In my previous post, I wrote about how the professionalization of empathy has consequences: for the therapists (or professionals) themselves, for society, and for individuals receiving counseling/therapy. In this post (and the next one) I hope to talk about some of the societal causes that have led to the professionalization of empathy, as well as some of its consequences.
The road that leads to the professionalization of empathy invariably winds through the territory of medicalization. Simply put, medicalization describes the process by which human behavior and conditions come to be identified as medical problems; thereby necessitating diagnosis, study, treatment, or prevention. In order for something to become medicalized it first needs to be pathologized, which is basically classifying something as abnormal or unhealthy. Even though these terms are often used pejoratively, this is not necessarily a negative thing. I do not think that anyone would argue with the fact that there have been unbelievable medical advancements that have taken place over the years which have led to much needed reduction in suffering and have even saved lives. In order to get to the point of having treatments for something, it first needs to go through the medicalization process so it can be diagnosed, studied, and tested. After all, in order to treat a disease, it needs to be classified as a disease first.
However, there is a very important distinction that differentiates the “psy-professions” (primarily psychiatry and psychology, but also other similar professions like counseling, clinical social work, psychiatric nursing, etc.) from other arenas of medicine. While in various sectors of medicine there are biochemical tests and diagnostic imaging that indicate rather objectively the presence of a disease (e.g. diabetes, cancer, tuberculosis, etc.), no such thing exists for psychiatry/psychology. Instead, the psy-professions rely upon the observation of certain behaviors, or the report of certain symptoms from the patient (or their family/friends/etc.). There is no blood test that can say you have bipolar disorder, and there is no imaging exam that can say you have depression. Because this is the case, while often having very thorough studies and research of various disorders, the arena of “mental illness” can be liable to subjectivity. Give me 10 different psy-professionals and the same patient, and have them each conduct a clinical interview with the patient while not sharing their findings with each other, and you may end up with 10 different diagnoses.
The lack of concrete, objective tests for mental illness is particularly concerning considering the scope of expanding medicalization as it applies to the world of psychology and psychiatry. Because the psy-professions deal with issues very fundamental to human existence--such as behavior, emotion, and socialization--the ever-expanding medicalization inexorably leads to ever-increasing human behavior and emotion being classified as pathological. Leading me (as well as a whole host of authors much more qualified than me) to beg the question: at what point will normal be considered pathological? Or have we perhaps already surpassed that milestone already?
The evidence that is most indicative of the expanding medicalization of human behavior and emotion comes from the psy-professions’ foundational text: The Diagnostic and Statistical Manual for Mental Disorders (or DSM for short). Currently in its fifth iteration, the DSM is considered the “bible” of the psy-professions because it contains the official diagnoses, descriptions, classifications, and criteria for mental disorders. It is authoritative and incredibly influential, driving various aspects of treatment, insurance, policy, training, and practice. And since its initial publication in the middle of the 20th century, it has been getting fatter.
The first version of the DSM was published in 1952 and was a trim 130 pages long, containing a total of 106 mental disorders. Fast-forward to today, the most recent version of the DSM (the 5th edition) now weighs in at a morbidly obese 947 pages long, containing more than 300 disorders (although this number is difficult to identify, as various disorders have multiple “subtypes” which may inflate the total number of disorders more depending on whether one views these subtypes as distinct occurrences or not). Again, because no objective test exists to aid in diagnosis, psy-professionals must rely upon a more descriptive process to identify possible disorders, thereby making what is included in the DSM in the first place quite vulnerable to bias, subjectivity, and culture-bound assumptions.
Perhaps the most infamous example of this culture-bound bias is the inclusion of homesexuality in the DSM as a mental disorder from its initial version in 1952 up until 1973 when it was removed. In a less noteworthy fashion, other mental disorders have come and gone in successive iterations of the DSM due to lack of sufficient evidence to justify their continued inclusion, including: passive-aggressive, hysterical, inadequate, and cyclothymic personality disorders; Asperger’s Syndrome; Schizophrenia subtypes i.e. catatonic, paranoid, disorganized, undifferentiated, and residual; among others. While these are examples of disorders that have been removed from the DSM, I highlight them to illustrate the ways in which the DSM has included in the first place various disorders that evidently did not have very strong scientific evidence.
