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The Bible of Psychiatry

Truth in Love 257

What is the DSM? How should biblical counselors approach it and think about it in a biblical way?

May 4, 2020

Dale Johnson: This week I am joined by Dr. Sam Stephens. He is our Director of Training Center Certification. We are now in the month of May, which is known around the world as Mental Health Month or Mental Health Awareness Month. This month, we want to give special interest to talking about the issues of mental health.

There’s so much information for us to talk about here. One of my visions with ACBC is that we reclaim the problems that people face from a biblical perspective. Over the next several podcasts throughout the month of May, we will talk about mental health and biblical counseling. I want us to bring clarity—if we can—on the importance of the secular worldview and how secular psychology categorizes human problems. Then we’ll examine how we would think through this in a thoroughly biblical way.

The title of today’s podcast is The Bible of Psychiatry. That phrase is used, even in the secular field, to refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM). I think it’s important that we begin there too. Many people view the Diagnostic and Statistical Manual of Mental Disorders as a scientific reference guide for psychiatry.

It is really the diagnostic material that psychologists and psychiatrists operate around. We’ll address it here on the podcast. We’re going to begin today—very small if we can again, because there’s so much information—to look at and inform you about the DSM. We’ll tackle questions like: What is it? How are we to approach it? How can we think about it in a biblical way?

I want to give you some knowledge that you may not know relative to the history of how this manual was created. I think these things are important and here’s why: I talk to so many pastors who—as they hear us talk about biblical counseling and biblical discipleship—are convinced that what we’re saying is true and right, but it’s almost as if they view the world of psychiatry and the things the DSM addresses in a separate category. They say, “I can do the things you’re telling me to do relative to discipleship, but I don’t know if I can address those things that are in the DSM.”

We don’t have to fear the DSM, and it doesn’t have to become a hindrance to true, legitimate ministry of the Scripture. Dr. Stephens, where I want to begin is by explaining for our listeners: What in the world is the DSM?

Sam Stephens: As many people in the field talk about it, it is the authoritative medical guide to mental illnesses and mental suffering. I think it’s important to note that many of us may ask the question, “Well, why does this matter for me? I’m in ministry. I’m in the church.” Alan Frances, who served as the task force chair for the DSM-4 (the previous iteration of the current DSM-5), speaks about not just its direct impact on the field of psychiatry. He talks about the broader societal impact that the DSM has had since the third edition, which was published in 1980. I want to read this brief quote. I think it’s really eye-opening here. He says this in his book Saving Normal:

“The DSM has a lot of societal influence because of the crucial boundary it sets between what is normal and what is abnormal. The DSM determines all sorts of important things that have enormous impact on people’s lives, like who is considered well and who is sick? What treatment is offered and who pays for it? Who gets disability benefits? Who is eligible for mental health, school, vocational, and other services? Who gets to be hired for a job? Who can adopt a child or pilot a plane or qualifies for life insurance?”

I don’t think many of us understand the broad impact the DSM has on everyday life. I think pastors need to understand that. It’s not just for a church member who is seeing a psychiatrist, or has been given a psychiatric diagnosis. It actually impacts broader society at large.

Dale Johnson: It now becomes the language that we use to talk about problems that we have—as if it’s some sort of scientifically defined threshold that describes what we call “abnormal.” That’s part of what Dr. Frances is saying. There are several books that have been written in reaction to the DSM-5 coming out, like Dr. Frances’ and we’re going to talk about those in subsequent podcasts. Part of what we want to do today is help you understand the fullness of what the DSM is.

The DSM is a book that’s been put together over time trying to delineate diagnostic criteria. It’s important that we understand what we actually mean when we say “diagnostic criteria.” You can read this directly from the introduction of the DSM—they seek to put together what they call a criteria, or collection of symptoms known as syndromes. A syndrome is simply a collection of symptoms that a person is experiencing.

When you look at the introduction to the DSM, it actually claims itself contrary to what most of us believe to be true about psychiatric diagnoses. The common culture believes very clearly that psychiatric diagnoses are a disease. We believe in them in terms of a disease model. We use that language consistently, and we often connect this to some sort of issue of the brain.

Yet, in the introduction to the DSM, they say, “Non-clinical decision makers should also be cautioned that a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder, or the individual’s degree of control over behaviors that may be associated with the disorder.”

