The Cultural Diffusion of the DSM

(Reader Warning: Long, winding, potentially nonlinear post ahead)

Cultural Diffusion, anthropologists say, relates to the process of new information, experiences, and syntax being absorbed into the culture. Once a large group of people start to behave on the new data, cultural diffusion has taken place. It is a sideways spreading phenomenon, as opposed to the familiar concept of education. Education has a finite starting point and it flows downward. Cultural Diffusion is crowd sourced. We can’t pin down the Genesis and the path isn’t linear.

We find it most obviously in language. Spend any amount of time in a non-opera crowd and you’ll likely hear words like, “Bruh, Fire, Bougie (you’ll see this spelled “Boujee” but that’s just wrong. Speaking of wrong, so is the meaning. The word originates in France in the 16th Century and it literally means “middle class” so today’s interpretation of “high class” or “fancy” doesn’t make sense to me). There’s also Bussin, Drip, Salty, Extra and Facts. Two of those words have made it into my regular vocabulary. Maybe three. That’s cultural diffusion. I heard them, inquired about them, made fun of them, and now they’re in me. Bruh!

Cultural diffusion is less obvious in our belief systems. We are traditionally quiet about what we believe. There are few societal wounds that cut deeper than being mocked by a crowd we respect for what we believe. When I was a young man I earned enough spending tickets to receive an invitation to traffic school. The room was filled with recidivistic rascals such as myself, but we were all strangers to each other, bound only by our inability to spot the pope around the corner. About an hour in, the instructor (who looked thrilled to be spending his evening with us) asked a question of the group. I can’t recall the question, or why I thought it was a good idea to speak up. I don’t even remember what I said. What I do remember is the entire room, including the instructor, all broke out in mocking laughter. This was over 30 years ago. I don’t answer traffic related questions in public anymore.

Sometimes language and beliefs cross streams and join together to form a lava flow of misinformation and misunderstanding. I think that’s exactly the tsunami we are in right now as it relates to mental health. Put a pin in that thought for a moment and we’ll come back to it.

Let’s talk about stigma for a minute. Stigma is a set of negative and unfair beliefs, accepted by a group of people, that imposes shame on another group. The desired effect of stigma is to discredit a group of people. For instance, we have a societal stigma against unhoused individuals. Unhoused individuals have far less power than their housed counterparts. The group has been discredited by society as a whole. We walk around the unhoused as if they are venomous. We certainly don’t seek either their counsel or permission. We have collectively placed a stigma this group, assigning them to a lower price tag, societally speaking.

After 9/11, with the speed of a wind swept wildfire, our country developed another stigma against citizens of middle eastern descent. Those individuals felt a new and sudden shame, being singled out for discrimination and violence based only on their heritage. Arabs, Persians, and Turks who dared attempt to fly in the months following the attack were sure to experience, at a minimum, a thorough search by TSA. In many other cases, they experienced physical and verbal assault. Their businesses shuttered due to declining customers. It was a widely held belief that the Muslim community was at war with the West. While this myth was completely false, it relegated the over 1% of the population who follow the Quran to, at a minimum, the kids table at Thanksgiving. In many more cases, they weren’t even allowed the scraps from the meal.

Stigma, simply put, is a mark of shame.

Mental healthcare has also experienced a long standing stigma throughout our history. I live in Lexington, Kentucky, home to Eastern State Hospital, the country’s second oldest Psychiatric hospital in the US. Until 1912 (it began in 1817) it wore a number of warm, inviting names such as: The Lunatic Asylum, The Lunatic Asylum of Kentucky, The Kentucky Lunatic Asylum (would loved to have been in the board room for than name change), Eastern Kentucky Asylum for the Insane, etc. For context, if you had symptoms consistent with a mental illness in the 1800’s, you might be a good candidate for trepanation. An ancient practice, trepanning was the practice of having a hole drilled in your head so the evil spirits had an avenue of escape. Oh yeah, this was done without anesthesia. The most widely utilized treatment for mental illness during this era was simply confinement and isolation. Often in cages. Another popular treatment of that time was an evidenced based practice called the Rotating Chair. They would place the patient in a chair and spin it around really fast, inducing vertigo, nausea, and vomiting. The belief was that the treatment would cause the patient to “purge” themselves of their ailment. The intensity of the rotation would increase based on the severity of mental illness.

As we evolved in our knowledge of the brain and how to treat those symptoms, the stigma began to reduce. Thankfully that stigma continues to dissipate. Currently, if you are under 30 years old, it might even be lit to have a therapist, tbh. Culturally, we are speaking of mental health symptoms with almost the same ease as physical health symptoms. Almost. Among the younger generations at least. This reduction in stigma has had some amazingly positive results in our culture.

Studies indicate a strong rise in help seeking behavior in the US, much of it due to the reduced stigma and the social acceptance of therapy. Outcomes also report people are more engaged in their mental health care, staying in treatment longer and reporting increased resolution for their symptoms. The American workforce reports increased employee productivity due to the quality and availability of mental health services. While there are few longitudinal studies that can delivery data to support this, American corporations are on track to spend $4.5 Billion dollars on EAP services. You can bet they’re not doing it to be nice.

