Therapy and the Myth of Diagnosis

Therapy and the Myth of Diagnosis

An excerpt fromAn Idiot’s Momentum – How the Mishandling of Myth Has Left Us Oblivious to God & Ourselves in a Nation at War

by Gary Rosenthal

The pressing issues that come under review in the consulting rooms of American psychotherapists today seem often at first glance to bear little relation to the headlines of the day.  An exception here has been the recent, widely endured financial crisis – this more so than the world’s ongoing ecological crisis – for here our interconnectedness to the wider world has finally, inescapably, hit home. 

But I have not spent one minute in a therapy session weighing the pros and cons of strapping a bomb to one’s chest in the defense of one’s religion.  And I’ve had no gung-ho Rambos straining at the bit to attack the Infidel, defend Mother Church, or the Homeland and its security.  This suggests that the population seeking therapy today in America is located largely within another meme, another bandwidth of consciousness, than that which this section of the book has largely labored to explore.  What people do report as their reaction to the latest eruption of the religiously/ethnically tinged violence in the world is more a feeling of helplessness, or a frustrated incredulity – in the face of what seems an insanity that no one can stop. 

One’s own form of insanity – that is, of being out of touch with the deeper Reality – is harder to recognize; yet in some way more pressing, whether in the board room or the bedroom.  And thus, by and large, what people talk about in therapy is not the conflagrations erupting daily all over a tormented planet, but the smoldering fires of their own frustrations, hopes and fears, confusion and ambivalence.  Like all human beings, therapy clients want to feel happy, fulfilled, and at peace.  Yet something is often niggling at them, like an irritant – which in best-case scenarios may give rise to a metaphoric pearl, as their presenting issue leads to a shift in their perception. 

But beneath the unique content that each week comes in the door to be treated, if I were to distill it all to what lies at the core, I would say that people suffer from a lack of essential being, a being-ness that might flood them with the fullness of their own unique lives—with almost all their presenting “issues” being an outgrowth, and a reflection of the lack of that. 

When their issues have been triggered, their voices and faces, as well as their thoughts and emotions seem altered and stressed, contracted in some way, as if they have suffered a dissociation from their source—like a fish become removed from the water which is its native context.  In this dissociated state, people encounter a fundamental insecurity – a doubt toward the universe, of its capacity to support them, their loved ones, or whatever it is that they hold most dear.  Yet this dissociated state and its doubt and anguish is not really separate from that which leads people to commit politically or religiously motivated acts of violence.  The existential insecurity and suffering is much the same, as is the dissociation from one’s deeper nature, regardless of which bandwidth of consciousness one is centered in. 

In the west, this anxious dissociation from essential being has spawned a growing service industry – of which I am a part – a growing service industry that has arisen out of a quest for a more ideal self, as if our actual ones are somehow not enough.  For today we have personal trainers and fitness coaches to help us create a more ideal body; we have spiritual guides, prosperity coaches, and time management consultants.  There are people for hire who come into our homes, reduce our clutter, make us more organized.  We have weight loss counselors, addiction counselors, marriage counselors – pet counselors even – and whether using aromas or body work, or “the work” of this trail-blazing person or that, a zillion different manifestations of something that goes under the name of “therapy.” 

This seems an age of specialization, not an age of generalists, and nowhere is the degree of specialization becoming more noticeable than in what is called "the helping professions."  In fact, in almost any large metropolitan area of the United States today we have guides and channelers, healers, coaches, and consultants coming out of our collective woodwork; and of a variety our grandparents could barely imagine – and seemingly had less need for. 

We go to consultants of all kinds who help us to maximize our relationship to time, to finances, to physical fitness and nutrition, to the stars, to our art, hobbies, and games, and to the colors of the clothing we might optimally wear.  We buy designer this and designer that, and it’s become a joke how particular we've become even in the way we today order our coffee.  We've grown used to having more options –and at the same time feel strangely lacking. 

For there has been a downside to our optimistic idealism, our Great Expectations.  At the same time that we feel in some way that the world should be our oyster, we come away actually having lives that often bear little resemblance to what we thought they might be, what we felt they should be, to the lives we've felt entitled, to the images of a "good life" that the media has set before us.  And what the media has set before us has been a cult of celebrity, a cult that is the exteriorization of our own tendency to make an ideal, an idol, and then shoot for that.  But as Nietzshe reminds us, “all ideals are dangerous, since they denigrate and stigmatize what is actual.” 

