It is said that if you visited a shaman feeling disheartened or out of kilter, he would want to know: "When did you stop dancing? When did you stop singing? When did you stop being enchanted by stories? And when did you stop finding comfort in the sweet territory of silence?" (Lewis: 2012). The value of the medicine man's inquiry is less about its specific questions and more about its asking-down-beneath-the-symptom. It reaches underneath the manifest signs of the trouble and towards the person's lived interiority. The accompanied search for personal meanings of suffering remains valid for our times, as a valuable meaning-making counterpart to the diagnostic model seeking to benchmark the maladies of the mind.
In her engaging book Mad, Bad and Sad. A History of Women and the Mind Doctors from 1800 to the Present, Lisa Appignanesi (2008: 484) includes French psychiatrist / psychoanalyst Jacques Lacan's observation that at least some of the people considered 'mad' through the modern diagnostic lens, may in fact have functioned well in religious communities and other networks. What is viewed as illness in one milieu might be upheld as a unique gift in another.
The phenomenon of hearing voices, for example, although viewed by psychiatry as pathology best removed, appears to manifest along a wide continuum and can in many instances be supported in ways not envisaged by the medical model. This is the fascinating stuff of Gail Hornstein's Agnes's Jacket. A Psychologist's Search for the Meaning of Madness (2009), in which she presents her intriguing research into voice-hearing. Hornstein has tracked down a great many voice-hearing people who have had much more help from peer-run groups out in the world - and without needing to halt the voices, than from drugs, electroshock and hospitalization, some the treatments for auditory hallucinations. Incidentally, Hornstein (2009: 16) points out that in the UK, the same percentage of people hear voices as suffer from asthma (4%).
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952 by the American Psychiatric Association. Its forerunner was the Statistical Manual for the Use of Institutions for the Insane (Tartakovsky: 2011). The DSM provides a standard language for clinicians, the pharmaceutical industry, insurance companies and others, bringing interested agencies on the same page, so to speak. Diagnosis continues to be strengthened by requirements of medical aids insistent upon the ticking of category boxes for treatment reimbursement. The when-last-did-you-dance approach is hardly likely to impress your medical insurer!
Mental health diagnosis does, of course, have purpose. It helps mind doctors to fine-tune their sense of what ails a client, and this can lead to appropriate treatment choices. It also helps treatment teams to dialogue using common reference points. Diagnoses can help clients too. For some it can be settling to have a name for something that might otherwise feel all the more bewildering.
Trauma-induced symptoms were systematically described for the first time (as Traumatic Neurosis) in the debut-edition of the DSM, and later redefined as Post Traumatic Stress Disorder in DSM-III. As a result of the categorization of trauma in DSM, a good deal more research followed, and finally there was also far greater recognition of the suffering of so many people living with ongoing aftermath-effects of trauma (Walter and Bates: 2012: 144). These kinds of benefits are clearly appreciable and we'd rather not be without them.
In The Shaking Woman or A History of My Nerves (2010), writer and explorer of mind/body terrain Siri Hustvedt explores the puzzling convulsions that first overtook her when speaking at a memorial for her father, a couple of years after his death. In the course of grappling with herself as a shaking woman, she delves into the knowledge banks of psychiatry, neurology, pharmacology and psychoanalysis. "Intellectual curiosity about one's own illness," says Hustvedt (2010: 6), "is certainly born of a desire for mastery. If I couldn't cure myself, perhaps I could at least begin to understand myself."
But as much as diagnosis can be helpful, it is also potentially divisive, alienating client from clinician and separating a person from their own directly experienced self. Categories have a way of depreciating the fine intricacies of what it is to be human, and stealing something away from the limitless versions of our human experience.
In contrast with a binary view of health / ill-health is a sentiment held by English paediatrician and psychoanalyst Donald Winnicott, whom Hustvedt (2010: 80) cites as follows: "Flight to sanity is not health. Health is tolerant of ill health; in fact, health gains much from being in touch with ill health with all its aspects."
Clinicians who hold lightly the preconceptions of their day often have noteworthy successes. I Never Promised You a Rose Garden by Hannah Green (published in 1964) is the bestselling, fictionalized real-life story of Joanne Greenberg (Esther Blau in Rose Garden) and the three years she spent as a schizophrenic patient at Chestnut Lodge in Maryland, US. Psychiatrist Dr Frieda Fromm-Reichman - portrayed as Dr Fried in Rose Garden - did the unthinkable and provided psychoanalytic therapy for Joanne at a time when psychiatry flatly disbelieved that talking therapy could be of any use to patients in a mental asylum. After three years of steadfast talking treatment, Joanne Greenberg recovered, left the institution, married, raised children and pursued a career as an award-winning writer (Hornstein: 2005: 223-238; 345-382). The sparse biographical details I've provided here do not, of course, begin to take account of an entire post-asylum life, richly lived.