So, way to go America! We’re moving the stigma line in the right direction!

OK, now back to that pin I asked you to use. The cultural diffusion of language and beliefs related to mental healthcare has created a problem in our current society. Namely, the general public has learned our terms. And they’re using them, integrating them, with barely a cursory understanding of the meaning or criteria. Our terms are leaking into the lexicon, and that’s not slay.

Here’s a few examples:

1. How many people do you know who claim to have OCD? I didn’t have to tell you what it stood for, did I? Around 1% of the population is at risk of having the condition sometime in their lives. But I’m hearing far more than 1% of the population talking about having it. I’ve even seen a van advertising a cleaning service who’s name was: OCD Cleaning. Diffusion has now co-opted the mental disorder to mean: “People who like order.” Well, that’s half of us! Half of us are soothed by order and the other half soothed by chaos. It’s pretty easy to tell which type you are: You’re now reading a blog for (hopefully) pleasure. Look around you right now. What do you see? Order or chaos? Good chance that’s what you like. But that’s not OCD. That’s just OC. No D. Meaning, you likely have features of obsessive or compulsive behaviors, but it doesn’t rise to the level of a disorder, because it doesn’t cause significant distress in your life.

In the DSM 5, (check out the criteria for yourself) the first criteria states, “Presence of Obsessions: Obsessions are recurrent, persistent, and intrusive thoughts, urges, or images that cause significant distress. These thoughts are not simply excessive worries about real-life problems. (italics mine). The third criteria says, in part, that the symptoms: cause clinically significant distress or impairment in daily functioning, social interactions, or occupational activities.

I’ve had clients come into my office certain they had OCD because they checked the front door twice before leaving. That’s not OCD, that’s just being smart.

2. If you do a little cursory googling, you’ll read that the prevalence of Bipolar disorder in the US is around 2.8%. That number is impacted, in part, by the number of people diagnosed with the condition. So I’m not sure how accurate that number is. Bipolar disorder might be one of the most over diagnosed conditions in our field (next to ADHD). Is it a real mental health disorder? Of course it is. Those that deal with Bipolar I and Bipolar II have a tight, narrow path, filled with obstacles to navigate in order to terminate or manage their condition. But I hear this word being tossed out in public like it’s a common condition. People who have a good day then a bad day are called Bipolar. People who are excited to see Taylor Swift in concert are called manic (that’s not mania, that’s just the ability to recognize damn good music). People who are sad are called depressed. Adolescents who culturally code shift from one group to the next are finding themselves in a psych office being prescribed life changing medications. Bipolar accusations show up regularly as weapons in couple’s counseling.

Here’s one way to spot cultural diffusion: Listen for a well placed “The.” Walmart existed for years, then became part of our collective vocabulary. About that time, we started hearing people say they were going to “The” Walmart. Similarly, I frequently overhear people use the phrase, “I bet he has the bipolar.” Anecdotal, I know. But still.

3. I’ve saved our most egregious bastardization for last. I bet you know what it is. This condition affects between .05%-5% of the population and it may be the most misunderstood, misapplied, and manipulated of all of our terms: Narcissistic Personality Disorder. While it’s true that the presence of narcissistic traits does not warrant a diagnosis of NPD on its own, the emergence of the word “gaslighting” in our everyday language should give us a clue as to its overuse. I’ve participated in roughly 20,000 therapy sessions over the years. That’s a lot of Kleenex! And I’d guess I’ve only ever encountered maybe 10 clients who met the diagnostic criteria for NPD. Maybe 15 on the outside. Anecdotal, I know. But still.

The co-opting of NPD is used more to describe relational dissatisfaction than anything else. I’ve even seen it lobbed at people who were confident, or sure of themselves, or who had the audacity to set firm boundaries. I overheard one conversation (I’m an ear hustler) at a coffee shop. A woman was complaining to her friend that her husband was a narcissist. Her criteria? Because he was mad at her for having an affair, thinking he was the only man on the planet. Even if he did think he was the only man on the planet, narcissism and arrogance are simply not synonyms.

One last trend I’m a little concerned about: I’m watching young therapists (and not so young) ride this cultural wave. Clinicians are being impacted by the cultural diffusion (see Conformity Bias). It might be wise for providers to return to the data and look at prevalence and criteria more closely. And pay attention to the phrase, “not better explained by.” What this means is, when considering the diagnosis, pay attention to what else might be going on in the person’s life that might better explain the client’s symptom narrative. Such as, if a client comes into your office with a 5 year history of methamphetamine dependence, and they were just discharged from an inpatient facility, maybe consider that their bipolar symptoms are not better explained by the SUD.

What I haven’t been able to sort out, and maybe this is where you can help me, is this: Which is the donor culture and which is the recipient culture in this diffusion process? I’m not sure which jersey I’m wearing most days. I guess I could always just pop some popcorn and sit back and watch.

But where’s the fun in that?