And so, for many of us, actual life has turned out to be more difficult than we thought it would be, and thus people today often have a sense of unlived potential, as if something is missing, as if life has failed them—if not their marriages then their jobs and careers, if not their marriages or careers, then their capacity to embody their deepest vision for themselves – as if they have been failing at life, of it or themselves having not measured up to "the ideal." 

* * *

The Myth of Diagnosis

Though I've characterized it in my own images, using my own clinical observations, I am far from alone in having noted a different kind of population showing up for therapy these days than in the time of Freud.  In fact it has become a commonplace that hysteria, the form of psychopathology that so much of Freudian psychoanalysis initially explored and treated, had largely disappeared during the course of the twentieth century. 

Writing in The London Review of Books (24 May, 2001) Mikkel Borch-Jacobsen alludes to “the well-known phenomenon of hysteria having disappeared in the course of the 20th century: today, one hardly ever encounters the spectacular attacks, paralyses, anaesthesias, hypnoid states, etc.  which afflicted hysterics in the era of Charcot, Janet, Breuer and Freud.  Other pathologies have taken over..." (my italics). 

In his book, Pluto: The Evolutionary Journey of the Soul, the contemporary astrologer, Jeffrey Wolf Green, notes that astrological Pluto was in Leo from 1937 to 1958, and that those born at this time have “a deep self-orientation, a more or less narcissistic orientation to life.” ( Parenthetically, it would also seem apparent that at least some part of what Osama bin Laden and his followers find so reprehensible about the West—and thus what they are trying to prevent from taking further hold in the Islamic world – is just this selfish, “narcissistic orientation to life.”  This same trait of selfishness shows up in the contemporary ideology of addiction, where Twelve Step groups recognize that in the spiritual dimension of life “self-centeredness” becomes addiction’s prime manifestation.) 

In an essay entitled "A Solution to Baby Boomer Selfishness," Ken Wilber writes “Boomer weaknesses, most critics agree, include an unusual dose of self-absorption and narcissism, so much so that most people, boomers included, simply nod their heads in acknowledgment when the phrase 'the Me generation' is mentioned.” 

And by the time Christopher Lasch's groundbreaking book, The Culture of Narcissism, was published in 1978, the therapeutic clinicians numerously quoted in it had already been noting a very different kind of population showing up for therapy – this having been noted by some of the clinicians for many years already, at the time of the book's publication.  More and more personality disorders were showing up for treatment, and more and more of them being people with “narcissistic personality disorders,” a disorder as I’ve mentioned that was formerly thought to be untreatable.  The most recent research provides statistics (footnote: Twenge, Konrath, Foster, Campbell, Bushman; CHANGE IN NARCISSISM/Egos inflating over time: A Cross-temporal meta-analysis of the Narcissistic Personality Inventory) that indicate that the trend toward narcissism in American culture has only increased – and dramatically – since the publication of Lasch’s The Culture of Narcissism. 

While being quite respectful toward the quality of diagnostic vision, its noticements of pattern characteristics, I find myself wanting to use quotation marks around the diagnostic category we are speaking of here (“narcissism”) –as part of my New Year's Resolution to hold even these eminently useful categorizations more lightly.  For one of the points I’ve hoped to develop in the course of this book is that we are all narcissistic to the extent that we are living estranged from our essential sense of presence, and thus, to the extent that narcissism has become endemic in the culture, it loses some of its relevance as a diagnosis for individuals. 

Besides, the very term “narcissistic” seems too condemning, often, for the very type it describes to be able to make use of.  In narcissism, the lack of adequate/accurate mirroring has not only led to a “dislocation” of the real self, but the loss of the real self has also left those suffering this condition with an underlying vulnerability that is easily wounded by how the self is being viewed by others.  And so for someone with a narcissistic problem, even being called "narcissistic" can be yet another wound, a “narcissistic insult.”  And often, one can lose the deeper outlines of the other – even if “successfully treating” such a diagnosis, and not the person. ( As Hippocrates, that father of healing tells us, “it is better to know the person who has the disease rather than to know the disease the person has.”) 

