Viable, Even if Not Valid: Greg Neimeyer on Diagnosis, Dimensions, and the Future of the DSM

00:00:00 Announcement: Welcome to Therapist Confidential, a psychotherapy dot net podcast. And now here’s your host, Travis Heath.

00:00:10 T Heath: Hello, everyone. Welcome back to the Therapist Confidential podcast. I’m your host, Travis Heath. And today I am joined by Doctor Greg Neimeyer. He is the CEO of the Performance Institute. He also previously served as the American Psychological Association’s associate executive director for continuing Education. And in that role, he played an important role in advancing professional learning and development for psychologists. All right, so what are we going to be talking about today? I think this is a really interesting topic. And to be honest with you, before I came into knowing Greg, I don’t know, maybe like a month or a month or so ago, I wasn’t aware about some of what we’re going to talk about today. So we’ll explore some potentially significant changes coming to psychiatric psychological diagnosis, including a movement away from traditional diagnostic categories and towards more dimensional approaches to understanding human sufferings. I don’t know, questions like what do our diagnoses actually tell us about people? What might they obscure? What happens when the medical model encounters the complicated meaning making beings that we actually are? Oh gosh. I have many other questions that I want to ask, Greg, but I’ll tell you one other thing. We were chatting before we hit record. Greg also brings a constructivist perspective to these sorts of questions, which is really intriguing to me, and maybe veers off from some of the stereotypes about folks who might be interested in diagnostics. All right, with all of that said, Greg, welcome to the podcast.

00:01:38 G Neimeyer: Glad to be here. Delighted.

00:01:39 T Heath: Would you mind saying a little about yourself so that the folks listening might get a chance to know you a bit?

00:01:45 G Neimeyer: Sure, absolutely. And I can tell you I’m already excited about the conversation simply because of the kind of questions you’re already sort of presaging us diving into. And they do speak to the contradiction that you talked about between my kind of orientation as a constructivist, a social constructivist on the one hand, and a deep and thoroughgoing kind of understanding and commitment, if you will, to psychiatric diagnoses. You know, it is true. I worked at APA for, whatever, ten years, twelve years as the director of the Office of See in Psychology and done a variety of other things in my life. But really, you know, in the core to the core, I’m an academic. I was a professor of psychology at University of Florida for thirty some years. And, you know, you can take the professor out of the classroom, you know, but you know how that goes. And so I really see myself as having a long standing kind of commitment to training and education, particularly in the realm of psycho diagnosis and psychotherapy. And of course, those fields, as you know, Travis, have grown and changed so dramatically. If you look at the difference between when you started your career and now, oh my goodness. And in some areas, if you’re practicing on the basis of knowledge that was out there and au courant, even as little as five or ten years ago, you know, you’re a troglodyte, right? That’s how rapidly things have changed and have grown and have evolved in select areas within psychology and psychotherapy. So the whole training and education field is really exciting because it kind of keeps you on the forefront of developments within the field. And, and that’s really my primary commitment that cuts across the wide variety of clinical and administrative contexts that I’ve worked in.

00:03:14 T Heath: Okay, let’s dive into this. So you’ve been following some potentially significant developments with the DCM ICD for those who maybe haven’t been paying close attention. And I think like once you get out in your career, time starts to move fast. And I’m not sure, you know, most mental health professionals are paying close attention, but can you help us understand what’s happening right now and why therapists should care about it?

