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Dealing with Diagnosis

Dale Johnson: This is the month of May and we are beginning what has become a tradition here at ACBC on the Truth in Love podcast. We’re going to talk about mental health awareness month. We don’t do this to celebrate mental health awareness month. We do this to provide biblical wisdom in our therapeutic culture, in our therapeutic age, as it relates to all the secular topics of mental health, mental illness, and that sort of thing. Now, I could not be more excited about this month. We actually get five Mondays to release issues related to mental health and I’m looking forward to the next several weeks. We have some really good guys lined up to talk about some very specific topics like OCD and Emotional Focused Therapy to give critiques on those things, to give biblical wisdom as we think about issues related to that, but that will be in the coming weeks. So, I hope you’re engaged throughout the month of May hearing the particular podcasts that we talk about. I think it will be very practical for you. It’ll challenge you in so many ways to engage the Scriptures as we think about and hear and rub up against all of the diagnoses that we hear from mental health that are so common and popular in our given culture.

I want to start today talking about this issue of mental disorder diagnosis. When we think about diagnosis, obviously we think about the DSM, the Diagnostic and Statistical Manual of Mental Disorders. That is the Bible of psychiatry. We’ve talked at length on this podcast about that particular book and I’m sure we will have many, many more discussions as it comes up in the future. The DSM-5 actually just created a revision, so obviously we’ll be talking about some of those things as it comes up here in the future. 

Today, I want us to talk, in some cases, a little bit more practical. David Powlison wrote an article years ago that was so helpful, and it’s still really, really helpful—We can include that in the show notes for today’s show—How to Counsel a Psychologized counselee. I want to talk very practically today on sort of where we stand now. Many of you who engage in biblical counseling, those of you who are certified members and you engage in biblical counseling, there’s a high likelihood that you are going to engage someone who has been diagnosed with some sort of mental disorder. Why do I say something like that? Well, the reason is because John Hopkins put out research in 2020 basically stating that 25% of Americans have a diagnosable mental disorder in any given year. That’s one in four. Think about that with the people that you interact with on a daily basis. If we were to utilize the construction of the DSM, the criteria that is built, what we’re looking at is one in four people. Now, the most diagnosed disorders are in the category of anxiety disorders, and these are disorders which include things like OCD. I mentioned we’ll be talking about that in the subsequent weeks during mental health awareness month. It also includes things like Generalized Anxiety Disorder or Socialized Anxiety Disorder. 

It’s really important that we pay attention to what’s happening relative to diagnoses. They are becoming inflated. They are growing in popularity, and part of that is a strategy that you see from the world of mental health to destigmatize these things that we call diagnoses or mental disorders. One of the reasons that we see a stigma that arises with disorders—this is something that the APA, the American Psychiatric Association, has been fighting for a while. This has been a stain on their approach to mental health. It’s the issue of stigmas that arise. When you have one in four people, part of the goal is, if more people are diagnosed, then it begins to remove the stigma that’s associated with diagnosis.

Now, why do I describe something like that? For us as biblical counselors, there’s a high likelihood that the people that you counsel will have some sort of diagnosis, so you need to have some familiarity with the diagnosis that they’re given. When I talk about the diagnosis—For example, if someone comes into me and they have some sort of diagnosis of some sort of mental disorder, I like to be aware of that. I actually then go to the DSM and I want to read the criteria. That helps me to understand a couple of things. Number one, it helps me to understand specifically what experiences they’ve had, how somebody saw them and understood their story and gave them some sort of label that fits certain criteria. They’ve experienced certain groups of symptoms in their life. It also helps me to understand their perspective on what they believe is wrong with them, or why they struggle with certain issues that they find themselves struggling with in life, and that sets a context for me. Now I don’t immediately go after those types of diagnoses. I don’t often even deal with those particular things, but it lets me know the types of symptoms and problems and experiences that a person is having, and what I try to do is learn to then ask questions in such a way that draws out those experiences. Then what I try and do is help them to understand their experiences from the Scripture primarily, because I believe, as David Powlison famously said, that the Bible explains our human experiences better than any other system. So that’s sort of the direction.

