Alfred Hitchcock Presents:
The DSM-5


“Oh, that’s a MacGuffin.”

“What’s a MacGuffin?”

“It’s an apparatus for trapping lions in the Scottish Highlands.”

“But there are no lions in the Scottish Highlands.”

… So you see, a McGuffin is nothing at all.

– Alfred Hitchcock, explaining the “MacGuffin”

What does the new DSM-5 have in common with an Alfred Hitchcock mystery?  They both rely on a plot device, something Hitchcock called a “MacGuffin”, for their narrative power.  At least that is the story that my German colleagues Manfred Wiesner, Lothar Duda and I like to tell.

One assumption that the three of us have in common is that we believe our realities to be socially constructed, in relationships, through the stories that we tell.  This assumption has tremendous implications on the ways we think and act, and especially upon how we think and act as psychotherapists.  Adopting this perspective means giving up on the idea of universal “Truth” with a capital T, instead seeing truths as nothing more than temporary social and cultural agreements or stories, subject to change along with changing relationships and circumstances.

In his wonderfully creative novel The Life of Pi, Yann Martell illustrates this idea by describing the encounter between two Japanese insurance investigators trying to research the “truth” around the circumstances of a shipwreck, and the lone survivor of that shipwreck, through the following dialogue:

Mr. Okamoto:  “But for the purposes of our investigation, we would like to know what really happened.”

Pi:  “What really happened?”

Mr. Okamoto:  “Yes.”

Pi:  “So you want another story?”

Mr. Okamoto:  “Uhh… no. We would like to know what really happened.”

Pi:  “Does the telling of something always become a story?”

Mr. Okamoto:  “Uhh… perhaps in English. In Japanese a story would have an element of invention in it. We don’t want any invention. We want the ‘straight facts’, as you say in English.”

Pi:  “Isn’t telling about something—using words, English or Japanese—already something of an invention? Isn’t just looking upon this world already something of an invention?”

Mr. Okamoto:  “Uhh… ”

Pi:  “The world isn’t just the way it is. It is how we understand it, no? And in understanding something, we bring something to it, no? Doesn’t that make life a story?”

If we give up our belief in (and call into question) a received truth — like the dominant mainstream biological explanations for human suffering, for instance — then we begin to create space for pondering new questions.  Instead of busying ourselves with how to change biologically and mentally “diseased” minds into more healthy minds, for instance, we instead confront more philosophical and political questions.  Like; how shall we continue to live together?  Or, what stories allow us to think/live/feel/relate etc. in the ways in which we would prefer to think/live/feel/relate etc.?

These are extremely important, though very complicated philosophical and political issues.  They touch upon the very core of our existence and values as human beings.  Whose story gets told in a psychotherapy session, and using whose language?  For which purposes do we advance particular narratives? Whose stories get negated?  And who decides which stories and purposes should be preferred?

Along these lines of thinking, we view the DSM-5 as but one of many possible stories that may be told with respect to human suffering.  Who and how was this narrative developed?  Who benefits?  What is gained and what is lost with the adoption of this “new” version of psychiatric “reality”?

To explore these questions we borrow a concept that the late, great film director Alfred Hitchcock described in an interview with Francois Truffaut.  Hitchcock described the “MacGuffin” as a common plot device typically woven into film scripts.  For Hitchcock, a MacGuffin was a certain kind of object, one which although largely irrelevant in and of itself, was at the same time essential to the film plot.  These MacGuffins, according to Hitchcock, were on the one hand “ridiculous”, “non-existent”, “empty”, and inherently without meaning, and yet, at the same time, the central point around which the entire story turned.

Should we begin to view DSM diagnoses as MacGuffins instead of discovered (neurobiological?) truths about the individual, they might begin to lose their superstitious power over our society.  Following the MacGuffin idea, questions arise about which narratives and characters are served by the diagnosis MacGuffin (like the pharmaceutical industry and mainstream professional psychiatry), and about whether there are other, perhaps more socially desirable alternatives to replace this particular plot vehicle?  And perhaps, more importantly, who gets to author narratives of self and who decides which narratives are to be considered preferable?  What new spaces and possibilities might we create for dealing with social, political and ethical questions, if we were to begin to develop other post-therapeutic vocabularies and discourses?

These are among the issues that are discussed in the current special issue of the Australian and New Zealand Journal of Family Therapy that was recently released as open access, in synch with the release of the new DSM 5.  From their beginnings in the post war 1950’s, the family and systemic psychotherapies have a long history of developing alternatives to mainstream medical and psychological theories, theories that challenged the individualizing, de-politizing and pathologizing  tendencies of the dominant medical, behavioral and psychoanalytic models.  And although the charge to achieve acceptance in the form of insurance billing rights has largely shifted the field’s emphasis away from critique and towards adaption and adjustment with the dominant medical model, the editors of this journal, Tom Strong and Robbie Busch, in gathering together this array of diverse perspectives, show that there is some critical spirit still alive and kicking within the field.  This collection of articles offers readers an alternative and constructive range of experiences, perspectives, opinions and practical approaches in the conversation between family therapy and the DSM-5.


For a more comprehensive examination of the diagnosis MacGuffin as well as a call for new visions that move us beyond the therapeutic state, you are welcome to read the following article that we published here at MIA.