00:03:38 G Neimeyer: Yeah, absolutely. Um, well, a lot’s happening now. I mean, if you look at where the American Psychiatric Association’s DSM, the Diagnostic and Statistical Manual of Mental Disorders has gone, you know, it wasn’t that long ago. It was fifty years ago that it was a purely thoroughgoing psychoanalytic document. You know, anorexia was understood as a fear of oral impregnation. Are you with me? So we’ve come a long way, baby. In that period of time. And then that those changes have only have only accelerated since the, you know, the advent of the DSM five in twenty thirteen. And as we’ve moved on now, the current version, DSM five TR accelerated still more. So it’s almost like strapping yourself to a rocket, a diagnostic rocket in terms of changes. And one of those changes is its articulation with the World Health Organization’s ICD International Classification of Diseases. And, you know, when I was trained, when most mental health professionals were trained, we kind of thought we kind of learned maybe by default, if not by design, that, you know, we lived our sort of diagnostic lives within the pages of the DSM, right? The Diagnostics and Statistics manual for the American Psychiatric Association. And then the docs, the real docs, the physicians, the MDS lived their lives in the ICD International Classification of Diseases. And so we saw those as sort of two different documents. But contraire, mon frere. They are joined at the hip. They’ve always been joined at the hip. The DSM is literally the Adam’s rib. It’s extracted from the ICD and it contains only ICD codes. There is no such thing as DSM code. It’s a completely derivative document. And that relationship, that historical relationship between the DSM and the ICD, with the latter being derivative of the former, has really only accelerated across time, where there’s an increasing movement toward trying to harmonize those two documents, trying to make them more similar, to try to make them more compatible, which, of course, from a clinical standpoint is really important because the idea, the whole idea of having two different and divergent diagnostic systems is itself pretty confusing. You don’t have that medicine. You don’t have like two different diagnostic systems. So a common nomenclature has been the goal from the very outset. One common psychiatric nomenclature that can be applied globally. And believe me, the World Health Organization with the ICD would like nothing better than that. Of course, they would like it to be under the auspices of the International Classification of Diseases. Because it’s free, it’s open access, it’s available to the public. There’s no charge. It’s not proprietary. The DSM is different. It is proprietary and it does cost money. It is owned by the American Psychiatric Association. So there’s this interesting tension and maybe a constructive tension between the DSM and the ICD for what you might call market share in the psychiatric space. You know, each would like in a sense, I’m saying this facetiously, but to eliminate the other from the field, they would like to have greater market share. And part of how you accomplish that is you create the magic term is harmonization or harmonizing the two systems so that they have a, they have an agreement. They have a pact. At this point. It’s been in operation for some years now. Any time one group decides to do something different, to introduce a different diagnosis, to change the criteria for diagnosis or whatever, if they diverge from what the other person is doing, then they are obligated to explain why they choose to do X instead of y or y instead of x. So you can see that creates a kind of force toward homogenization, because you’re accountable for any differences that you insist on. And there are important areas of I mean, there are big differences that the two systems will cling to. I mean, the DSM doesn’t recognize complex post-traumatic stress disorder, for example, but the ICD does. Well, that’s a that’s a difference that makes a difference. And it’s one of those things where they each look at the data and they kind of say, is the glass half full or is it half empty? One group says, you know, clearly complex PTSD is a horse of a different color. It’s it’s qualitatively different. It’s more severe, it’s more chronic, it’s more developmental. And then the other group says, all of that evidence is preliminary. So we’re not quite ready to make that commitment. So they can diverge and they do diverge. But as it currently stands, they’ve got to explain any instance in which they intentionally diverge, creating that kind of force or momentum toward harmonizing.

00:07:46 T Heath: This is fascinating. I love the way you described it as like competing for market share. I mean, late capitalism is ever present, but part part of what you know, I’ve started to to learn a bit from you is this this movement away from category or categorical diagnosis towards a more dimensional form of diagnosis? And I’m wondering if you can help folks understand what that really means in practice and why it matters.

00:08:12 G Neimeyer: Sure, absolutely. Well, that’s a really good question, Travis. And it matters tremendously because, look, here’s the deal. Most mental disorders occur along a continuum. They don’t it’s not all or nothing. You’re not either depressed or not depressed, right. You are a little oppressed, a little more depressed, a lot depressed, seriously depressed, chronically depressed, qualitative and quantitative differences in depression. And so a dimensional approach allows for wide variability along whatever the diagnostic criteria may be a categorical one. You’re either satisfy the criteria or you don’t. And you’re either in or out. You’re either either antisocial or you’re not. You’re either depressed or you’re not. You’re either oppositional defiant disorder or you’re not. Well, in a dimensional approach, everybody fits somewhere along a dimension. So you have two huge advantages. Number one, in a dimensional approach, no person is left behind like everybody fits somewhere. And importantly, no two people fit in exactly the same place. And if you think about it, that’s kind of what our experience of people is like. Like no two people are exactly alike. And the categorical approach is fundamentally problematic. Let me give you an example. Okay. So let’s say for clinicians, unipolar depression, we’re all quite familiar with that. You have thirteen symptoms. DSM says you have to have six or more of these thirteen symptoms. You know, more often than not across a two week period or more. Okay. So person one comes into you and they have they meet criteria one through six, person two comes into you and they meet criteria seven through thirteen. Those two people have no symptoms in common, but they have an identical diagnosis. Okay, so something’s rotten in Denmark. Are you with me? This is not ideal. Okay. This is a categorical approach. So a dimensional approach, you know, attempts to array people along a variety of different dimensions that are clinically relevant, that have utility and locate everybody somewhere in psychological space. Everyone has believed since time immemorial that the first movement toward Dimensionalization would happen in relation to personality disorders and eating disorders. They’re the two that are most prone to and accessible, if you will, to a dimensional approach. And they’re the ones that have all the biggest problems with comorbidity, right? I mean, if you look at the ten approved or authorized or credentialed personality disorders, the vast majority of personality disorders are combinations. They’re not one, they’re two or three or more, which is why then you have things like cluster A, cluster B and cluster C. They cluster them together to enhance diagnostic reliability. Same thing with eating disorders. You know, before they added binge eating disorder in twenty thirteen to the category of eating disorders, two thirds of all psychiatric diagnoses in the eating disorder category were not covered by anorexia or bulimia, so two thirds of them were not otherwise specified. So there’s something wrong with the diagnostic system when two thirds of the things that fall in that category aren’t covered, and we only added another fifteen or twenty percent when we added binge eating disorder. So it’s still the case that the majority of diagnoses in eating disorder category are not otherwise specified or other specified. So a dimensional approach allows you to overcome that. You instead have a variety of dimensions like an eating disorders over controlled, under control, attention over scrupulous attention to body dysmorphia versus not eating restraint versus impulsivity. Whatever the dimensions are, you measure those dimensions and you locate a person along those dimensions. Again, no two people fit in exactly the same place. The DSM has been trying to dimensionalize since its diagnoses. Since since, well, back in nineteen seventy nine, nineteen eighty with DSM three R, it hasn’t succeeded, but the ICD has. And the ICD, for the first time in its most recent incarnation, with the personality disorders tossed out all ten of the categorical personality diagnoses. You know, the antisocial, the avoidant, the dependent, the schizoid, schizoid schizotypal tossed all of those out and dimensionalized the entire system. So for the first time ever, we have a dimensional approach to diagnoses in one area. The DSM has not accepted that yet, but the ICD eleven has a completely thoroughgoing dimensional approach to diagnosing personality disorders. So because the two systems, as I mentioned, already, are required to harmonize, they have to justify any instance in which they maintain an intransigent adherence to divergence. That creates tremendous pressure for the DSM. Next time around to explain why they would adhere to what hasn’t worked for the last fifty years and not go to what the new guy, the World Health Organization’s ICD, has done. So that’s an example of how this harmonization is likely to result in radical evolution or revolution of the DSM in ways that are consistent, in this case with Dimensionalization following suit with the ICD.

