Dale Johnson: This week on the podcast I have with me Dr. Jenn Chen. She’s ACBC-certified and has taught biblical counseling at seminaries, universities, and conferences. She’s also been featured on biblical counseling observation videos and recently published Biblical Counseling and Mental Disorders [1], which is what we are talking about today.
Jenn was previously licensed as a clinical psychologist in 2002, after earning a doctorate in clinical psychology and a master’s degree in marriage and family therapy from Christian institutions. She was formely trained in evidence-based practices and psychotherapy. However, midway through her psychologist career, Jenn ended up receiving biblical counseling, after which she returned to school for a master’s in biblical counseling—and ultimately left the secular mental health field to practice biblical counseling.
Jenn, it has been wonderful getting to know you. I’ve enjoyed the time the Lord has allowed us to share together and getting to know you and your story. I’m really eager to see the fruit the Lord has produced in you, in particular as you talk about in this book. Welcome to the podcast—I’m looking forward to our time together today.
Jenn Chen: Me too.
Dale Johnson: Now, I’ll confess, we’re a little behind on this one, but I was trying to save this for Mental Health Awareness Month. That’s the time when the secular world acknowledges mental health awareness, and what we try to do in the podcast is revisit ideas from the mental health world and I wanted to save this discussion for this week. We are going to talk about your book which was released last October at our ACBC annual conference and has already sold very well. The Lord is clearly blessing the work you’ve done.
So, let’s get into talking about this issue of the DSM. I like to ask authors, because I’m always just intrigued. A book just doesn’t happen, right? A book comes about by a story, a backstory, where there’s a certain interest or something that intrigued you, or now is the right time, you were seeing a gap, whatever the case might be. I just want to hear how this particular book, that you’ve written with Shepherd’s Press, came together and you took on this project. So, what was the intrigue?
Jenn Chen: It started out through conversations with Dr. Ernie Baker, who is the editor for the Critical Issues in Biblical Counseling series. He would ask me questions about diagnoses or talk to me about one of his counselees with a particular diagnosis, and I’d offer some thoughts. Over time, he said, “You should write a book on that.” And I would just laugh!
But what I kept hearing in biblical counseling circles was people using DSM terms and recognizing that there is a big difficulty in truly understanding what the DSM is versus what it’s intended to do. I wanted to help biblical counselors not be intimidated by these labels used in the DSM or assume that once someone has a DSM label, it must be handed over to a secular professional.
Dale Johnson: That’s really helpful. I think for the lay person it is very intimidating, hearing a diagnosis label it comes with this concept that there is a disease, which I want us to talk about. But first, could you explain for our listeners: What is the DSM?
Jenn Chen: Definitely. The purpose of the DSM is great. They really want to be able to communicate with each other about a group of symptoms and a label because they want to identify what is going on and then study causes and develop a treatment for it. This helps in researching possible causes and developing treatments. So, in a way, they’re trying to address suffering in the world.
And I want to be clear—I’m not denying that people suffer. The things they’re experiencing are real. But the DSM’s labels are man-made and have a lot of faults with them. Given what they’re trying to do, it’s a very arduous task, and yet it does fall short. But this is their best effort at this point in time.
Dale Johnson: That’s right. The technical term is nosology—the categorization of disorders. This is what the secular world wanted to do: create categories where there would be a common language because what was happening in the asylum was so much confusion. And they just wanted to have a similar language that they could talk about if there were any breakthroughs in some sort of treatment or ways that could help different issues that people were seeing.
Overtime, you see this develop. The first DSM was released in 1952. We’re now on the DSM-5 revision. It’s expanded; in its current state it is about 1,000 pages and contains roughly 500 diagnoses. These diagnoses are criteria-based approaches. So they’re giving, as you mentioned, diagnostic labels that have criteria written in them. Where those are expressions of the things people experience. I think that’s a noble task, wanting to try and catalog in some way what people are experiencing, trying to use similar language.
