One of the problems with mental health diagnoses is that they are highly stigmatized categories that take their meaning not only from their clinical descriptions but also and sometimes primarily from the negative cultural accretions that accompany such descriptions. This is particularly true in the Western world, which has a preoccupation with intellect, reason, and clarity of thinking. In such a cultural milieu, mental health challenges can easily be perceived as challenging each of these socially valued attributes and, in so doing, challenging our conceptions of what it means to be fully human.
Tanya Luhrmann notices this particularly in the diagnosis of schizophrenia in America: “One of the challenges of living with schizophrenia in the United States is the clear identity conferred by the diagnostic label itself. To receive care in a society so acutely aware of individual rights is to receive an explicit diagnosis. A patient has the right to know. But the label ‘schizophrenia’ is often toxic for those who acquire it. It creates not only what Erving Goffman called a ‘spoiled identity,’ but an identity framed in opposition to the nonlabelled social world.”9 Describing someone as having schizophrenia or being a “schizophrenic” has significant social and relational consequences, at least in Western cultures. As Esmé Weijun Wang put it in relation to her personal experience of living with schizoaffective disorder: “Giving someone a diagnosis of schizophrenia will impact how they see themselves. It will change how they interact with friends and family. The diagnosis will affect how they are seen by the medical community, the legal system, the Transportation Security Administration, and so on.”10
Importantly, this “spoiled identity” stands in direct opposition to those claiming to bear witness to “normality.” This is why schizophrenia can be so alienating. Built into the description is an assumption of distance and presumed Otherness. However, this is not true in all cultures, as we will see. Indeed, in certain cultures it is not possible to be “a schizophrenic”; constructing people in this way is just not what such cultures do. A question we will explore in various ways as we move on is this: What is it about Western culture that constructs schizophrenia (and other forms of mental health challenge) in such a way as to make it so dehumanizingly stigmatic?
Stigma Is Pathogenic
It is clear that thin stigmatized descriptions produce spoiled identities and force expectations downward. Stigma is thus pathogenic (it causes pathology) in that once it is named, the stigmatic description actively causes harm. Stigma dehumanizes people living with mental health challenges. But it also dehumanizes the stigmatizers, who are trained to see only parts of other people without caring for the whole of them (like the doctor in my opening vignette). Stigma thins our vision and hardens out hearts. It is destructive for all concerned.
The issue of stigma will come up throughout this book. For now, we just need to notice its devastating impact and the ways it thins people out and hurts them.
MAKING UP THIN PEOPLE: THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM)
Psychiatry is a hermeneutical and descriptive discipline. It describes and interprets unconventional mental health experiences and responds in ways that bring hope, healing, and relief. We will focus on the issue of interpretation later. Here we concentrate on the descriptive dimensions of psychiatry. Historically via psychiatrists such as Karl Jaspers,11 and in contemporary times through the detailed work of Andrew Sims,12 an approach to description has emerged known as descriptive psychopathology. This phenomenological tradition provides rich and deep descriptions of psychopathology so that psychiatrists can gain insight and create rich and thick descriptions that help them develop deep and therapeutic understandings that lead to effective clinical intervention. Andrew Sims lays out this approach as follows:
The study of individual personal experience is fundamental to psychiatry. Descriptive psychopathology is the precise description and categorization of abnormal experiences as recounted by the patient and observed in his behavior. There are two components to this: careful and informed observation of the patient, and phenomenology, which implies, according to Karl Jaspers, the study of subjective experience. The descriptive psychopathologist is trying to hear what the patient is saying without any theoretical, literary or artistic gloss of interpretation, and without the mechanistic explanations of science used inappropriately. In order to achieve understanding, phenomenology uses empathy as a precise clinical tool.13
The purpose of such a phenomenological approach is not to explain what is going on but to try to understand it: “In Jaspers’ usage, understanding is contrasted with explanation. Understanding, in this sense, involves the use of empathy, subjective evaluation of experience by the ‘understander’ using his or her own qualities of observation as a human being: feeling inside. Explanation is the normal work of natural science involving the observation of phenomena from outside, and objective assessment. Both are required of the practicing doctor but whereas the method of observation in science is carefully and comprehensively taught, teaching the method of empathy to give subjective understanding is frequently neglected.”14 Sims draws attention to this phenomenological tradition but acknowledges that it does not get the recognition it deserves either in medical education or in practice.
One of the reasons this phenomenological tradition has been “lost” relates to the systems currently in place through which we make diagnoses and describe mental health challenges. These systems prefer thin descriptions to the richness and thickness of the phenomenological look. Part of the issue, as we have seen, relates to time. If you have only fifteen minutes with a patient, gathering rich phenomenological detail is not going to be high on your list of priorities. But lack of time is not the only reason for the thinness of psychiatric descriptions.
The Power of the DSM
The practice of psychiatric description (diagnosis) is organized according to the groupings and categorizations that compose diagnostic manuals such as the World Health Organization’s International Classification of Diseases (ICD)15 and the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).16 These manuals contain the criterion used to redescribe persons’ experiences in terms of commonly observed symptoms and to develop the formal names for mental health conditions. By “redescribing,” I refer to the process whereby a person