00:12:43 T Heath: With what you just said quickly, I’m curious, what do you think is the DSM, of course, isn’t a person who makes a decision. Right. But what do you think is the Dsm’s reservation about adopting what you just described with the ICD?

00:12:56 G Neimeyer: Okay, so there are a number of them. It’s a great question. The DSM is inherently a little bit more, I would say conservative than the ICD. When you look at the two different systems, you look at the different their degree of plasticity and how porous they are. The DSM is just a little bit more a little bit more scientifically driven. Obviously, it’s far more homogenous because it’s all about basically mostly American psychiatrists. The ICD includes, you know, dietitians, physicians, nurses on and on and on. So it’s far more of kind of sort of a polyglot community and multi interdisciplinary. So DSM tends to be a little bit more conservative. You know, I think that’s, that’s one of the things. The other is this okay, I mentioned that the DSM is proprietary, right? And that means that the system is a part of the American Psychiatric Association’s annual budget. It’s part of a big part of its revenue generation. So when they went to make changes in the personality disorder in DSM five and five, TR went to make changes in the personality disorder section. They knew what was happening with the ICD. They knew that the ICD was going to move toward the dimensional approach. Now of course, the ICD. The DSM five is based on the ICD and uses the ICD ten codes, not the eleven codes. The ten codes the DSM articulates with the ICD ten. Incredibly, those codes were created in nineteen ninety. So we’re using we’ve moved to nineteen ninety codes. Okay. And that’s an upgrade because we were using ICD nine codes from nineteen seventy four. So we’ve caught up one generation, one generation behind. But they could see the DSM five could see that the ICD was going dimensional. And so they tried even before the ICD, they tried to dimensionalize. But here’s a big problem. What do you choose as your dimensions, whether it’s eating disorders or whether it’s personality disorders, what do you choose as your dimensions? Well, when it came to the personality disorders, which is the one the ICD made changes in the DSM looked around and they’re like, it’s got to be scientifically driven, right? It has to be empirically based. And they did, as you know, in the DSM five, they did introduce a hybrid model. It was part dimensional and it was part, you know, categorical. It was it was a dimensional system of ratings along dimensions. And then you ultimately would confer a categorical diagnoses, which is kind of like taking one step forward and two steps back. You work harder to get to the same place you were previously categorical diagnosis. But when they tried novel dimensions, what they realized is we either have to invent dimensions, which is going to be really hard to have reliable and valid, you know, just creating something de novo, brand new. You need to have ten, twenty, thirty years of research to develop dimensions that, you know, have some psychometric properties, have clinical utility and psychometrically good reliability and validity. But what they could do since, since they can’t do that, they could adopt an extant system. So an extant system would be, and as an example would be Ted Millon’s Multiaxial personality system. But the big problem is Ted Millon’s Multiaxial personality system is proprietary. So if I use his system, I got to pay him something. So this creates you pump the brakes, now you’re pumping the brakes, right. And so so they couldn’t do it. They were kind of stuck between betwixt, in between. They couldn’t go to something completely novel because it didn’t have the empirical and scientific rigor. They couldn’t go to something tried and true because they would have to pay for it. So they were kind of stuck between a rock and a hard spot. The ICD was not stuck between a rock and a hard spot. It’s a little bit less scientifically predicated, if you will. They’re a little bit more bold, they’re a little bit more adventuresome. They’re a lot more interdisciplinary. So they were quite comfortable in moving to a dimensional system. And it’s a non-proprietary document. They pay nobody anything. It’s free open access. So they were unconstrained and unencumbered in relation to the strictures that prevented the DSM from doing what they could do, you know, relatively unproblematically. So they become the leaders.