In the 1980s, there was a shift where it was not just something psychiatrists and psychologists used in their desk drawer, right, as a common language. Somehow, through biopsychiatry and pharmaceutical involvement, this became a book that is now well known to the public. And it’s definitely utilized in the public sphere, which is a part of what you’re describing as the danger of some of the labels. So, what I want to get into now is talking about when people use the term “a mental health diagnosis,” what are we actually trying to communicate when people use this? Maybe you can say what the mental health world intends with the DSM versus the way that it’s often utilized in more of a disease-type model.
Jenn Chen: When someone is labeled, it means the person who interview them saw a set of symptoms that fit a particular category. These symptoms fit into a particular label that “may” point to a mental disorder underneath. And this word mental means it affects what we think, what we feel, what we do—which biblically describes the heart. So, it is not necessarily that when you have these certain symptoms, you then can check it off the list and say, “Oh yes, now they have this disorder.”
Another mistake that’s very common is that people often assume, “I have clinical depression, so I must have a biomedical disease.” The label then becomes a clinical condition that needs to be treated by professionals and possible medication versus this is the particular label they are using to try to communicate about the symptoms that are hanging together with you. But one of the problems too is that there is such a huge overlap with so many of the symptoms that you don’t even know, is this major depression or actually generalized anxiety disorder? There were studies that showed there’s like 80% overlap of some of the symptoms. And so, is it two different things? Is it one thing? Is it a bunch of different things and they all look similar? And so, there’s this language that is trying to clarify, but sometimes it ends up distorting and or magnifying one part and then obscuring something else.
But then also then coming to the assumption of because it is treated with a psychotropic medication, therefore now it is biomedical. So that is one of the big difficulties or the big confusions of “I have mental illness” that somehow there is a disease process or an illness process going on somehow biologically. And not to say, you know, our emotions, our whole body, but does that mean that now it can almost translate into now it’s my neurotransmitters or now it’s my brain injury or now it’s, I mean, not to say that there is TBI, which is very real and has symptoms associated with it and suffering, but a lot of these labels are not biomedical in nature. And then the treatment, when it’s described medically, then the treatment becomes medical. And so things even like disordered sexuality have now become mental illnesses. It is almost to the point where, well, it’s something we have to accept because it is an illness. Then there’s no morality, no moral agency for that. For example, pedophilia is in the DSM as a mental illness.
Dale Johnson: Now that you bring that up. There is a strong movement in the direction of decriminalizing this concept. I would predict that at some point in the future, we’ll see very similarly to the story that we saw with homosexuality where it was removed from the DSM, which is a whole different issue. We’re going to see something like pedophilia removed from the DSM as if it’s some sort of disorder. You’re going to see it decriminalized because once you jump down this slippery slope of sexuality and you label it a certain way, now it becomes free reign to whatever preferences a person has.
Very helpful in describing the sort of biomedical perspective that when you get a label, many people just assume that this is some sort of illness. Now that you have a label, there’s an understood cause. Most people relate that cause to being something biomedical. How do we know people assume that? It’s because, as you mentioned, they offer medicine, and that medicine is intended to fix or repair something that’s happening in the brain chemically or whatever. That’s sort of how the story goes in a broad sense. So, the DSM has really become something that is, you know, trying to label diseases. And they even described that they hope it leads to a fully informed treatment plan and this sort of thing. And so, it has become a part of the common language that we see consistently in our culture. It’s something that’s become very confusing because here we’re describing the difference between, yes, absolutely, people experience despair, people experience anxiety, people experience ebbs and flows even drastically and dramatically and quickly from mania to despair. We experience those things. Those things are real experiences, but now we’ve labeled them, provided explanatory power through this thing called the DSM. And now it’s taken on a medical model approach. And we have a tendency to think very differently about what it is that we have or just what it is that we’re experiencing. Those are two different things.
