Fixing The DSM
Guest article by Matthew of the Jinkies
The DSM-IV is The Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, published by the American Psychiatric Association, Washington D.C. (1994). This is the main diagnostic reference of Mental Health professionals in the United States of America. It catalogues mental disorders, including description, diagnostic criteria, treatment and research findings.
In my work as an activist I seem to find myself discussing the DSM-IV's classifications much of the time. Be it asexual, transgender or plural activism, the same theme seems to arise: A disorder in the DSM-IV exists that seems to describe our experience of sexuality/gender/existence. It implies things about what comes with that and what is required to be like us. It implies that our experience is broken or disordered.
Let's focus on plurality. The DSM-IV defines two disorders that cover the plural experience.
Dissociative Identity Disorder describes a very specific form of plurality. There are a number of apparently arbitrary criteria for how the plurality must be experienced; any other experience of plurality would not be DID. These criteria include: loss of memory when others in the group are using the body; being, at least initially, unaware of each other; being formed due to severe and repeated childhood trauma. The criteria for DID also make it clear that the condition is a form of dissociation. (The implication is presumably that in perceiving others in the body, a person is dissociating from parts of their 'own' personality or memory.)
So, DID is not described by the experience of being more than one entity working within a single body. Instead, it is defined by a number of symptoms which tie the disorder to a very specific way of being, a subset of the plural experience. We would instead suggest that one is plural if one shares their mind and/or body with others.
Dissociative Disorder Not Otherwise Specified is a cover-all disorder for any kind of dissociation that is not defined by the specific criteria of other DSM-IV dissociative disorders. The DSM treats plurality as a type of dissociation: therefore DDNOS covers all experiences of plurality not defined under DID. It should be noted that DDNOS is an extremely wide term, which also covers a variety of experiences to do with dissociation (mentally distancing yourself from some aspect of your body, life or experience) none of which have any particular connection to plurality (although, due to the nature of DID as defined, it could be seen as an extension of Dissociative Fugue. However this does not match the reality of plurality as it is experienced).
There are a number of complaints that one could raise about these disorders.
Firstly, plurality is defined as to do with dissociation. There certainly exist those who experience a plural existence due to dissociation of some kind, but there are many others whose plurality is absolutely nothing to do with dissociation. Many would say that, by defining plurality as dissociative, the rest of plural experience is written out of existence.
Secondly, the very specific arbitrary criteria for DID emphasise that subset of plural experience as being 'the official way' to be plural. Plural people may believe that they cannot share the plural experience -- many individuals sharing one body -- because they do not meet the criteria of DID. By being relegated to DDNOS, they might believe themselves to be other or less than plural (I've seen people self-deprecatingly complain that they "can't even get dissociation right" when given this diagnosis). This promotes arbitrary divisions amongst plural people, leaving those who have DID focusing on the diagnostic criteria and those who have DDNOS believing they are 'not multiple'.
So do we need to fix the DSM?
It's clear that there are many problems with the descriptions of plurality currently given. The experience of many plural people could definitely be improved if the DSM more accurately reflected the diversity of plural experience.
But what is the DSM? It's used by psychiatrists to identify disorders in their patients. While some systems experience difficulties connected to their plurality, perhaps due to problems with in-system communication, there is nothing inherently disordered about sharing your body with others. (A more pragmatic view sees the DSM as a catalogue of billing codes for insurance companies: if one's condition cannot be identified in the book, one's insurance company will not meet the cost of treatment. In fact, in many cases psychiatrists will give the diagnosis of DID if the patient manifests 'multiple personalities' rather than if they meet the actual criteria of DID).
The DSM does not exist to describe all the variants of functional human experience. It specifically lists disorders. Do we really want to put our energy into giving ourselves a more representative disorder? Is it really desirable to seek visibility through changing the way a disorder is defined? Do we even want the plural experience classified as disordered?
If plurality itself is not inherently disordered, then perhaps it has no place in the DSM. While it is desirable for psychiatrists to understand the reality of plurality when treating people within plural systems or helping entire systems who require assistance to become more functional, should this visibility be achieved by classifying plurality itself as a disordered condition? I would suggest that visibility and understanding of plurality in general society would achieve this without pathologising the plural condition itself. People who are functional but different from the norm gain recognition and visibility in society through the media, through activism and through just being themselves and not hiding who they are from friends and colleagues.
Plurality is a valid way for human beings to exist. It is just as valuable as singularity. It is definitely the case that some plural people experience great discomfort from the experience of sharing their body, even if their system otherwise functions smoothly, but is this a case for maintaining the DID and DDNOS diagnoses? Should a system be shaped into a singular form if some of its members have issues with their position?
I would suggest that the next revision of the DSM should replace DID with 'Ego-Dystonic Plurality'. (There is a current classification, 'Ego-Dystonic Homosexuality', where homosexuality, not a disorder in itself, causes great discomfort to the level of being a disorder.) This would recognise the existence of plurality and that some systems and members of systems can have problems with being plural. The disorder in this case would not be plurality itself, but would instead be the inability to accept or function with that reality. The treatment would be help in accepting or functioning within that reality, not an effort to change it.
Some people are disordered by their plurality/asexuality/transgenderism; the rest of us need not be pathologised simply by the fact of being different from the accepted norm.
So should we fix the DSM? Perhaps. It would be useful to remove DID and leave more open, inclusive criteria for plurality in its place. Little-known or -understood experiences, such as asexuality and indeed plurality, might gain from more accurate or inclusive definitions, but our work in defining and promoting these criteria should not focus on the DSM. Non-disordered experiences do not belong in the DSM: they belong in the world, in the media, in fiction and in our lives. General understanding of our 'variant' lives will not come from the psychiatric community; it will come from our example.
PUBLIC COMMENT WANTED on Changes to the DSM-V Support criterion C! If criterion C is included, natural and self-recognized multiples can be out in therapy without necessarily getting a DID diagnosis.