00:16:29 T Heath: Gosh, yeah. The politics of this are fascinating. Thank you for sharing that. And, you know, you’re bringing up the idea of empiricism, scientific foundations. And I am curious your thoughts on this because, I mean, what’s your understanding of what it means to call a diagnostic system scientific, when the very things that we’re attempting to measure are shaped by culture, history, relationships, social context. I mean, maybe I’m calling on your constructivist side here a bit, but I’m curious your thoughts about what we mean when we’re talking about scientific foundations here.

00:17:03 G Neimeyer: Okay, so now now you’re rubbing Aladdin’s lamp and the constructivist Greg Genie is going to come out. So yeah. So this is a good thing. So here’s what I would say. The concept of science, the dsm’s relationship to the concept of science is different than it used to be. Let me let me say what I mean by that. In the old days, when Bob Spitzer introduced what most of us were trained to recognize as the as the pillars, it was called the pillars of the DSM. He introduced a multiaxial system. Obviously that’s gone. He introduced the fact that DSM would be empirically driven, not so psychoanalytically driven, and it would be evidence based. Okay, so we know it’s no longer Multiaxial. They drop that back in DSM five because it has to conform to medicine and medicine is not multi-axial. So that’s gone. The other is we know it’s a retreat in DSM three. It was completely atheoretical trying to move away from psychoanalysis. It’s no longer a theoretical right, because now the presumption is beginning with DSM five, that all psychiatric distress and all psychological disorders are due to underlying neurobiological dysfunction. Well, that’s a metaphysical claim. That’s not psychoanalysis, but it’s a metaphysical claim. All psychological disorders, all psychiatric distress are due to an underlying neurobiological brain dysfunction. That’s a big, powerful statement. The third one is the evidential one. That’s what is the relationship to science. Well, you know, back in the day of Bob Spitzer and DSM three, the idea was that psychiatric diagnoses would be evidence based, evidence driven. I would say the DSM five and five TR are more like evidence infused or evidence consulting. It’s a it’s not that it’s devoid of evidence, it’s just that ideological aspects, including the addition of new disorders, become, if not a prepotent factor. They become a player in a way that wouldn’t have been allowed previously. That said, the concept of science itself is morphine and changing, and so many of those aspects that would have in earlier Dsm’s one, two, three, three or four TR that would have been ancillary, that would have been removed, that would have been secondary, are now coming to the forefront. And part of those are all of those contextual factors that inform frame, scaffold. It’s the crucible of psychopathology, the crucible of psychological distress that were so secondary back in the day. But now they’ve become figural. And the DSM has actually created a couple of years ago, they created a standing committee. It will stand in perpetuity called the future of the DSM Strategic Committee. That’s what it’s called, and have four. It has four subcommittees. One of them we kind of already talked about, it’s about dimensionalizing diagnoses. But the second one is this one that is all about the infusion of culture and societal sort of factors, and it’s called the Cultural and Environmental Determinants of Mental Health subcommittee. A mouth filling subcommittee term. But the idea there is and let me just give you an example. And everyone will recognize this as a clinician. You have two people coming into you. They both have, say, a moderate unipolar depression. One of them is gainfully employed, has a nice house and is insured. The other one has the exact same diagnosis. But they are they have they’re homeless, they have no job and they have no insurance. Well, from a clinician standpoint, we realize we’re dealing with somewhat different beasts there, right? Yes. They share depression, but the context are crucible in which that exists is so dramatically different that we would we would be foolish to turn a tie, a sort of a deaf ear to the significant differences in the way those disorders are presenting. Well, this subcommittee around the environmental determinants of social mental health is designed to spend time and attention, incorporating just exactly that into all the psycho diagnoses in medicine. They talk about it in terms of things like the term is social determinants of health. Social determinants of health can be things like access to clean water, access to housing access, what kind of environment you’re raised in, whether you were subject to trauma, whether you were raised in a chemically dependent family, all the adverse childhood experience stuff, all of those things that are contextual, contextual things that help frame presenting problem or diagnoses those now become, there’s almost a figure ground inversion. Those now become key in psychiatric diagnoses in a way that back until the DSM five, for sure, they weren’t even really considered. But because the ICD has always considered them, they have them under what they call the Z codes and the R codes. The DSM has started to borrow those and bring those in to psycho diagnosis itself. So there’s one subcommittee of the future of the DSM Strategic Committee is dedicated expressly and exclusively to doing just that, bringing context into psycho diagnosis. Now that’s a sea change. That’s a big sea change. And it’s a sea change that, you know, that makes a constructivist smile, right? Because it recognizes that these are not these disorders are not stand alone cognitive intrapsychic processes, that they are scaffolded within the crucible of broader social contexts and inseparable from the interpersonal, emotional, relational, cultural and societal factors that many people would argue constitute them, not just inform them, but actually constitute them. And don’t forget, there are many instances in psychiatry in which wholesale disorders vanished when there were significant cultural shifts. Mhm. You know, don’t forget, the number one most commonly diagnosed disorder up through the last century was hysteria. Well, once women got the vote right and got a voice and got power and became present in the culture, the symptoms of hysteria that were ninety nine percent female vanished. And the notion is, and certainly people like Jerome Wakefield from Canada would be strong. Opponents of this social constructionist notion is that these. These are basically psychiatric diagnoses or idioms of distress that are culturally contingent and culturally produced. And so it shouldn’t surprise us that, given diagnoses, have they run their course in a way that is structured within a culture according to predictable dynamics around things like socioeconomic status and gender and so forth. And you can see that very clearly in the DSM. I mean, you just take gender and you can just pretty much you see those that are lopsidedly female and lopsidedly male, the female are lopsidedly. The expressive disorders in the conduct are lopsidedly male. So it would be foolish again to turn a blind eye toward the notion of these, you know, these major social determinants of health as informing not just the form that these distress, these idioms of distress take, but actually the formation of those idioms of distress.