In a sense, psychotherapy’s clinical diagnoses in themselves constitute a myth – and like any myth, when you are standing within its archetypal field, you tend see everything about the person through its tinted lens.  Today a majority of the clients I see could be thought of as having narcissistic “features” – perhaps just living in this culture taints us in this way –though the number of clients who might properly be diagnosed as a (full blown) “narcissistic personality disorder” is far fewer. 

As a therapist I find that employing the diagnostic label as a lens can sometimes help me to see facets of a person I hadn’t noticed before, and at other times it can make the vision lazy and reductionistic, or lead to a boxing effect in which what is unique and singular slides out of view, and one is only noticing what marches within the outlines of the pattern. 

If monotheism suffers from the way God is often concretized, narcissism and all other forms of psychopathology suffer from the ways that one has concretized the self (in assuming that who we are is this patterning – as well as the self-image that comes to symbolize it).  Yet the profession of psychology that would help us address our collective forms of conditioning itself commits a concretization, while conditioning us toward a particular point of view – in the way it has objectified the soul as a pathology to be treated, and then, like the western medical tradition out of which it developed, treating the patient for symptom relief, while failing to provide a wider systemic perspective, a perspective that should include the spiritual, or more transpersonal dimensions of development. 

And lacking familiarization with the empty yet shimmering spaciousness that lies as the essential ground of being, there is a lessened ability to better reflect the deepest sense of our nature which is prior to all forms of conditioning and shaping.  Without an understanding of sunya, as Joseph Campbell has suggested, religion thus fails to apprehend what the symbol “God” is truly pointing to – but without a fuller apprehension of sunya psychology fails to reflect and embody the deepest nature of the self.  This spiritual deficit ultimately limits our profession of psychology in its ability to fully treat the main form of psychopathology in our culture – narcissism – which I have suggested is not only a personality disorder, but in some way, an identity disorder. 

“The myth of diagnosis” stems from a medical model.  It's a myth of etiology, a mythos of pathology (psychology’s version of “original sin”) that would go back to early childhood (versus a pre-existent archetypal basis) for its origins.  But this perspective seems to place too much emphasis on the “nurture” versus “nature” factor, as if who we are is solely the product of human engineering, or what was done to us when we were young and impressionable.  In this way, an inordinate amount of contemporary therapeutic vision seems to become fixated on the family of origin in general, and upon the experience of the client as child in particular, in accounting for how we came to be the way that we are. 

In part for this reason, I attempt in this book – as I do in my therapy practice – to bring to the work a larger cultural context than that of the family, by also locating the individual within a culture, and the culture itself within a wider range of mythic reference.  For aside from possibly increasing our sense of victimization (through focusing so exclusively through the harrowing, narrowing lens of what happened to us in childhood) the prevailing therapeutic perspective seems at the same time to hold a view of human beings as coming into life as a kind of tabula rasa or blank slate, without a discernable uniqueness already in place. 

And I don’t think this is accurate.  Nor would any mother who has had more than one child.  Nor would any astrologer.  Nor would most of the world’s religions believe that we come into this lifetime without some kind of predisposition already in place – for the ideas of karma, or past lifetimes, are spiritual tenets common to many of the world’s religions – and present even in some forms of Christianity prior to the Counsel of Nicea in the fourth century.  But as we have said, the overly rational perspective that has prevailed in western psychology has divorced itself from such notions (such as karma or past lifetimes) and so everybody must be born with a blank slate, which in turn leads to an over-emphasis on early childhood as the causative factor in how we came to be the way that we are – often lending as well an aura of victimization to our sense of the person. 

There’s something a little two-dimensional about “the myth of diagnosis” – though the insurance companies love and insist upon it, and will not pay for treatment unless conceived through its lens.  Like fundamentalism of all kinds, it too tends to employ a literalistic and flattening kind of lens, and like fundamentalistic monotheism the mythos of diagnosis has a special Book it would turn to and thump as an ultimate reference—The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. 