What are they claiming? They’re claiming that the DSM does not demarcate cause. In fact, in the DSM, there’s not one biomarker—a biological marker that explains causality for the criteria that’s given for any mental disorder. Often biblical counseling is railed against with people claiming that we don’t accept science, or we don’t believe in science. Nothing could be further from the truth. What we’re wanting to try and do is say “Let’s look at the science and see what the science actually says.” There’s a flood of information consistently coming out that demonstrates how philosophically based the Diagnostic and Statistical Manual of Mental Disorders is.

They’re looking at criteria, such as someone has a symptom of an unwanted emotion. Their philosophy is guiding them in how they categorize those symptoms. For us as Christians, it would be radically different. Our philosophical approach, our Christian worldview, dictates how we would see those types of emotional dispositions.

That’s a little bit about what the DSM is. The first official DSM was created in the 1950s. The second was added in 1968, and the third came out in 1980. The fourth one—where Alan Frances was the the DSM-4 task force chairman—was an addition in the 90s. Now we have the latest one in 2013: the DSM-5.

These manuals are not primarily done by specific scientific inquiry and research. These are put together and made by a collection of people, who are appointed by the American Psychiatric Association (APA) to decide what goes into the DSM. In psychiatry—unlike the rest of medicine—members of a consensus group, meaning a task force of men and women chosen by the APA, get together to make and unmake diagnoses. The membership sometimes votes on whether a controversial diagnosis is a disease or not. Meaning, they literally sit around a table and discuss these ideas of clinical utility and what they believe should go into the DSM and what should be voted out of the DSM.

Sam Stephens: Basically, it’s diagnosis by committee. When I first engaged with the DSM, my assumption was that like any other medical reference book or document, that there would be a lot of hard sciences backing up their claims—things that come from the physical sciences, and data that would back that up. Yet, even from within the field, there are many people that are practicing psychiatrists who say, “Our entire field has been built on this faulty assumption. We’re promoting ourselves as a hard science, as a medical science.”

In fact, in the 70s, many people think of psychiatry as going through a time of crisis. They were asking questions like, “Are we going to continue in this way? We’re not really considered a medical science. We’re definitely not a hard science. We’ve not nailed down a very strict nosology, where we classify diseases in a very scientific, orderly way.” They were trying to define themselves.

In the DSM-1, which as you mentioned was published in the 1950s, the language focused on reactions that people had to circumstances in their lives. With the DSM-2, and then definitely with the DSM-3, you see how it moved further and further away from normal responses to life into medical language and scientific language. For our listeners the caution would be: When you read this type of literature, you need to be very discerning. On the surface, it seems very objective. It seems very authoritative and scientific. But even these very influential writers in the field point out that there’s a lot of subjectivity behind the diagnoses they describe.

Gary Greenberg mentions in his book, The Book of Woe: The DSM and the Unmaking of Psychiatry, that when he asked many very influential psychiatrists that worked on the DSM-4 about the various diagnoses and criteria, they admitted to him that these are really just fictive placeholders, they’re useful constructs. It’s the best that our profession can come up with, with the knowledge that we have, but unfortunately the names and the descriptions that psychological sufferings have been given up to this point far exceed the knowledge that we have right now.

Dale Johnson: Well, it’s interesting because Alan Frances, who we mentioned earlier, says something very similar. He says, “The absence of biological tests is a huge disadvantage for psychiatry. It means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change. It’s like having to diagnose pneumonia without having any test for the viruses or bacteria that cause the various types of lung infection.” He’s admitting the subjectivity of how we come up with these criteria.

Now all that to be said, I think it helps us to see that this stronghold of “science” (perhaps I would argue scientism) that our culture has bought into completely, may not be as sure as we’ve thought.

How do we make sense of this for us? Why is this important for us in biblical counseling?

Sam Stephens: I want to speak directly to our pastors, those that are actively ministering, the first answer would be: Don’t be intimidated by the language and philosophy of the world, especially as it relates to this particular topic. I know that if you’ve not been trained medically, dealing with medical language can be very intimidating. Sometimes you can’t even pronounce some of the words. When I began to read a lot of the literature out there, I began to see that this is a philosophical document. It’s an attempt to bring on the legitimacy and the authority of science to a philosophical document.

We can engage with the DSM and not fear that we're not trained well enough, or that it's going to be able to speak to things that the Scripture does not speak to comprehensively and authoritatively. Click To Tweet

We can engage with the DSM and not fear that we’re not trained well enough, or that it’s going to be able to speak to things that the Scripture does not speak to comprehensively and authoritatively. When counselees and when members of your church come to you with a psychological diagnosis (maybe they’ve self-diagnosed, which is pretty common, or they’ve actually received a diagnosis from a psychiatrist), don’t let that be a turn off switch for you. Don’t then think, “I can’t speak into that because this is science and I’m not trained that way.” No, let us encourage you to engage.

