of moral anorexia—a sort of refusal to take in the goodies that are out there because we all know they're tainted. I think that in some ways you've got to be fair to yourself and to others and say that the life lived entirely outside is very, very difficult and in some ways less effective. There are people who I have helped not by virtue of my education, or my training, or my insider-ness, or my license. It is something inherent to those that have allowed me to help them, but my availability to them, even if it's not about money, just the fact that I'm out there and legally practice my trade, just the fact that I'm available to them is what made it possible for me to help them.

GG: In both of the books that we've been talking about, I write a little bit about my actual practice, but I hate doing it. I would not be disappointed if I never did it again. I don't know if that's a principled stand—I just don't like doing it. I think it's really hard. I don't know if you ever saw the TV series “In Treatment.”

GG: That was the most realistic handling of psychotherapy ever, that I've seen, in the mass media—and it was boring. Nothing happens. I mean, it's okay with me, I was interested in it, but I don't think it did well because it's just day-to-day what goes on in therapy. It's really hard to write about. There are some people who can pull it off nicely, like Irvin Yalom, but for me anyway, the person that I am as a therapist is not someone that I want to write about.

GG: If someone comes into my office for therapy, I feel like it's a total breach to write about them, even if I ask for permission. Even if I disguise them. That's how I feel about it, having done it now a few times. The Book of Woe went through a very, very extensive legal review and the case material was altered to the point that it was no longer factual. It was really fiction, and if I'm going to write fiction I should write fiction. I really believe that. I don't know that a reporter has any obligation, or even ability, to be objective, but to intentionally make shit up? If you’re going to make it up, make it up. If you're not going to make it up, don't. And if you can't write about it without making it up, don't write about it.

GG: I guess so. I never really thought about that. No, I would say it’s the other way around. I have to forget about my writer self when I'm doing therapy. I can't really think about myself as a writer when I'm working with people. Once in a while something so fascinating occurs, so remarkable that you picture yourself writing about it, but in general therapy is something that I go and I do, and it's a performance—and I don't mean that in a cynical way—it's a thing that I do. But the writing draws on all of me in a way that the therapy doesn't.

GG: I guess so. I never really thought about it before. There's something that I do as a therapist—there's a way that you use yourself, and all of you has to be available to yourself. But you also as a therapist have to bracket certain things. You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient. It's like, “Okay, yeah, that's something that I feel, and I've got to figure it out, and I've got to deal with it here.” But I can't take it for granted any more than I can take it for granted if I had a sexual impulse, or some strong negative reaction to somebody. Whereas with writing, that's a whole different kind of discipline, where you have to take whatever it is and transform it into words.

GG: No. I probably should, but I think if I did I wouldn't be able to maintain both disciplines, because people actually do read my writing.

GG: Oh yeah. Sometimes they do. I've got a relatively wide readership, but I'm certainly not a famous writer, and therefore most of the people that I work with may not even know that I have a writing career.

GG: No. I don't bring it in at all. My books aren't in my office. I don't mention it.

GG: Yeah, of course. I don't talk about the argument I just had with my son either. Actually, there are situations in which I might talk about writing, but it very much depends. I see people who are artists or writers, and with those people I do sometimes bring it in.

GG: Well, I was doing therapy for many years before I got into writing.

GG: Thank you.