The DSM-IV is a 943 page door-stop.  This, the official diagnostic manual of the American Psychiatric Association, lists “Religious or Spiritual Problem” almost as an after-thought – in the “v-codes” near the end of the book, amongst “Other Conditions that May Be a Focus of Clinical Attention,” and just prior to “Criteria Sets & Axes Provided for Further Study.”  Of its 943 pages the DSM IV devotes a total of two sentences to the entire category of religious and spiritual problems.  At least it acknowledges there might be some kind of a problem here.  I mean it could be worse.  There could be no category indicating our contemporary psyches and culture have been suffering due to religious or spiritual problems. 

As I’ve attempted to reflect, these religious and spiritual problems have been with us and in fact have dominated the psychic landscape since the beginnings of recorded history, some 6,000 years ago.  Even if our profession of psychiatry can barely bring itself to speak of religious and spiritual matters, surely someone has noticed this: people often get a little nuts when they talk about God.  And God-talk –or religion, which Joseph Campbell likes to define as “a misinterpretation of myth” – has to a great extent shaped the way we view our world, which at the moment isn’t in particularly great shape.  Because of God-talk, we've had century after clueless century of Holy War.  Because of God-talk, the richest nation in the history of the world now finds itself economically hemorrhaging in Afghanistan and Iraq. 

While seemingly nearly oblivious to such a history – if not wanting to distance itself from it, the myth of diagnosis as cataloged in the DSM IV manages at the same time to be too bound to history, and our personal history in particular – to be a myth in the broadest sense; and so fails to give us the vantage of a timeless, transpersonal perspective on our lives.  For our contemporary myth of diagnosis fails to reflect, and in fact has no frame of reference for the deeper dimension of our humanity, for that which is not fixated, bound, or marked by conditioning. 

Instead, the myth of diagnosis has dissociated itself from the gods and from spirit almost entirely out of its worship of rationality.  This in itself could be said to be pathological – while making the diagnostic vision predisposed to only recognizing pathology – for as a psychological maxim goes “when we compartmentalize we pathologize.”  Going back to Freud, here the thinking of mainstream western psychology has retained the reductionistic approach to the psyche, where as Ken Wilber has pointed out in his writing about the pre/trans fallacy, since no higher context is thought to exist, then the more transpersonal levels of development are either ignored or explained as a regression to pre-rational structures “since they are the only non-rational structures conceived of, and thus the only ones to accept an explanatory hypothesis.” 

In this way mainstream western psychology provides an ultimately limited map of the human soul and of the human potential, as if optimal development goes no farther than achieving the station of a “well adjusted neurotic” – i.e., where one has been emptied of any non-rational perception.  And this robs mainstream western psychology of a “fruition stage,” such as is found in, and is the goal of, all non-exoteric spiritual traditions. 

This also keeps “psychology” and “spirituality” ever divorced from each other, rather than promoting some kind of psycho-spiritual integration.  It keeps our psychology wearing a medical apron, ever focused on psychopathology, as if the care of the soul were the treatment of a disease.  The divorce of psychology and spirituality impedes the more psychologically aware from having much of a voice in the culture’s ongoing religion-tinged dialogs and debates--such as abortion, gay marriage, stem cell research-- which in turn often leaves the more fundamentalist parts of the culture (who are often less psychologically aware) leading and shaping these debates.  And the reductionism of our psychological profession – and here one thinks of the term “head-shrinker” – keeps us disoriented, if not mythically dissociated from our deeper, more innate, spiritual nature, which is also to say it keeps us taking ourselves to be what we’re not – which is the broadest definition I have been bringing to narcissism. 

This condition – of “taking oneself to be what one is not” – is not how narcissism is most commonly viewed in my profession.  Though the profession of psychology might recognize some element of truth to this way of framing narcissism, the definition would sound too vague.  And if this were a professional book rather than a trade book geared toward a lay audience, I would include here passages from Kohut, and numerous other clinicians, all of whom would have slightly different but technically nuanced perspectives on the subject.  But the more technical writing about narcissism would likely sound boring or off-putting to all but a professional audience before we had gone very far.  I would lose most of what I take to be, and would want to be, my readers.  Even I find this more technical and “scientific” approach to the psyche somewhat boring, for it in itself often seems encapsulated by a particular vantage – the Orange meme – and as we have seen, it too is often “mythically dissociated.”  But from the perspective of most psychologists, the criticism I would expect to my way of regarding narcissism really does need to be voiced more fully; and it would be, I should think, that my definition is so vague that it would include almost everybody. 