Dale Johnson: I think that’s critical. When I travel around the country and I’m talking in different places, I hear from pastors. This is one of the biggest hindrances in their mind toward biblical counseling. They have some sort of fear, as if they’re pitting faith against science. I want them to read about how people are viewing the DSM. Now that we’re 70 or 80 years into this process, there is so much literature on how the DSM’s contents—its structure, categorization, and diagnoses of problems—are philosophical constructs. They are constructs that have been put together from the perspective of a different and worldly philosophy. These things matter. Even regarding the language that we use in biblical counseling, I think it’s so important for us to bring back some of these ideas and explain them from a biblical perspective.

I’m hesitant to adopt the language of the DSM. You’ll hear me sometimes talk about depressive feelings. I often don’t use the word “depression” and part of that has to do with my hindrance to jump into the baggage that comes with those categories of depression as defined by the DSM. There’s an assumption behind all of that, which says this is some sort of biological or brain disease. That claim is unfounded— even people in the field are acknowledging that there’s no science to back that up. I want to release pastors from feeling like there’s a tension between faith and science.

We don’t have to fear that in the Bible. This is the Bible’s domain. It’s talking about these issues in the lives of their people. David Powlison wrote very eloquently in the Journal of Biblical Counseling about how to counsel a psychologized counselee. When you understand the DSM, it helps us to understand what that person believes about their identity, what they believe to be true about themselves, and what they are experiencing. It helps us to then take the truth of Scripture and help them see how their experiences are better explained by Scripture and the Scriptural narrative, and why the Bible says we struggle with different things over and against what the world is saying.

Let’s let’s see if we can sum this up. We’ve talked about a lot of things. You and I knew this was going to be a difficult conversation in part because we are burdened by this to such a degree, and we want to free pastors and ministry leaders in thinking in this way. Yet, we also want to be sensitive. We want to be sensitive that our culture is saturated with this language. People who buy into the language, their heart is they want to help people. We want to promote that desire to be helpful for people. But what I’m concerned about is what Paul mentions in Colossians 2:8—that we give into vain philosophy and empty deception. Now, through years and years of experimentation, we see that these things are not philosophically neutral. They’re actually not complementary to the truth revealed in Scripture. They’re actually contradictory to the truth revealed in Scripture.

With all this said, how do we then view the DSM?

The DSM is the world's attempt to explain the problems that people face without God. Click To Tweet

Sam Stephens: The DSM is the world’s attempt to explain the problems that people face without God. Pastors are going to see this, and the church is going to see this more and more. This is not going to go away. If the pattern holds, the DSM is going to get larger and larger and larger. The hyperinflation of diagnoses is going to continue to be a valid concern. The church is going to have to make a choice. Are we going to recede? Are we going to give up our responsibility in addressing the stuff of life and the lives of our flocks? Are we going to give that up and allow the world to not only address the problem and define it, but also bring a solution to bear?

You think of things as such as temper tantrums, or the inability for small children to focus, or overeating, or addictions—these things are being taken over by the psychiatric landscape. Before long, what’s going to be told to pastors (and what’s really being told now functionally, if you want to be honest) is, “You can’t speak to this.” Well, if this is true and this continues, we won’t be able to speak to anything.

Dale Johnson: These things are not ethically or morally free. The domain of psychiatry is encroaching further and further into the domain that God has clearly laid out as the responsibility of the church. One of the things that we want to see, as we view the DSM, is we want to be able to dispel and to tear down some of those ideas that you may have previously had relative to the DSM. We want to give you clarity that what they’re doing is the best attempt possible. If God isn’t real, this is the best attempt possible to try and categorize human problems.

We want you to be confident in what God has revealed His Word to deal with these types of problems that the DSM tries to acknowledge, but the Bible is already spoken to. Click To Tweet

I’m not saying that what they’re trying to do is not a noble thing. They’re just doing it from a very different philosophical disposition. They’re trying to do what they can to help people. The problem is that we’ve bought into that from a Christian perspective. By proxy, it’s led to us being lacking in confidence in the Scripture. We want to dispel those things that lead us away from our own confidence in the Scripture. We want you to be confident in what God has revealed His Word to deal with these types of problems that the DSM tries to acknowledge, but the Bible is already spoken to.

Bibliography of Critical Psychology
TIL 230 | How to Help Psychologized Counselees
TIL 206 | The Concept of Mental Health
Speaking Truth in Love: Counsel in Community