00:23:38 T Heath: I’m curious where you’ll weigh in on this one. So even if we move from categories to dimensions, for example, I think we’re still operating within a framework that assumes psychological suffering is primarily located within people. Right. And I’m curious your thoughts about that, along with how much does this really shift the the underlying influence of the medical model?

00:24:02 G Neimeyer: Yeah. Well, and, you know, I think time will tell the tale there. Travis. And I think that’s, that’s really insightful because what’s happened is the DSM has met the enemy in its itself, right? And so as it has retreated into a more of a biological model. And interestingly, you mentioned that because the third of the four subcommittees is what they call subcommittee dedicated to identifying biological biomarkers for different diagnoses. So it’s a thoroughgoing commitment to this biological, um, you know, origins of psychological distress and psychiatric disorders. The more it does that, more it retreats into that internal notion, the more it the more it isolates itself from, I think, broader developments within the field of psychotherapy, for sure, but also separates itself from a much more contextually sensitive ICD. So as it tries to harmonize, I think it’s going to find increasing. There are many points of traction, but there are also many points of friction. And one of the significant points of friction, I think, as we move forward, is that the Dsm’s intransigent adherence to this sort of biological neurobiological model, which articulates beautifully with medicine, is not going to articulate beautifully with the ICD. That is much more multidisciplinary, because it’s it doesn’t have that kind of steadfast commitment to the internal psycho biological origins of psychological distress. So it’s going to be interesting to see how that plays out across time. The DSM is moving headlong in a direction that could potentially paint itself into a corner.

00:25:30 T Heath: I’m also curious about your sense of the relationship between diagnosis and power. Like who gets to decide what constitutes a disorder? How do cultural, let’s say, values, assumptions influence those decisions. And that that occurs even when we believe we’re being objective. You know, so I’m curious your sense of the relationship between diagnosis and power.