Perhaps more concerning than the disorders that have been removed are the ones that have been added. For example, does your child have temper tantrums? If you answered yes (which everyone who has kids did), then they can now be diagnosed with “Disruptive Mood Dysregulation Disorder.” Are you advancing in age and notice that you’re more forgetful than you were as a young adult? Well now you’ve got “Mild Neurocognitive Disorder.” Are you struggling with grief and sadness after the loss of your loved one? Well now in the new DSM there is no longer a bereavement exclusion for depression. So rather than understand your grief in the context of a normal and expected mammalian response, you’ve got Major Depressive Disorder and hey, want some Celexa? If you have been so elusive as to evade any of the 300+ disorders codified in the DSM, there is “Unspecified Mental Disorder,” an extremely vague and unhelpful diagnose that definitely has you covered.
There is not necessarily a classification in the DSM (that I am aware of) that explicitly diagnoses an emotion in and of itself as a disorder. However, various emotions, or the control (or lack thereof) of their expression, are littered throughout the DSM as indicators of various disorders. The more the DSM expands to include what might be considered normal behavior, the more that normal human emotion also becomes stigmatized and classified as pathological, thereby necessitating a professional or medical response. I will return to this concept in the next blog post, but first I want to conclude this post by speaking more about the problematic consequences of medicalization.
Please don’t assume that I harbor negative feelings toward psy-professionals, I am technically one of them myself. And I don’t harbor any particular resentment toward the DSM or the multitude of professionals that contribute to its formulation. I truly believe that the vast majority of psy-professionals are well-intentioned and reasonable individuals with their patients’ best interests at heart. And I also know that psy-professionals have helped countless people alleviate suffering and have been crucial forces for good in millions of people’s lives.
That being said, the manner in which ever-greater amounts of human behavior are being classified as pathological is demonstrative of a conflicting incentive structure. The more that human behavior and conditions are pathologized, the more they then become medicalized. As I said earlier, when something is medicalized it becomes something to be studied, researched, diagnosed, classified, treated, and prevented. The more disorders that exist, the more that we will need psy-professionals to study, treat, and prevent those disorders. The more we will need medications and therapies to alleviate the suffering associated with these disorders. The more we will need self-help books to help us improve ourselves in the privacy of our own homes. All of this leads to more jobs, more job security, more money, and perhaps most importantly, more influence.
In today’s United States of America, it is becoming harder and harder to be normal. While the psy-professions’ practical monopoly on defining what is abnormal behavior and abnormal psychology advances, so too does their proscriptive and prescriptive influence, exerting a tremendous amount of influence over procedure, policy, law, expectations, and culture. The prescriptive influence plays out in both senses of the word, medical and societal. Behavior deemed as abnormal that then becomes pathologized necessitates treatments to be prescribed, whether in the form of a pill, a behavioral therapy, or some other kind of intervention. These are the professionals and interventions that help the person with the abnormal behavior or psychology get back to normal.
You might be asking yourself at this point, what is “normal’? Well, this is where the other sense of prescriptive influence enters the fray. By defining what is abnormal in behavior or psychology, one must have at least some kind of idea of what normal looks like. Obviously, defining something as subjective and complex as normal is no easy task. If I were to survey 1000 random people and ask them to define what normal looked like, sounded like, and acted like, I would likely get a 1000 different responses. Despite this subjectivity, psy-professionals exert a tremendous amount of influence over what is seen as normal in America.
The quest to achieve normal is the proverbial brass ring that has dwindled to the point that it appears impossible to grasp. The capability to classify certain groups of behaviors and psyches as abnormal and others as normal--thereby medicalizing the one while also shrinking the scope of the other--is to prescribe certain behaviors, personalities, traits, and temperaments that you should have or strive for, while proscribing the ones that you should not have. Additionally, the existence of the psy-professional arena as the experts on human behavior and psychology prescribe the expectation that the best possible solution to resolve the pathological abnormal is to bring it to treatment with a psy-professional. Thereby generating a pattern wherein psy-professionals not only define the normal from the abnormal, but also reinforce dependency on the psy-profession as the only place that can treat it.
These prescriptive and proscriptive process may indeed get actually codified into policy and law, but more often the influence on culture and community is more abstract. I believe that the culture of Allegheny College, where I work in the Counseling Center, serves as a reasonable illustration of how this process takes place. While I understand that Allegheny College is by no means a generalizable and representative sample of the vast and multiplex American culture that we all operate within, I think that it will help to illuminate certain important elements of this prescriptive/proscriptive influence over societal and communal expectations. (To be continued...in the next blog post [ew, weird and corny blog post teaser]).