I want you to help us to understand, as you do in the book I think very clearly, what the DSM is. Or what it’s accomplishing and what it’s really not, because it’s trying to do certain things, but it’s also not trying to do certain things. I think we need to make clear what that is. And Jen, here’s why I think this book that you’ve written is so important. What I see more and more happening in the biblical counseling movement is an ascendancy of the labels and language of the DSM, just as you mentioned, where people are giving credit much more to the framing of the DSM. People are giving credit much more to the labels of the DSM. They are almost giving credit toward those labels where the Bible then has to answer a person’s experience according to that mental health label. As opposed to saying, “what I hear you describing, that this experience is actually better explained through the Scripture versus this secular document where it’s been misunderstood.” So, help us to understand what the DSM actually is as a cultural document that’s trying to use common language and then what it’s not, some of its limitations.
Jenn Chen: Right. So, it’s intended to be able to communicate about symptoms that hang together and give them a label. And then sometimes it’s ended up using for billing, for communication, for being able to get a certain number of treatments, whether a certain medication. So, if a person is getting a certain psychotropic medication, it has to fit within the diagnoses that that type of medication treats.
Dale Johnson: And then the protocol that comes with it.
Jenn Chen: Yes.
Dale Johnson: Let me back up. I want to make sure that we clarify that you talked about symptoms that are grouped together. Now I want to dive into that just a little bit and then I want you to continue talking about what the DSM is. This is a really important distinction because symptoms that go together is actually the definition of mental disorder, right? It’s a collection of symptoms, which is known as a syndrome. Syndromes are simply a collection of symptoms. They are not describing etiology or cause. So, I think what you’re saying is what it’s doing, that’s a really helpful distinction because I think so many people misunderstand. They take the DSM as if it’s some sort of physician’s desk reference and that we clearly know what the cause is of this depression it’s because serotonin is this or anxiety is because of this. And so, we have to make that distinction clear. You’re giving a clear articulation to say these things are symptoms lumped together. That’s actually what the proper definition of a “mental disorder” is. And they’re not claiming anything more than that, even though it’s used differently.
Jenn Chen: Yeah, it’s a mirror description and it is based on the person who interviewed you because what can happen is another person might interview you and actually give you a different label or labels because you can get more than one of them.
Dale Johnson: That is so important. You said this earlier and I just think it’s so important that people don’t miss that is what we’re talking about in getting these “diagnoses,” they are not blood testing. There’s not that sort of medical engagement. We’re doing interviews. It’s very subjective. And this has been one of the biggest critiques from a secular scientific perspective is: how scientific is this? Is it testable and retestable? If you were to do this interview, right? You said, “Well, I think this person has X.” And then another psychologist would do the interview and they say, “Well, I think it could be this one or this diagnosis.”
you’re seeing that lack of consistency. That’s been one of the greatest criticisms within psychiatry and psychology that we know of. The DSM is a part of this, what’s called diagnostic inflation that’s happening and the lack of scientific vigor and consistency. So that’s a really important piece of the puzzle that you’re bringing to the surface that people maybe skip over very quickly.
Jenn Chen: Right. And this is what the secular folks are saying, not the biblical counselors. It’s to the point where people who are president of the National Institute of Mental Health, which is one of the highest positions in the field of mental health, saying the DSM is not valid, meaning it’s not necessarily describing things correctly. And then it is not reliable, meaning we’re not all talking about the same thing when we think we are. And therefore, we don’t even think we can do research using the DSM. The National Institute of Mental Health, actually with the DSM-5, has now developed their own new nomenclature, nosology, because they don’t think the DSM is scientific enough.
And yet, people go to a doctor, psychologist, mental health professional and get this label and then believe, “Okay, this is what I have.” And now because they say I have this and now this is what I’m supposed to do. And it has to come from a mental health professional because they know what’s going on.
Dale Johnson: That’s so important to offer clarity there. You talk a little bit in the book as you summarize what the DSM is, you talk about the biopsychosocial framework, which I think is very interesting. That’s under unbelievable scrutiny today, the whole concept of the biopsychosocial model. But maybe we shouldn’t go in that direction. You talk a little bit about the heuristic, the concept of a heuristic framework. Describe what they’re trying to accomplish with the DSM.