00:25:53 G Neimeyer: Well, it’s a really good one. And I’ll tell you, I’ll tell you a story, Travis. I’ll tell you a story that speaks directly to that. And I’ll never I’ve never forgotten it. And it’s been almost fifty years ago, forty some years ago on my first or second practicum, I’ll never forget, I was at University of Notre Dame, and this was back before cell phones or any of that. And I was going into a client. I was going in with a client in the in the counseling center where I was doing a prac. And I had my, you know, manila file folder with me. And I was reading, I’d seen this guy one time and going into the second session, walked through the door and as I walked through the door into the therapy room and brought him in, he sat down. The administrative assistant called me and said, you know, you’ve got a phone call. And I said, okay, just one second. I put the folder down. I walked out, took this quick phone call going into session to meet, you know, get hold of you just in fifteen minutes. Sure. No problem. I walk back in and the client had picked up the folder. They’d picked up his folder and. And he looks up at me. He’s looking at the folder, reading the folder from my previous notes, looks up at me and he says, what does psychopath mean? And I’m like, wow. Oh well, what does psychopath. And that that underscored for me two things that were very, very powerful. One is, well, of course I felt terrible. And one is that that we were cultivating a kind of there was kind of some sneaky poo there, you know what I’m saying? That that we would say things about clients that we were uncomfortable in sharing with them. And also, to your point, it really underscored the power of psychiatric diagnosis. Now, I didn’t I didn’t literally diagnose him as a psychopath, but I did, you know, the case notes clearly reflected the fact that I saw aspects of psychopathy. So I take very seriously that these labels are powerful and it places, it places the diagnostician in, I think, a privileged but potentially fraught position. And so clearly from the framework of most contemporary therapies. The discussion of psychiatric labels get processed with the client. You know, like this. Does this make sense for you and many therapists, you know, people deal with that, that power differently. Some people are very comfortable with it. Some people are uncomfortable with it. So they do things like with their client, they’ll say, well, this is what we need to put down for insurance reimbursement purposes, but it doesn’t constrain, you know, kind of the work we’re doing. We’re just calling it an adjustment disorder with mixed emotions, or we’re just calling it whatever. But, you know, don’t take that too seriously and don’t think too much about that. And then sometimes it gets talked about in more thoroughgoing terms. What does that mean to you? Here’s, here’s what this label, how it’s understood within the vernacular and the culture of psychiatry or psychology, in what way does that fit with or not fit with you? And then, you know, how can we modify or contextualize what we report you as experiencing in a, in a way that’s consistent with your understanding, your own phenomenology of experience that you’re comfortable with. And so, you know, people handle that power in different ways. The DSM itself is, is is silent on that. And I think that’s an area that remains a growth area. And again, because it draws from this medical model and incidentally, that power, that power can be double edged. So, you know, a lot of times, and I’m sure you’ve had this experience, I’m sure most clinicians have where somebody comes in and they’re, you know, they’re lost, right? They feel think of Alice in Wonderland, right? You know, they’ve fallen through the magic mirror. They’re confused. They’re upset, they’re distraught, they’re anxious, they’re depressed. They don’t know what they’re experiencing. And then you go through and you say, well, you know, it seems to me like what you’re experiencing is really consistent with an agitated depression. This happens fifteen percent of the population experiences an agitated depression at some point in their lives. And this is very responsive to psychotropic medications and cognitive behavioral therapy. And sometimes you’ll see people just melt with relief because it has a name, right? So now you know, now you know what I have, I know what I have, you know what I have. And that gives me tremendous hope and tremendous confidence because I thought I was going insane or I thought, whatever. So, so the label doesn’t have to be negative or destructive to be powerful. Now, that doesn’t also mean that it’s valid. And I think that’s where we get stuck. You know, there’s that eighteenth century German philosopher Hans Vaihinger who talks about the function of fiction. You can have something that is a viable understanding that isn’t a valid understanding. All folklore fits in that category, right? It can be a viable way of making sense of something, but it’s not necessarily a truthful way of understanding. That doesn’t mean it can’t be useful. Some people would argue that all religion fits in that category. The function of fiction, right? It’s a viable way of understanding aspects of morality and human conduct. It provides a framework for making meaning. It doesn’t mean that it’s right and it doesn’t have to be right to be useful. And so sometimes when it comes to psychiatric diagnoses, clinicians will do that. Well, this is let’s just think of this as as a functional fiction, right? Let’s just think that this is a functional fiction. It’s just like folklore doesn’t have to be right. Don’t have to be true to be helpful as a way for us to just kind of get a toehold or a foothold on what you’re experiencing. So that’s it. That’s going to be an ongoing issue, right? I mean, just that any medical model is going to create endemic challenges in relation to the way in which we handle and don’t just ignore the endemic power dynamics associated with psycho diagnosis.

00:30:54 T Heath: Yeah. You know, one of my concerns sometimes is that diagnoses can become identities. They don’t always become identities, but they can. And especially, you know, with the proliferation of, of social media and TikTok and all of this anecdotally, anyways, I worry that that may be happening even more. I don’t know if it is or if it isn’t, but it feels that way anecdotally. So people then move from saying something like, hey, I’ve been diagnosed with depression to I am depressed.

00:31:24 G Neimeyer: It’s true. Yeah.

00:31:26 T Heath: And I wonder what you make of the ways diagnostic language can shape, you know, the stories people come to tell about themselves in this way.

00:31:34 G Neimeyer: Well, it’s a really good one. And you’re speaking to, you know, you’re striking to the heart of narrative therapy in a way now. Right?

00:31:41 T Heath: So maybe how how dare you, Greg.

00:31:44 G Neimeyer: I know it’s it’s talking about identities, talking about identity. So yeah, so there, there, you’ve got it right. The narrative can become your truth and it can become your identity. Narrative can support the development of an identity that can be, you know, a destructive and self-fulfilling one. And so the whole idea within narrative therapy of the externalization of the disorder. So this is not me, this is something out there that I am contending against. Labels can be psychiatric diagnoses can be that too. Now, there are many instances in which we can see that we slip up in that we call somebody a schizophrenic, as opposed to somebody who has schizophrenia. And the, you know, a recognition of the has rather than the identification of it is gives you the leverage so that the person is not located in that space. The person is located outside of that space, working against the symptoms of depression, the symptoms of schizophrenia, or whatever. So I don’t think that psychiatric diagnosis obligates us to move in their direction of identification, but it certainly prevents us presents a slippery slope that could allow us to get there if we’re not vigilant. And I think that’s part of the responsibility of a therapist. Even when a person has that relief function associated with, you know, odd grid, you’ve named it. So now I can relax. I sometimes will find myself saying, just because we can name it doesn’t mean we can treat it. You know what I’m saying? You know that those are different creatures. So yeah, I think we have a handle on what this might be called. Now let’s talk about how we can begin to approach it in in a way that’s consistent with you as a person and the goals and objectives that you have. So no, I, I definitely hear you that identification is, you know, is a challenge. That’s, again, I think it’s endemic to the psychodiagnostic approach that from a medical model.