Now, the question getting back to the issue of stigma: Why is it that these mental disorders—even still today, even though they’ve become very popular and widespread and you see the inflation of diagnosis all over the place with one in four Americans being diagnosable in their experiences—Why do we still see the issue of stigmatization? I think this is an important thing for us to consider. 

For those who have diagnosable mental health disorders, there is still a stigma associated with that. What you’ll see if you read about mental health awareness month is, they encourage people to just talk about these things in a therapeutic way, just to describe and to talk about the issues that they have with mental health. In talking through those issues, what they want to do is destigmatize the issue as if it’s something that’s okay, but we have to realize, one of the things that’s driving that stigmatization is—and I’ve talked about this on the podcast before—the church has contributed to that stigmatization because we’ve allowed those diagnoses to be something that’s separate and other outside of the church as if the church cannot deal with those particular issues that a person is struggling with in life. So, I think it’s important that we regain confidence in the Word, that the Word describes those experiences better, and that yes, we are primarily called to engage people who have those symptoms, who have those types of experiences in life that are even considered diagnosable. Now, one of the things that I think is really critical for us to consider is, why are these diagnoses so stigmatized? Why is it that people feel this way? There are a lot of explanations for this. One primary explanation, I think, is that people certainly see this as something that is a deficit to them. This hinders their functionality in life.

One primary thing that I think is missing is the way in which we’ve reduced these problems to biological explanations and we’ve done this in our culture, particularly since the 1980s for sure. I want you to hear, we’re not the only culture that has tried to minimize or reduce explanation of our problems to simple biological means or biological causes. In fact, psychopharmacology has been used to some degree for many, many centuries. I want to read you a quote from a book that I think is really important work. It’s called Three Hundred Years of Psychiatry and it’s by Ida MacAlpine and Richard Hunter. We often get sort of myopic in our view, thinking that what’s happening today is what’s always happened, or it’s happening more intensely today and this has never occurred before, but you’ll hear from these guys that this is exactly something that has happened in our history in the past. This is what they say, “Each age indulges in the conceit that nervous disorders are on the increase because of the complexity of its civilization with its discontents. The 7th century had its sleepers and pills to purge melancholy, the 18th century its specific medicines, and the 19th century its composing pills and herbaceous tranquilizers, and most of those concoctions were mixtures of alcohol and laxatives.” Now, I bring that up just to simply say that our attempts at trying to reduce these problems of man to something that’s biological and simply throw medicine at it, it is not new to our age. I think we just feel more advanced and scientific in our approach to that. So as you hear that from this book, Three Hundred Years of Psychiatry, it’s really interesting to me, how are we to understand what’s going on in psychopharmacology right now? 

I’ve recently been reading this book by a man named Edward Shorter who’s a very committed biological psychiatrist. He teaches the history of medicine and the history of Psychiatry at the University of Toronto. He has written this new book that came out, I think it was the end of last year, 2021, The Rise and Fall of the Age of Psychopharmacology. I think it’s important for us to hear him as a committed biological psychiatrist. He’s describing what he calls the rise of psychopharmacology, which he would pinpoint really post 1955, and then it builds into its heyday really 1980’s, 1990’s, early 2000’s, and he’s seeing a digression in that because of the subjectivity of mental health diagnosis and the lack of efficacy that we see with the psychopharmacology that’s used. Listen to the way in which he describes a part of the fall of psychopharmacology. This comes directly from his book. This is what he says, “Psychiatric drugs are still prescribed today in massive numbers. Yet the frame is shifting. Observers increasingly recognize that the intellectual paradigm of ‘neurotransmitters and their reuptake’ has been exhausted, that there are no new drugs in the pipeline, and indeed that no new drug classes or novel mechanisms have been conceived for decades. The field’s professional literature, at least that regarding drug trials, has been hopelessly corrupted and the prescribing of an endless chain of SSRIs is something you don’t actually need specialty training in Psychiatry to do, nor for that matter, as a psychologist increasingly clamor, do you need a medical degree to do it.” Now those are some interesting statements from a guy who is very committed to biological psychiatry. In fact, he wrote a history of psychiatry in which he favors that perspective of biological psychiatry, yet here he’s saying that it’s essentially that this whole approach is quite bankrupt. In fact, arguing consistent with what he says here, about 80% of psychopharmaceuticals are prescribed by general practitioners, so that research actually affirms some of the things that Shorter is saying. This is a part of what increases the stigma that we see. The stigma actually remains because the diagnosis is really often assumed to be the same as some sort of biological cause when in reality the diagnoses that are given are often very, very subjective. The offering of a pill to correct something that was a supposed chemical imbalance, it raises some issue of stigma with it. 