Jenn Chen: So, they’re not trying to give a definitive, “this is major depression.” They want to because that would really help with research. But it’s more of a rule of thumb of “this looks like this”. This is a framework, but there isn’t a cause for it. For some reason it is part of how the bio, psycho and social come together, which is why the clinical interview is so necessary. Because you’re kind of thinking through, wait, how might biology contribute to these symptoms? The person’s psychology, their cognitions and their inner world. And then culturally, how does this all fit to why they might be experiencing these symptoms? And so that’s the subjectivity of it.
Dale Johnson: I think that’s really key. You’re highlighting that part, the subjectivity. I want you to give me a thought. You use this sort of language in the book where you describe the DSM trying to give credit for what it’s actually doing. You use the concept of a rough, culturally attuned guide. Describe a little bit about that concept of the DSM as a culturally attuned guide. I guess the reason that intrigues me is because you can’t take the DSM and let’s go to India and implement it, right? It is a culturally attuned guide.
Jenn Chen: Yes. I don’t want to overgeneralize, but there can be general commonalities in how different cultures might express themselves, you know? I come from a Japanese American background and my expression of emotions may be a little more muted. And then having worked in the African American community, it’s almost the extreme. So, if somebody is expressing something very loudly and you’re not from that community, you could think, oh, they’re just hysterical, right? And they could look at me and think, oh, she’s just so repressed and something’s wrong because she’s not able to express herself. And so that same sign or symptom is influenced by the cultural glasses that we’re wearing.
Dale Johnson: I think that’s so helpful because what normal in our culture might not be normal in other cultures. And we do see that we prize and label things according to culturally what we think is normal and abnormal. And yet, we now move in a direction of, as you mentioned, to try and say that this is biomedical.
Let’s finish today talking about what the DSM is not because I want to bring you back. There’s so much more to talk about in your book that I think is really helpful. We’ve alluded to some of this stuff, but even though the culture has a concept of what they think the DSM is trying to accomplish. We need to make some clear demarcations of even though it’s communicated in a certain way, that these labels mean that you have something. Let’s make a distinction of what the DSM is actually not. You talk about this in terms of diagnosis. You talk about this in terms of it’s not presenting a biomedical perspective and so on. Help us to understand a little bit about what the DSM is not doing or what it can’t really do for us.
Jenn Chen: Right. So other than a very few limited in the neurocognitive disorders area, they’re not biomedical disorders. And I’m not saying there’s no biology involved whatsoever.
Dale Johnson: Jen, I think what you just said is really important. You’re making a distinction to say that what’s happening here, we’re not saying that the body’s not involved. That’s really important distinction. Some people say, well, if you’re denying that mental disorders happen or that we’re denying that the body’s involved, nobody is saying that the body’s not involved. But we have to make sure that we keep clear: just because something is reflected in the body doesn’t mean it’s caused by the body.
That’s a really important distinction that demonstrates biblically that there’s a holism that’s happening and the Bible makes clear that anthropology flows from the inside out. So obviously, when the heart is moving and active in certain directions, the body will be consistent with the disposition of our heart. And so, when we think or believe in a certain direction, it’s going to be reflected in our body because we’re holistic. The body is operating according to the design that God gave it. And so, of course, there’s destruction of the body. It’s not determinative in the same way as the heart is on the outer man expression. And that’s really important. So, I appreciate that you’re distinguishing between identifiable biomedical influences, bodily decay of neurocognitive type issues. But then we’re also recognizing most of what’s in the DSM is not that. We’re describing something that’s a part of experience. It does express itself in the body. So, we’re not denying that that happens. But we’re just trying to say that the cultural narrative of cause from the body is not the proper explanation and hasn’t been demonstrated scientifically.
Jenn Chen: Exactly. It’s not scientific to say with a lot of mental diagnoses, “Oh, this means I have a disordered mind biologically.”
Dale Johnson: Very good. I want to make sure that you come back next week and join us finish-up talking a little bit about your book. One of the things I’m going to ask you next week is what it is that you hope to accomplish in the writing of this book. What is it you hope people would look into? So hopefully you’ve enjoyed today and enjoyed our time with Jen, and we’ll look forward to being with her again next week.
Helpful Resources:
Explore our past Mental Health podcasts [2] and additional resources on our website.