Alfred Hitchcock Presents:
The DSM-5

Eugene Epstein

September 13, 2013
 

“Oh, that’s a MacGuffin.”

“What’s a MacGuffin?”

“It’s an apparatus for trapping lions in the Scottish Highlands.”

“But there are no lions in the Scottish Highlands.”

… So you see, a McGuffin is nothing at all.

- Alfred Hitchcock, explaining the “MacGuffin”

 

What does the new DSM-5 have in common with an Alfred Hitchcock mystery?  They both rely on a plot device, something Hitchcock called a “MacGuffin”, for their narrative power.  At least that is the story that my German colleagues Manfred Wiesner, Lothar Duda and I like to tell.
One assumption that the three of us have in common is that we believe our realities to be socially constructed, in relationships, through the stories that we tell.  This assumption has tremendous implications on the ways we think and act, and especially upon how we think and act as psychotherapists.  Adopting this perspective means giving up on the idea of universal “Truth” with a capital T, instead seeing truths as nothing more than temporary social and cultural agreements or stories, subject to change along with changing relationships and circumstances.
In his wonderfully creative novel The Life of Pi, Yann Martell illustrates this idea by describing the encounter between two Japanese insurance investigators trying to research the “truth” around the circumstances of a shipwreck, and the lone survivor of that shipwreck, through the following dialogue:

Mr. Okamoto:  “But for the purposes of our investigation, we would like to know what really happened.”
Pi:  ”What really happened?”
Mr. Okamoto:  “Yes.”
Pi:  ”So you want another story?”
Mr. Okamoto:  “Uhh… no. We would like to know what really happened.”
Pi:  ”Does the telling of something always become a story?”
Mr. Okamoto:  “Uhh… perhaps in English. In Japanese a story would have an element of invention in it. We don’t want any invention. We want the ‘straight facts’, as you say in English.”
Pi:  ”Isn’t telling about something—using words, English or Japanese—already something of an invention? Isn’t just looking upon this world already something of an invention?”
Mr. Okamoto:  “Uhh… ”
Pi:  ”The world isn’t just the way it is. It is how we understand it, no? And in understanding something, we bring something to it, no? Doesn’t that make life a story?”

If we give up our belief in (and call into question) a received truth — like the dominant mainstream biological explanations for human suffering, for instance — then we begin to create space for pondering new questions.  Instead of busying ourselves with how to change biologically and mentally “diseased” minds into more healthy minds, for instance, we instead confront more philosophical and political questions.  Like; how shall we continue to live together?  Or, what stories allow us to think/live/feel/relate etc. in the ways in which we would prefer to think/live/feel/relate etc.?
These are extremely important, though very complicated philosophical and political issues.  They touch upon the very core of our existence and values as human beings.  Whose story gets told in a psychotherapy session, and using whose language?  For which purposes do we advance particular narratives? Whose stories get negated?  And who decides which stories and purposes should be preferred?
Along these lines of thinking, we view the DSM-5 as but one of many possible stories that may be told with respect to human suffering.  Who and how was this narrative developed?  Who benefits?  What is gained and what is lost with the adoption of this “new” version of psychiatric “reality”?
To explore these questions we borrow a concept that the late, great film director Alfred Hitchcock described in an interview with Francois Truffaut.  Hitchcock described the “MacGuffin” as a common plot device typically woven into film scripts.  For Hitchcock, a MacGuffin was a certain kind of object, one which although largely irrelevant in and of itself, was at the same time essential to the film plot.  These MacGuffins, according to Hitchcock, were on the one hand “ridiculous”, “non-existent”, “empty”, and inherently without meaning, and yet, at the same time, the central point around which the entire story turned.
Should we begin to view DSM diagnoses as MacGuffins instead of discovered (neurobiological?) truths about the individual, they might begin to lose their superstitious power over our society.  Following the MacGuffin idea, questions arise about which narratives and characters are served by the diagnosis MacGuffin (like the pharmaceutical industry and mainstream professional psychiatry), and about whether there are other, perhaps more socially desirable alternatives to replace this particular plot vehicle?  And perhaps, more importantly, who gets to author narratives of self and who decides which narratives are to be considered preferable?  What new spaces and possibilities might we create for dealing with social, political and ethical questions, if we were to begin to develop other post-therapeutic vocabularies and discourses?
These are among the issues that are discussed in the current special issue of the Australian and New Zealand Journal of Family Therapy that was recently released as open access, in synch with the release of the new DSM 5.  From their beginnings in the post war 1950’s, the family and systemic psychotherapies have a long history of developing alternatives to mainstream medical and psychological theories, theories that challenged the individualizing, de-politizing and pathologizing  tendencies of the dominant medical, behavioral and psychoanalytic models.  And although the charge to achieve acceptance in the form of insurance billing rights has largely shifted the field’s emphasis away from critique and towards adaption and adjustment with the dominant medical model, the editors of this journal, Tom Strong and Robbie Busch, in gathering together this array of diverse perspectives, show that there is some critical spirit still alive and kicking within the field.  This collection of articles offers readers an alternative and constructive range of experiences, perspectives, opinions and practical approaches in the conversation between family therapy and the DSM-5.

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For a more comprehensive examination of the diagnosis MacGuffin as well as a call for new visions that move us beyond the therapeutic state, you are welcome to read the following article that we published here at MIA.
A conference touching upon many of these issues, “Beyond the Therapeutic State:  Collaborative Practices for Individual and Social Change,” will be held in June of 2014.