DSM-5: How the Emperor Got His Clothes

Therapist and author Gary Greenberg presents “DSM-5: How the Emperor Got His Clothes” at the 2012 International Society for Ethical Psychology and Psychiatry (ISEPP) Conference in Philadelphia, PA. Greenberg is a practicing psychotherapist in Connecticut and author of “The Noble Lie” and “Manufacturing Depression.” He has written about the intersection of science, politics, and ethics for many publications, including Harper’s, the New Yorker, Wired, Discover, Rolling Stone, and Mother Jones, where he is a contributing writer. This is latest in a series of conference presentations which will be featured on MadinAmerica.com


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. My question is, who or what oversees the APA? They’re a loose cannon that is left to oversee itself and we all know how well that works! Because of this, the APA feels no need to be honest and transparent, and can lie as much as it wants to the American public. A prime example of how absolute power corrupts absolutely. This presentation also supports what Paula Caplan points out about trying to get the APA to respond to the complaints lodged against it. It just refuses to deal with anything and gives no reason as to why it chooses to deal with people this way. Nothing but smoke and mirrors combined with snake oil and flim flammery par excellance! Sheer quackery! And yet the American public accepts it all; hook, line and sinker.

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    • I am so happy that someone is talking about the APA. I don’t understand how such a “governing body” allows a “Dr.” to practice however they like without any overseeing? Think about it, if a medical doctor (non-psychiatrist) fell asleep on the job, let’s say, there would be serious mal-practice suits going on and possibly a loss of license. But if a psychologist does the same on a “patient’ let’s say for years, he or she gets off scott free! There is no oversight, there are no checks and balances. Therapists have the potential to affect a person’s life in a way that is MORE dangerous than other types of doctors. So why do we let therapists have free reign? It only stops when the therapist does some so egregious as sleeping with a “patient” or taking their money, at which point, action is taken. Think about this!!!! I had a therapist (psychiatrist) when I was young who slept, EVERY SESSION, for four years! I was too fragile to let anyone know what was happening. I assume that this human being is still working. I had another therapist who insisted on calling me constantly and generally invading my life to the point where it became a “cult-like” situation. I extricated myself with great difficulty. This man is still practicing. Yet another therapist decided to eat food every session. I was again to fragile to speak up, so she thought that was perfectly ok. What does it all mean? It means that people are getting “screwed” by therapists who have no checks and balances on them by the APA. Therapists can do whatever they want, and they do. They exercise tremendous control over a person’s mind (especially a fragile one) and they violate rules of practice, never get caught and continue making money at it. Enough is enough!

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  2. “The DSM is a mutt, but our mutt till something better comes along?”

    Yet is that something better already here and this blaming shaming game of social politics, in which we are here engaged, truth & reality are not the agenda. Business as usual social politics is the agenda, in order to cover-up the real agenda of survival need, and its raw energies of human motivation.

    Perhaps Gary Greenberg would come to see that something better, if he were to take the time to disengage from the one up man-ship of social politics and engage with others of his profession, who are in fact engaging with the cutting edge of science and art of psychotherapy.

    Although, perhaps, like I did, he finds dealing with the raw emotive power of sensation & emotion difficult. Perhaps, like I did, he finds the pale imitation of life in our cognitive constructs, easier to cope with in the face to face reality of mutually constructed, two person therapy.

    In my journey, it was a personal failing during therapy with my clients that was partly responsible for a deep need to discover the meaning of the word “affect.” A word which cannot be fully understood by way of conscious awareness, and the reason the social politics of debate will continue dance around the real issue in mental health, our evolved human nature.

    Reader’s may like to consider excerpts from the cutting edge of science & psychotherapy and perhaps come to understand their own need to avoid real self-awareness, and the double-bind in our nature, contained in our brain-nervous systems. Please consider;

    “An essential clinical principle in working at the edges of right brain windows of affect tolerance dictates that at some point the threatening dissociated affect must be activated, but in trace form, and regulated sufficiently so as not to trigger new avoidance.

    “The questions of how much and when to activate or to permit this activation, so as to repair the dissociation rather than reinforce it, must be addressed specifically for each patient” (Bucci, 2002, p. 787). According to Bromberg, “Clinically, the phenomenon of dissociation as a defense against self-destabilization … has its greatest relevance during enactments, a mode of clinical engagement that requires a [therapist’s] closest attunement to the unacknowledged affective shifts in his own and the patient’s self-states” (2006, p. 5).

    This self-destabilization of the emotional right brain in clinical enactments can take one of two forms: high-arousal explosive fragmentation or low-arousal implosion of the implicit self.