A conference touching upon many of these issues, “Beyond the Therapeutic State:  Collaborative Practices for Individual and Social Change,” will be held in June of 2014.


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Eugene Epstein
Steps to a Post-Therapeutic Future: With a strong interest in how popular culture and psychiatry/psychotherapy reflexively influence one another, Eugene writes critically about aspects of the therapeutic era or therapeutic state in which we, (that is, those of us living in parts of the western first world), find ourselves.


  1. You post reminds me very much of Post-modern thinking. There is no Truth but lots of little truths running around. After coming into contact with Post-modernism I’ve come to believe that the only thing that really matters is how I choose to define myself and the meaning that I give to my own “story.” Psychiatry cannot impose it’s bogus “truth” on my story nor does it have any right at all to try to do so. What I can’t understand is why it wants so badly to do so.

    Your article and the one writen earlier this year have much food for thought. Here in America family therapy seems to have fallen by the wayside.

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    • Yes, I think that one of the most powerfuladvantages of postmodern narrative theory, from a political standpoint, is that it shows the limits of the single (global or universal) story, and points toward the many positive aspects of polyvocality, along with the idea that multiple stories may exist concurrently.

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  2. The DSM is used to put metaphorical ropes on people, to drug them and control them. The new inquisition. Do you or your child have untreated mental illness?

    [Persecution is as old as man. What distinguishes inquisitions are communications, bureaucracy and single-mindedness. It is the last feature that gives rise to what Mr. Murphy calls “the inquisitorial impulse.”

    “Moral certainty ignites every inquisition and then feeds it with oxygen,” he writes. But to keep it going, one must also have an organized bureaucracy that establishes a set of repressive procedures that are formalized in law and enforced by an institutional power.]

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  3. I am a graduate of an art school that was ranked number one in the nation the year I graduated. And both my pre- and post- drugged up artwork relate to the concept of how to view reality. I played with the concept of layering various views, from different distances, of an object onto a canvas simultaneously. My theory is that no one views an object in exactly the same way. So by incorporating multiple views of an object to represent that subject matter, the viewer is reminded of the importance of multiple perspectives at various distances to truly understanding the reality of any object. And the viewer should also garner an understanding that everyone sees the world differently, and all viewpoints are part of the bigger picture, thus important. I think my attempts to capture, in the two dimensional world, these concepts is similar to your post modern theories.

    This being my perspective, you can imagine how insane it was for me to deal with the psychiatric industry – people who believe only in a completely unscientific “bible” that I knew nothing about, and felt only their perspective was reality. Literally, my former psychiatrist declared my entire life a “credible fictional story” in his medical records, after I confronted him with the fact I’d been handed over my family’s medical records with some of his comments of me. And I’d learned he’d drugged me up based on a list of lies and gossip from people I had medical evidence abused my child. But he never bother to believe a word I said, “I don’t believe her.”

    I believe life, and any understanding of such, must be multi-dimensional (i.e. a point is one dimension, a line is two dimensions, a cube is three dimensional, time is the forth dimension, etc. to the 11th dimension, according to the physics minded, I understand). Nonetheless, based on my dealings with psychiatrists, belief in the DSM and one’s own perspective of superiority only, is a strictly one dimensional view on reality, a dot.

    I don’t believe people with such an awe-inspiringly simplistic view of reality will ever be able to help others. I don’t mean to be rude, but I literally have never met dumber people than the “psychiatric professionals” I personally dealt with. Truly, change is needed within the psychiatric mind set, if the psychiatric professionals ever want to actually help their patients. How can you expect to help someone if you have no understanding whatsoever of who they are, what their history is, and what they’re now going through? You can’t. How insane to believe all people fit neatly into the psychiatric “bible” of stigmatizations.

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    • I am sure that, as an art school graduate, you are familiar with this famous line from Pablo Picasso:
      “Si hubiera una sola verdad, no se podrían hacer cien lienzos sobre un mismo tema.” or “If there were only one truth, it wouldn’t be possible to do 100 variations on the same theme.”
      The challenge is in expanding our tolerance for all of those possible variations.

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  4. Oh, as to the artwork I did while being drugged up and weaned off meds, those works do tell a story over time of painting iatrogenic bipolar. They are works that visually depict what it feels like to have one’s head smashed in, have atrophy of the brain caused, with a slew of drug “Foul ups.” And they include works that depict the drug withdrawal mania and psychosis, as well. So, they do visually represent the apparent reality that the DSM is a listing of the serious mental illnesses that the psychiatric drugs cause. I think the psychiatric industry should stop creating their mental illnesses in all people now, especially since they are “doctors” who had promised to “do no harm.”

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  5. Forgive me for being utterly disgusted by a psychiatric industry that has sunk to the level of drugging up mommies with medical evidence of child sexual abuse, because it is profitable for therapists to keep the child molesters on the streets raping the little children. Sexually abused children are easy to label with made up disorders, then torture with drugs. But this caused six children in my neighborhood to kill themselves. Then, of course, a subsequent cover up by the “caring,” but disingenuous, local psychiatric community. Please stop harming people, especially little children, “psychiatric professionals.”

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