Now, I want to talk specifically about this issue of diagnosis as well. I want to bring in Allen Frances to talk about this particular issue because I think it’s so important. Now, you remember, Allen Frances is not a God-fearer, but he was the leader of the DSM-4 task force. He was the chairman who actually helped write the specific criteria that created the DSM-4 which was released in 1994 in its first edition and then in subsequent revisions. Here’s one of the things that I think is so important regarding what he says about diagnoses. He says, “There are no biological tests in Psychiatry” and then he gives a caveat, “with the exception of tests regarding dementia” that are essentially just looking at FMRIs and the shape of the brain, and trying to understand what is operating in the brain and not. So getting back to the quote, he says, “There are no biological tests in Psychiatry. None are in the pipeline for at least the next decade. Psychiatric diagnosis depends completely on subjective judgments that are necessarily fallible. They should always be tentative and must constantly be tested as you know the patient better and see how the course evolves.” Now I find that statement from him exceedingly interesting because what often happens is, even in the biblical counseling movement, I think we have a tendency to want to be deferential to a secular system. Most people in our culture are swimming in a stream that assumes the therapeutic language. They assume the therapeutic worldview. What I mean by that is, they assume that biblical counseling has to catch up to the advancements that are found within the mental health system, the therapeutic system. I think we’re giving them too much ground in assumption when we talk about the issue of Psychopharmacology in diagnosis, when we talk about the issue of diagnosing itself and how subjective that is. You’re hearing one of the primary psychiatrists for the last 20 years warn people against the subjective nature. I’ve heard psychiatrists describe that when they hear some of the symptoms that people are experiencing, often they can diagnose them with three, four, maybe even five diagnoses from the DSM.

We have to ask ourselves, what’s driving this? What is pushing the envelope here? What forces us to continue to move forward? Well, certainly we have to wonder, is it the economics or the capitalism that’s driving some of this corruption within the mental health system? I think for us as biblical counselors, we need to be confident that biblical counseling doesn’t need to “catch up” to the advancements of where the mental health world is. I think we need to understand where the mental health world is and understand it as a subjective approach to people and their problems, not to give it the credence of some sort of upper echelon of science to which many of the experts within the field would question, at least at this point, the things that we truly know about the problems that people face in life. 

We can’t just reduce problems of humanity down to simply psychological issues or biological issues. We are holistic beings and we have to be able to incorporate the beauty of our image of God in man in how we think about human problems. It’s such a critical thing for us. So, we have to be cautious about premature diagnosis. This is something that Allen Frances warns about constantly, in part because premature diagnosis was fueled by capitalistic gains. If you think about someone who relies upon this for their well-being, their living, their financial security is dependent upon offering a diagnosis in order to be reimbursed by a third party. I’m not saying that people are corrupt in doing that. What I’m saying is that the system itself demands a premature diagnosis being given when some of the experts are warning that we should be cautious because of the subjective nature of a diagnosis that’s given.

Let me give you one more thing from Allen Frances that I think is really critical in this topic as well when we think about diagnosis. He says, “How simple it would be if our patients’ symptoms conformed closely with the neat little packages that are contained in the DSM definitions, but real life is always so much more complicated than what is written down on paper.” Can we just say amen to that? He’s absolutely right. The complexities of life, the dynamics of human life, yes, including body and soul, are so much more complex than the simplicity of basic subjective criteria that’s written down on a piece of paper. So I don’t want you to fear those particular diagnoses as you counsel people, inevitably, who are diagnosable or who have been diagnosed. I want us to be confident. Now, how are we to think about this? Oftentimes when we hear people with a diagnosis, we need to have a specific aim. We can be confident that the Bible explains their symptoms, their experiences, their problems certainly better and gives better answers, because the Bible is going to help them to understand that they can be made new, not just cope with the certain issues that they have. 