    Visualize two planes of one window of affect tolerance in parallel to another window: One represents the patient’s window of affect tolerance, and the other the therapist’s window of affect tolerance. At the edges of the windows, which are the regulatory boundaries, the psychobiologically attuned empathic therapist, on a moment-to-moment basis, implicitly tracks and matches the patterns of rhythmic crescendos/decrescendos of the patient’s regulated and dysregulated ANS with his or her own ANS crescendos/ decrescendos.

    When the patterns of synchronized rhythms (represented as oscillating dynamic changes within the windows) are in interpersonal resonance, this right brain– to– right brain “specifically fitted interaction” generates amplified energetic processes of arousal, and this interactive affect regulation in turn co-creates an intersubjective field between the surfaces of two parallel planes.

    The dynamic intersubjective field is described by Stern (2004) as “the domain of feelings, thoughts, and knowledge that two (or more) people share about the nature of their current relationship. This field can be reshaped. It can be entered or exited, enlarged or diminished, made clearer or less clear” (p. 243, my italics).

    An intersubjective field is more than just an interaction of two minds, but also that of two bodies, which— when in affective resonance— elicit an amplification and integration of both CNS and ANS arousal (see chapter 3 of Schore, 2003b, on the communication of affects in an intersubjective field via projective identification). At present there is an intense interest in incorporating the body into psychotherapeutic treatment.

    The solution to this problem is to integrate into clinical models information about the autonomic nervous system, “the physiological bottom of the mind” (Jackson, 1931).

    This system generates vitality affects and controls the cardiovascular system, effectors on the skin, and visceral organs. Stress-induced alterations in these dynamic psychobiological parameters mediate the therapist’s somatic countertransference to the patient’s nonverbal communications within a co-constructed intersubjective field.

    The ANS contains dissociable sympathetic energy-expending and parasympathetic energy-conserving components. Extending this intraorganismic concept to the interpersonal domain, two dissociable intersubjective fields may be co-created: (1) A sympathetic dominant, high-energy intersubjective field processes state-dependent implicit memories of object relational– attachment transactions in high-arousal states (Table 3.1); and (2) a parasympathetic dominant, low-energy intersubjective field processes state-dependent implicit memories of object relational– attachment transactions in low-arousal states (Table 3.2).

    Note the contrast of somatic transference-countertransferences in the dual intersubjective fields. Also, the form of primary process expressions in affect, cognition, and behavior differ in ultra-high and low-arousal altered states of consciousness.

    Thus high- and low-arousal states associated with terror and shame, respectively, will show qualitatively distinct patterns of primary process nonverbal communication of “body movements (kinesics), posture, gesture, facial expression, voice inflection, and the sequence, rhythm, and pitch of the spoken words” (Dorpat, 2001, p. 451).

    Recall that sympathetic nervous system activity is manifest in tight engagement with the external environment and a high level of energy mobilization and utilization, whereas the parasympathetic component drives disengagement from the external environment and utilizes low levels of internal energy. This principle applies not only to overt interpersonal behavior but also to covert intersubjective engagement-disengagement with the social environment, the coupling and decoupling of mind– bodies and internal worlds.

    Recent models of the ANS indicate that although reciprocal activation usually occurs between the sympathetic and parasympathetic systems, they are also able to uncouple and act unilaterally (Schore, 1994). Thus the sympathetic hyperarousal zone and parasympathetic hypoarousal zone represent two discrete intersubjective fields of psychobiological attunement, rupture, and interactive repair of what Bromberg (2006) terms “collisions of subjectivities”

    It should be noted that just as emotion researchers have overemphasized sympathetic dominant affects and motivations (flight– fight), so have clinicians overly focused on the reduction of anxiety-fear or aggression-rage states. An outstanding example of this continuing bias is the devaluation of the critical role of dysregulated parasympathetic shame and disgust states in almost all psychotherapeutic models.

    Similarly, psychodynamic affective approaches have highlighted the roles of rage and fear-terror in high-arousal enactments, and subsequent explosive fragmentation of the high-energy intersubjective field and the implicit self. As a result there has been an underemphasis on the low-energy, parasympathetic dominant intersubjective field. This is problematic, because clinical work with parasympathetic dissociation, “detachment from an unbearable situation,” is always associated with parasympathetic shame and disgust dynamics.

    Indeed two of the most prominent shame theoreticians, Gershon Kaufman (1989) and Michael Lewis (1992), have hypothesized that dissociative disorders represent a pathology of the self based fundamentally on unacknowledged (implicit) shame. I would like to offer some thoughts about these two potent negative affects that appear in the low-arousal intersubjective field.