00:33:29 T Heath: Earlier you were talking some about, you know, like reimbursement and third party payment and so forth. And there’s like, there’s a tension, I think I’ll say many therapists experience between the language they use to get reimbursed and then the language they might use to understand the people sitting across from them. And I’m wondering what you think this disconnect tells us about the profession. And is there, in your view, any realistic way to maybe close that language gap? Or maybe it doesn’t need to be closed? I don’t know, but it seems like it could be problematic to me.

00:34:00 G Neimeyer: Well, I think I think minimally that gap deserves to be interrogated, examined, and negotiated thoughtfully. I don’t know that it’s necessarily intrinsically and endemically destructive because I think therapists are creative in relation to, like you say, how they handle that. This is what I do for diagnostic purposes for reimbursement. What we do in therapy can be a different kind of discourse. A different kind of dialogue. But I think it speaks to broader issues as well. And they’re also they’re political and financial and for better and for worse. I mean, it’s really interesting because like, when I give talks on the DSM and stuff, like in, uh, in England or incidentally, any other, uh, developed first world nation other than the only other nation on this planet that has non socialized, met some form of socialized medicine that’s a first world country. The only other one that shares with us a capitalistic approach is a country called South Africa. Like everybody else has some form of socialized medicine. So when I talk over there, they’re like, why do you do diagnosis? Like, why do you do it at all? It doesn’t make any sense to me. They just they can’t wrap their minds around it. And the only way that it makes sense to them is epidemiologically, it only makes sense so that you can code, you know, disorders so that you can look at, you know, issues of prevalence and issues of incidence and incidences of comorbidity. So from that, health care, broader health care, epidemiological perspective, not individual diagnostic therapeutic Perspective. But in the United States, we’re so thoroughly. It’s. We we have the challenges. We have many gifts associated with it. So please understand I have a balanced appraisal of this. There are many gifts associated with a capitalistic driven healthcare system. Okay, like a healthcare for some select portion of the population, you can choose your healthcare provider. You can choose your healthcare coverage. You typically can get services more quickly, at least if you’re insured. So there are many advantages. But one of the disadvantages of that capitalistic system, when your healthcare is, is not provided for you as part of your governmentally provided services, is you’ve got the tensions around making money. And so it puts us into a system where you have to play within that capitalistic system of healthcare, within psychology and psychotherapy. And that’s not territory that many psychotherapists are necessarily natively trained in. And so it feels to them almost inauthentic, as if they’re gaming the system in some way, shape or form, or that it’s just kind of like a necessary evil to as an inroad to be able to provide the services that they want to be able to provide. And there are not many psychologists, and many therapists are not advantaged by the healthcare coders that they have. In medicine, where most physicians can work primarily on the treatment side, and they just hand over to the coders to get all the coding piece done. Well, psychologists and psychotherapists a lot of times are doing that themselves. So there it’s it’s, I think, more frustrating to them to play this kind of dualistic life. But I think that becomes as the DSM and as ICD take into account greater contextual variables that are sensible to psychotherapists, I think that gap begins to narrow, and it doesn’t have the same degree of inauthenticity that I have to do this to diagnose than something entirely different to treat. And I think we are better served by having a world in which psycho diagnoses have what the ICD refers to as clinical utility. The DSM is trying very much like they’re like one of their subcommittees is dedicated toward. For the future of the DSM is dedicated toward trying to enhance clinical utility by looking at an infusing functionality into diagnoses. So it’s not just what you have, but what it does, what it prevents you from doing, and what its impact on your life is. Well, for psychotherapists, having that degree of clinical utility, that is the function, the impact and functionality of a disorder on somebody’s life that resonates with them tremendously because they’re basically trying to get people to function more effectively in their lives socially, recreationally, occupationally, interpersonally, whatever. So as we move toward more functional diagnoses, which are definitely there in some areas of, you know, like in the areas of developmental disorders, the functionality is part and parcel of diagnosis. Like it goes hand in hand. You can’t, I mean, you literally specify a degree of functionality and identify what functional constraints there are in the person’s ADLs or whatever it may be. Well, we don’t have that all in a thoroughgoing way in psychiatry at this point, but that’s the direction that things are moving. So as we move in that direction, I think the gap will be closed. uh will be closing in relation to this experience of a disconnect between psychic diagnosis and psychotherapy.

00:38:28 T Heath: I have just a couple more for you. I’m curious what you make of diagnosis and AI as AI is moving, at least it appears to me so quickly that we can’t really keep up with it. And yet there’s no choice. It’s here. It’s it’s we’re not preparing for what might happen at some point in the future. It’s already here. But in terms of diagnosis, I’m curious your thoughts about it because, I mean, historically, Inter-rater reliability has not been all that high, right in the DSM. I’m not saying AI will solve that. In some ways. AI, I guess, could make it worse. It could make it better, I’m not sure. But I’m wondering your thoughts about AI and diagnosis in the DSM.