And that is exactly why I like it.  For though this criticism of my perspective would be a valid one, the virtue here is that it casts a wider net—and in a narcissistic, scientistic, mythically dissociated culture, we need the largest net we can find.  For almost all of us are fixated in some composite of first tier memes, lacking in presence, and thus taking ourselves to be what we’re not.  And so to heal from our various psychopathologies and confining narcissism we may need a wider angle, a different view. 

For as Joseph Campbell reminds us, when a myth no longer contains a transpersonal or mystical dimension, then “you don't have a mythology, you have an ideology.”  And when it comes to ideologies, the twentieth century should have taught us – if nothing else – their inherent and glaring limitations.  But if psychology divested of spirit gives rise to an ideology, an incomplete form of mythos, there is something equally lacking in a spiritual approach that has divested itself of psyche.  For this splitting apart of spirit and psyche also hinders one’s spiritual development. 

Here one may be capable of successfully employing spiritual practices that shift the assemblage point, thus allowing one to access genuinely transpersonal states.  Yet if people have not adequately reprocessed the lingering psychological and emotional and cultural conditioning that comprises our “idiot’s momentum” – or what Sufism calls “the Commanding Self” – the momentum of this commanding idiocy inevitably reclaims us.  Here spiritual practices may function somewhat like a helium balloon – or a drug – that is, temporarily lifting people up and out of the confining prison of the ego structure.  But as long as the ego structure remains inadequately reflected, interpreted, worked with, dis-identified with – in other words, de-constructed – the helium inevitably begins to leak out of the balloon – and people fall right back into their prison, back into the confining nature of their more conditioned perspective. 

The deconstruction of egoic structure first pre-supposes that one has attained a level of development for which deconstructive work would be appropriate; in many cases, and at different junctures in a therapy, more structure, structure-building, may be what’s called for.  And we might see these needed “structures” as being not so dissimilar from what the prophets of monotheism attempted to provide – but with the further point being that once these structures have done their work, not to reify them such that they become what Karen Armstrong calls “idols.” 

As a therapist, one sees some form of “helium balloon” surprisingly often, even – if not especially with – clients who have a long history with spiritual practices of one sort or another.  And our predilection toward addiction comprises another instance of “helium.”  But something always is remaining uncooked to the extent that the psychological obscurations (that make the helium seem necessary) remain inadequately addressed. 

Here there are, almost inevitably, gaps in development, failures of integration, or what has been termed “spiritual bypass” – that is, the employment of spiritual practices to ”bypass” the more problematic, or unprocessed parts of our human-ness.  Or there is the tendency for a “pre” and “post” mishmash; and in all these cases, a lack of “stability in the view.”  Here, Spirit remains compartmentalized, split off from the rest of the soul.  And when this is the case, people remain as tourists to their own deeper nature.  And so, the wiser we are, not only can we see this split-off, dissociated quality in others, but the more we see how this is true for ourselves—the ways we are not fully grounded in our own deeper nature.  Even a Buddha, they say, is still working on himself somewhere. 

In a way though, the myth of diagnosis – with its victimizing focus on a youth who was wounded – would find its place in two myths which I feel would better ground our understanding of “the contemporary psyche” – as well as provide our contemporary psyches with better orientation toward the holy groundlessness that lies ever beneath our feet.  And I will spend the remaining parts of this book (and perhaps a book or two to follow) in exploring these other myths, as well as using them as lenses through which to see many things, including a “mystical dimension.” 

But having cautioned myself in numerous ways – that I don’t always heed – it nonetheless seems clear that if, as both Lasch and I propose, that “every age develops its own peculiar form of pathology,” and if narcissism, increasingly is our emerging peculiar form of pathology, then this would also suggest we would do well to have a better understanding of the myth – or myths – that stand behind this particular pathology, and that might help us to heal it. 

Move over Oedipus, Addiction, Yahweh and Allah.  So long DSM IV.  Hello, Echo and Narcissus.  Hey there, Pluto and Persephone.