    In my very first work I proposed that the parasympathetic state of shame, a highly visual affect subjectively experienced as a “spiraling downward,” represents a sudden shift from sympathetic energy-expending hyperarousal to parasympathetic (dorsal vagal) energy-conserving hypoarousal (Schore, 1991). I expanded this model in my 1994 book, in which I offered a developmental model of the interpersonal attachment origins of the primary social emotion of shame in socialization dynamics that onset in the second year.

    At about 14 months,   [T] he toddler, in an activated, hyperstimulated, high arousal state of stage-typical ascendant excitement and elation, exhibits itself during a reunion with the caregiver. Despite an excited expectation of a psychobiologically attuned shared positive affect state with the mother and a dyadic amplification of the positive affects of excitement and joy, the infant unexpectedly encounters a facially expressed affective misattunement, thereby triggering a sudden shock-induced deflation of narcissistic affect.

    The infant is thus propelled into an intensified low arousal state which he cannot yet autoregulate. Shame represents this rapid transition from a preexisting high arousal positive hedonic state to a low arousal negative hedonic state. (1994, p. 203)   In the same work I integrated various observations of shame researchers and clinicians in order to describe the prototypical painful autonomic concomitants of the nonverbal, highly visual emotion of shame, including its rapid (re) expression in the intersubjective field during a stressful mis-attunement-triggered rupture of right brain– to– right brain therapist– patient attachment communications. At all stages of the life span, the mis-attuned relational transactions of shame trigger gaze aversion (Tomkins, 1963), a response of hiding the face “to escape from this being seen or from the one who sees” (Wright, 1991, p. 30) and a state of withdrawal (Lichtenberg, 1989).

    Under the lens of a “shame microscope” which amplifies and expands this negative affect (Malatesta-Magai, 1991), visible defects, narcissistically charged undesirable aspects of the self, are exposed (Jacobson, 1964). “It is as though something we were hiding from everyone is suddenly under a burning light in public view” (Izard, 1991, p. 332).

    Shame throws a “flooding light” upon the individual (Lynd, 1958), who then experiences “a sense of displeasure plus the compelling desire to disappear from view” (Frijda, 1988, p. 351), and “an impulse to bury one’s face, or to sink, right then and there, into the ground” (Erikson, 1950, p. 223). This impels him or her to “crawl through a hole” and culminates in feeling as if he or she “could die” (Lewis, 1971, p. 198). The sudden shock-induced deflation of positive affect that supports grandiose omnipotence has been phenomenologically characterized as a whirlpool— a visual representation of a spiral (Potter-Effron, 1989)— and as a “flowing off” or “leakage” through a drain hole in the middle of one’s being (Sartre, 1957, p. 256).

    The individual’s subjective conscious experience of this affect is thus a sudden, unexpected, and rapid transition from what Freud (1957a) called “primary narcissism”— a sense of being “the center and core of the universe”— to what Sartre (1957) described as a shame-triggered “crack in my universe” (Schore, 1994, p. 208). Note the right brain perceptual and painful bodily based alterations that herald an implosion of the implicit self and a state of passive disengagement. Sylvan Tomkins (1963), a pioneer in affective science, contrasted the pain associated with the sympathetic terror state with that of the parasympathetic shame state:  

    Though terror speaks of life and death and distress makes of the world a vale of tears, yet shame strikes deepest into the heart of man. While terror and distress hurt, they are wounds inflicted from outside which penetrate the smooth surface of the ego; but shame is felt as an inner torment, a sickness of the soul. It does not matter whether the humiliated one has been shamed by derisive laughter or whether he mocks himself. In either event he feels himself naked, defeated, alienated, lacking in dignity or worth. (p. 118)”

    Excerpts from “The Science of the Art of Psychotherapy” by Allan N. Schore.

    It is “awareness” of internal states of being which are “hidden” from public view in our normal social politics of shame. Just as a need to the maintenance a comfortable internal state makes it easier to prescribe a medication than deal with the raw emotive energies of real-life survival at the heart of mental illness.

    Our consensus reality or cultural zeitgeist is built on a need to deny such internal states of being in order to maintain an emotive equilibrium, calm, balance or harmony within our so-called civil society. A need of denial which has led to a cognitive construct of civilization riddled with un-civil conflicts of interest in the survival game of social politics.

    Perhaps people may come to understand that the Emperor with no clothes is actually the human mind and its need to deny the body and the power of “affect.”

    Best wishes to all,

    David Bates.

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    • Well David, I skimmed the surface.
      I dare say, even this read is hypothesis, presented as something real.
      Many therapists play games in their own minds, and practice on people,
      which itself is dangerous.
      Why bring this kind of game into therapy, unless you are dealing with
      an equally interested person into their own crevices?

      So would this analyses and hypothesis then be it? The final word?
      Many people are still able to live a partly happy life until someone plays with
      their minds.

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