Demystifying the DSM 5
Lawyers and judges mean well, at least most of the time. At least I think we do. But although courtrooms are theaters at which life-defining dramas are conducted, the law is blind to life's larger purposes. To explain things, we turn often to experts. To explain the twists and turns that lead some folks to ruin, we call upon psychiatrists. What if it turns out the shrinks don't know much more than we do?
I read Joel Paris's, The Intelligent Clinician's Guide to the DSM 5, with a sense of desperation. A new Diagnostic and Statistical Manual. Good, I thought. Surely, I can turn there to get a better road map to help me understand the raw need with which many clients come knocking on my door. I am a criminal defense and civil rights lawyer; from time to time I litigate high-conflict divorce cases. I often look at the client sitting across from me with the sense that I must translate a foreign language to them. The law deals with "reasonable people." These fictions are said to "bargain in the law's shadow." I am supposed to help them understand the law. It is too often speaking Greek to the deaf.
The law does an okay job at getting the obvious cases right. A person who is insane cannot conform his or her conduct to the requirements of law, so-called volitional insanity; a person who doesn't know what they're doing might suffer cognitive insanity. These cases are rare. More common are folks incompetent at the time of representation -- folks who cannot either understand the nature of the charges against them, or are incapable of assisting in their own defense. These are easy cases, I say.
The harder cases are the day-to-day grist of a criminal lawyer's mill: Folks whose vision of the rational just isn't anything like what the law is prepared to call reasonable. The law is less reason's cheerleader writ large than it is a series of cattle prods, directing folks against their will down foreign chutes. Lawyers, who lack any training in mental health, are supposed to counsel all manner of people. Yet what of those folks with personality disorders -- the borderline, the narcissistic? How does a lawyer reach them? We get zero training in law school on mental health.
I assumed the DSM 5 might offer some tips, a guide for the untutored in the uncharted land not of florid mental illness, but of the near-craziness that clogs court dockets. I hoped a book on using DSM 5 written for clinicians might offer help.
Paris offered no hope. The manual is less hard science rooted in a sense of causation and course of disease than it is an impressionistic survey. What drives classification of mental health issues is often the desire of pharmaceutical companies to sell the latest drug. Fads influence diagnostic decisions more than we like to think, hence the great rush to conclude that ever more folks are depressed, or suffering from ADHD. Need insurance reimbursement? Then fight for recognition of your "illness;" if you get get the diagnostic right codes, you might just get paid. Where to draw the line separating the harsh reality of life from mental illness? Paris struggles as much, apparently, as do lawyers.
Paris writes eloquently and persuasively about the shortcomings of the DSM 5. He notes its diagnostic algorithms are too complex for busy clinicians. What governs in medical offices are impressionistic surveys and conclusions.
Ouch, I say. A thousand times ouch. By the time an expert testifies in court, all ears are attuned to listen to great truths about the psyche. So much in the law turns on circumstantial evaluations of mental state. We need help distinguishing specific intent, intent, recklessness and negligence. What if it turns out the psychiatric experts have little to say? Are we kidding ourselves by listening to them?
Read Paris's splendid little book if for no reason other than to understand that the DSM 5 is no Bible -- not even close. It turns out medicine is not much better than the law at understanding why some people suffer so much more than others.
In the meantime, I'm still looking for accessible literature that will help me understand the avalanche of human need I see daily. Any recommendations?