In Cape Mental Health's published report for 2014/15, dignity is the explicit theme. Part of preserving dignity, surely, is working against stigma. But the labels that exist as part of a diagnosing model tend to do the opposite, creating stigma and mistrust. This occurs especially, perhaps, when labels enter the public reference domain and begin to accrue derogatory value. The step between pop reference to mental health labels and random name-calling (and perhaps also too-liberal self-diagnosis) is a small, but damaging one.
"Narrowing or medicalizing definitions too much," says Appignanesi (2008: 484), "limits the boundaries not only of so-called normaility, but of human possibility." Indeed, mental health diagnostic categories tend to focus on deficiency, limitation and deviation. In general they do not cultivate hope and possibility. Categories would be more useful if they did this. Post Traumatic Stress Disorder, for instance, holds greater possibility when held in conjunction with the concept of Post Traumatic Growth.
The map is seldom the territory, and an individual's lived experience of their inner terrain is unlikely to match any diagnostic formulation. I have yet to meet an individual who is not infinitely more interesting and expansive than they would be if viewed through a categorising, diagnostic lens.
Categorization can induce stasis. Affixing a label creates a gluey kind of is-ness. Far more manoeuvre-friendly is Carl Rogers' notion that “a person is a fluid process, not a fixed and static entity; a flowing river of change, not a block of solid material; a continually changing constellation of potentialities, not a fixed quantity of traits.” (Quotes from Carl Rogers, On Becoming a Person).
If we are willing to live as a process, with its peaks, plateaus, inclines, precipitous edges, potholes and periodic plunges, our most uncomfortable states will invariably not be perpetual, but will morph and re-form. Just as our brains, remarkably, have plasticity, so is inner life subject to alteration, remission and impressive reconfiguration.
In her quest to make sense of herself as a shaking woman, Siri Hustvedt (2010: 90) draws on phenomenologist Edmund Husserl's distinction between two kinds of body: korper and leib. Korper is the physical body, the body of science and medicine, the body as object, that which can diagnosed and medicated. Leib is something different, and more; it is the directly experienced body - the embodied 'I'. Leib is the whatness and howness that we find in ourselves. For a groundbreaking depth-exploration of the limitless authentic knowing that comes from tuning into the living body directly, see the work of Eugene Gendlin.
Ultimately, perhaps, what is 'wrong' or out of sorts is best known by the person's directly lived experience of it - the leib-reality. Categorisation can obscure the view of the emergent - the perhaps still nameless something that might be pressing, or more lightly nudging, to nose an opening into life.
REFERENCES
Appignanesi, L. (2008). Mad, Bad and Sad: A History of Women and the Mind Doctors From 1800 to the Present. London: Virago Press.
Green, H. (1964). I Never Promised You a Rose Garden. New York: New American Library.
Hornstein, G.A. (2005). To Redeem One Person is to Redeem the World. New York: Other Press.
Hornstein, G.A. (2009). Agnes's Jacket: A Psychologist's Search for the Meaning of Madness. New York: Rodale.
Hustvedt, S. (2010). The Shaking Woman Or A History of My Nerves. London: Hodder and Stoughton.
Lewis, W. (2012). www.elephantjournal.com. Retrieved July 23, 2016, from
http://www.elephantjournal.com/2012/07/in-many-shamanic-societies-if-you-came-to-a-medicine-person-complaining-of-being-disheartened-dispirited-or-depressed-they-would-ask-one-of-four-questions/
Quotes from Carl Rogers. (n.d.). Retrieved July 23, 2016, from https://www.verywell.com/carl-rogers-quotes-2795693
Tartakovsky. M. (2011) How the DSM Developed: What You Might Not Know | World of Psychology. Retrieved July 23, 2016, from http://psychcentral.com/blog/archives/2011/07/02/how-the-dsm-developed-what-you-might-not-know/
Walter, M. and Bates, G. (2012). Posttraumatic Growth and Recovery from Post Traumatic Stress Disorder, Essential Notes in Psychiatry, Dr. Victor Olisah (Ed.), InTech, Retrieved July 23, 2016, from
http://www.intechopen.com/books/essential-notes-in-psychiatry/post-traumatic-growth-and-recoveryfrom-post-traumatic-tress-disorder