So if we were to describe the cultural milieu, or the environment in which we currently find ourself in, one of the reasons that diagnoses are very popular is what Carl Trueman calls the psychological self. We live in an environment where descriptions of modern man have changed drastically. In fact, I love the way that Carl Trueman describes this. He uses Philip Rieff and Charles Taylor’s understanding of the modern self. This is what he says, how they describe it, “Psychological categories and an inward focus are the hallmarks of being a modern person.” He goes on to describe that this is what Charles Taylor would say is expressive individualism. Now, I think that’s so important that this is a part of what we’re constantly fighting against. People gain their identity by expressing their feelings from the inside out. It’s not the ways in which we are committed to things outwardly or the identity that Christ gives us from the outside as He makes us inwardly new and then we live in that reality. We live in that identity. Our culture is swimming in completely the opposite direction, in what Carl Trueman calls the psychological self, in wanting to express ourselves individually. I think we need to be very aware of this cultural milieu. I think we need to be very aware of the tide that’s flowing here and how people approach us even. Really when they approach religious things, what they’re trying to do is often perform to gain an identity as opposed to live as a result of their identity, and the fruit of their identity becomes those religious actions, attitudes, and moral leanings. We’re doing something totally different with people in the culture today and so we need to know what we’re up against, what strongholds we’re tearing down within people in order to build them back up into the beauty and the purity of the gospel of Christ. 

Let me describe this whole section the way that Carl Trueman gives it to us in his new book that he calls, The Rise and Triumph of the Modern Self. This is what he says when he talks about the current milieu of people, the current trajectory and the way people think about themselves. He says it like this, “it is actually the result of the slow but steady psychologizing of the self and the triumph of inward-directed therapeutic categories over traditional outward-directed educational philosophies. That which hinders my outward expression of my inner feelings—that which challenges or attempts to falsify my psychological beliefs about myself and thus to disturb my sense of inner well-being—is by definition harmful and to be rejected. And that means that traditional institutions must be transformed to conform to the psychological self, not vice versa.”

Now, what Carl Trueman is describing here I think explains why our culture is growing in diagnostic inflation. It explains that we want to have labels that give expression to who we are and how we feel on the inside. Then we are hypersensitive and hyper-offended when people oppose that because we believe that they’re opposing our identity, not false beliefs. So what confidence do we have? You know, the Scriptures should give us all the confidence in the world that it is, as Peter would say, a more sure thing than even his own experience as he walked with the Lord. But listen to what the Proverbs say. You know, we put a lot of hope in what the mental health world can produce for us. That gives us some sort of gnostic-like insight. I think we need to be cautious about that.

Listen to what the Proverb says, “The purpose in a man’s heart is like deep water, but a man of understanding will draw it out.” That’s Proverbs 20:5. We have the ability, with the Word and the power of the Holy Spirit. The power of the Holy Spirit, by the Word, can unveil the heart of people, and not just unveil it in a way of conviction as to what’s going on in the heart, but also in a way of transformation. So much so that we believe that the beauty of the gospel of Christ is transformative for people, not just simply a coping mechanism, not just a motivating factor to perform better to create some sort of new identity. No, the gospel of Christ recreates us into a new identity from which now we can flourish to walk at peace with God and other people and be settled in the dynamics of our heart in our inner man. That’s the ability that we have, empowered by the Spirit with the Word of God because the Holy Spirit is the transforming agent and we can’t allow the philosophies of the mental health world to overtake the responsibility that the Scripture gives to His Word and to His Holy Spirit to accomplish the work that only He can accomplish in the recesses of the inner man.

Helpful Resources:

How Do You Help a “Psychologized” Counselee? [1] Article by David Powlison.

Three Hundred Years of Psychiatry [2] by Ida MacAlpine and Richard Hunter.

The Rise and Fall of the Age of Psychopharmacology [3]by Edward Shorter