Narrative Construction & Psychotherapy

Written By: Dr. Yedidya Levy

Mental health is intimately tied to narrative construction around the self. Many mental health diagnoses can be articulated, at least in part, as maladaptive self-conceptions. For example, the depressed individual might “see” themselves as some variation or combination of inadequate, hopeless, helpless, and so forth. The anxious individual may experience themselves as unsafe, weak, or threatened. The psychotic individual might experience themselves as persecuted, prophetic, messianic, or otherwise uniquely significant.

To understand what psychotherapy “does,” we first have to understand what constitutes mental illness, or the thing psychotherapy purports to remedy. Many scholars have noted the difficulty with the term “mental illness.” Depression, anxiety, and PTSD do not, as of yet, correspond to a single identifiable biological ailment. These diagnoses have biological correlates, but through biological means alone, we cannot diagnose a mental health disorder. Anxiety disorders are not diagnosed by brain scans, nor is depression diagnosed through samples of gut bacteria. Rather, the information used to confer a mental health diagnosis is gathered through an assessment with a mental health professional and is often supplemented by information from other sources.

Diagnosis in mental health involves gathering a history of symptoms and attempting to map them onto established criteria. This process is flawed for many reasons; I will name three. (1) Diagnoses are a coarse and overly generalized way of trying to understand idiosyncratic human suffering. (2) Diagnoses are highly dependent on the quality of the diagnostician, their interview style, and the openness of the patient to the questions being asked. (3) Diagnoses say relatively little about what is actually going on for the client. They are descriptions, not explanations.

As Allen Frances, Chair of the DSM-IV Task Force, has argued, mental disorders are best understood as constructs that are descriptive rather than explanatory and are useful primarily for communication and treatment planning rather than as definitive statements about causality (Frances, 2013).

In the hundred years that followed the introduction of psychoanalysis, the number of recognized mental health diagnoses multiplied, and diagnostic manuals expanded considerably. The Diagnostic and Statistical Manual of Mental Disorders is currently in its fifth edition, while mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949 and have been included in every subsequent revision (American Psychiatric Association, 2022; World Health Organization, 1949).

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.

Frances, A. (2013). Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. William Morrow.

World Health Organization. (1949). Manual of the international statistical classification of diseases, injuries, and causes of death: Sixth revision. World Health Organization.