00:39:12 G Neimeyer: Well, I’m I’m tempted to say that. Let me let me check chat because, uh, you know, because that’s what I do in everything else in my life. You know, it’s a really good question. and I think the answer is pretty much like it is in every other respect in relation to AI. It’s hard to say. I mean, it’s changing so rapidly and it’s so thoroughly infused into everything at this point that I, I think it’s hard to even envision the direction that things will head. It’s hard to imagine that AI won’t be leveraged to enhance diagnostic reliability. That seems. It seems unimaginable that that isn’t true. I’ll give you one example, just one simple example. I mentioned that Biomarkers Subcommittee for the future of DSM Strategic Committee, the Biomarkers Committee. Well, one thing that they’re pursuing is a proxy biomarker is leveraging AI to identify speech patterns, tonality, and so forth as indicators of psychiatric diagnoses. And they have like seventeen, I think it is psychiatric disorders now that there’s tremendously high ninety five percent higher. Kendall tau and reliability in psychiatric diagnoses based on little snippets, like I’m talking about ten or fifteen words that somebody says, but simply the tonality, the phrasing. It’s really all the paralinguistic aspects of associated that are associated with it allows psychiatric diagnoses with a ninety five percent level of agreement in relation to things like Alzheimer’s, in relation to things like depression, in relation to things like anxiety disorders. So there’s an example of leveraging AI to enhance diagnostic reliability by creating this proxy biomarker. Well, I mean, that almost seems cosmic. It seems like something out of a Ray Bradbury sci fi book. We had this discussion ten, ten years ago, but it’s here. They’re doing it right now as we speak. So and that’s just a single example that seems cosmic, but there are hundreds of those as we speak now. And who knows, tomorrow or in a month or in six months or a year. I do see AI as having a very significant role in relation to psychiatric diagnoses, in ways that are not altogether clear at this time, but in all likelihood, as with many other sea changes in culture, likely for better and for worse, they’re likely to be significant advantages and disadvantages that accrue from, you know, application of AI as we know it today, which may not be the AI as we know it tomorrow. So it’s a really good question, and it’s a question that I think the answer is still up in the air.

00:41:40 T Heath: Okay. I’m going to leave you with this one. And of course, we could probably do a three hour podcast just on this. So, so I get that it’s a big question, but I’m just hoping for a little sense of what you where you might go with this. So if you could, um, let’s say fundamentally rethink psychiatric diagnosis, let’s say from the ground up. So you’re not revising the system we’ve already inherited, right? But you’re rethinking it and you can design it from the ground up. What are some cardinal features of what you’d want it to look like?

00:42:09 G Neimeyer: A really good question. I’m glad you saved the easy one to last.

00:42:12 T Heath: Yeah, that’s just that’s what I do. Greg. Yeah.

00:42:15 G Neimeyer: You know, I’m, I’m kind of you know, I hate to say that I’m a dualist, but I’m kind of I’m kind of won over to viewing psychiatric disorders and distress as problems in living. And so that means that you could get the same, you could come to the same disorder from very different roots. You could have the same experiences that give rise to very different disorders. But on the other hand, I would still reserve a place for those that are those clearly biologically driven disorders. Now, I don’t I don’t want to retreat to the old analytic notion where they talked about organic and functional disorders or organic disorders with everything. They had a known organic cause, phenylketonuria, you know, Alzheimer’s, Huntington’s chorea. And then functional was everything that functioned as if it was organic, but it didn’t have a known biological cause. So I wouldn’t want to retreat to quite that, because that kind of assumed that eventually, through the march of science and particularly biologically oriented science, all the functional disorders would fall to be understood as organic. We just haven’t gotten there yet. And that’s kind of what the DSM has kind of been a bedrock assumption of theirs for quite some time, so I’m not sure I would go that far, but I would reserve a space for those that are clearly schizophrenia, for example, clearly genetically and biologically oriented. But but I would clear the space and not try to shoehorn into that same model problems with living. And that’s where I think approaches that are far more contextual are far more constructivist. I think Michael White’s narrative therapy is a great case in point. I think most social constructionist and constructivist approaches, I think the most liberal applications, not the mechanistic versions of cognitive behavioral, fit that model. You know, they see the person as a whole person. And even interestingly, I think increasingly, some of the humanistic theories that we would have thought of being relatively fuzzy twenty or thirty years ago have made advances in ways that still respect the whole person in a way that they don’t get dissected as they do within a medical model. And I think that dissection does an injustice to humanity. And most psychotherapists are actually working with the whole human. So I think those models that preserve the integrity of the whole human, in my view, probably are going to find the greatest purchase moving forward in the field of psychotherapy.

00:44:29 T Heath: Doctor Greg Neimeyer this was a joy. I really appreciate the complexity of the conversation. You entertaining my my weird questions. I find that this is a topic that often, not always, but often, I don’t know. It feels like a bifurcated topic, right? Where people are in their camps and they’re either anti DSM or they’re very pro DSM. And what we lose in, in those sorts of conversations is any complexity, right. And any possibility for where things might go in the future and curiosity around that. And so I just really enjoyed listening to your, uh, to the nuanced perspectives and understandings that you’ve brought. So thanks, thanks for making time for this podcast today. I appreciate you.

00:45:13 G Neimeyer: My pleasure. Thanks so much, Travis.