Self, Narrative, and the Culture of Therapy

In her thought-provoking paper, Tekin (2014) investigates some of the factors that contribute to a mood disorder patient’s self-insight. Tekin argues that a psychiatric diagnosis in some cases impacts decisively the patient’s self-reflection, to the extent that her interpretation of her actions and interpersonal relationships becomes filtered through the ‘lens’ constituted by the relevant symptoms described in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In her view, a person suffering from a mood disorder has impoverished self-insight, and her comprehension of events and states of affairs in her life is dominated by the symptomatology of the disorder. Without denying that the DSM’s symptom-based descriptions are valuable in clinical settings, Tekin’s point is that the DSM’s ‘hyponarrativity’ and the lack of emphasis on unique individual circumstances contribute to impoverished self-insight.

Tekin rightly draws attention to an often forgotten aspect, namely, the fact that the DSM is embedded in a complex social, cultural, and institutional context. To measure the effect that the DSM and its particular symptom-based approach has on self-reflection and insight, a methodologically adequate analysis must also take into account what Tekin refers to as the ‘DSM culture,’ which includes the sociocultural environment in which the DSM-informed representation of mental disorders circulates outside the clinical context. I agree that attending to this sociocultural dimension is crucial for a suitable analysis of the phenomenon in question, but I also think that there is a sense in which Tekin’s project should go further. The ‘DSM culture’ is itself embedded in and rendered intelligible through a deeper cultural understanding of self, health, and disorder. In what follows, the aim is to contribute to Tekin’s project by uncovering this deep layer of our collective self-understanding, particularly a therapeutic discourse and a specific therapeutic narrative of the self.

Therapeutic Discourse

Some important roots to our current understanding of self and the social world emerged in the late eighteenth century. Since then, there has been an increasing recognition of the fact that, to an extensive degree, the building blocks of our identities are intrinsically tied to key images and narratives that frame our experiences and embody the values that guide our actions. The nature of these building blocks is largely intersubjective, and they are only available from within a socio-cultural context, which ultimately functions as the normative source of identities. In other words, being embedded in a culturally shaped horizon of significance is necessary for a process in which we constitute ourselves by making up our minds about what we care about (Taylor 1991; Varga 2011).

At the same time, with regard to the building blocks of our identities, the development of the sociocultural institutions of modernity has generated a rather arduous ambiguity. Eva Illouz (2003, 2008) has compellingly described how developments in modernity have created previously inexistent forms of psychological distress, while at the same time heightening an individual’s sense of entitlement to a life devoid of such distress. It is in the midst of such ambiguity between a growing sense of entitlement and forms of psychic suffering generated by modernity that it was possible for psychology and a specific therapeutic discourse to achieve the massive cultural influence that it still enjoys today.

Therapeutic discourse can be traced back to several factors, but among the most important ones are Freudian psychology and the nineteenth-century New Thought, which, among other things, aimed at cultivating ‘healthy-mindedness’ and at conveying the optimistic message about the healing ability of belief. As branches of Freudian psychology increasingly became compatible with the ‘self-help’ movement, the message was that ‘individual growth’ and the ‘whole self’ are ultimate goals that are actually reachable by deliberate acts of will. In addition, with the work of Carl Rogers and Abraham Maslow, therapy increasingly envisioned helping to enable self-realization, and forms of mental disorder became regarded as distortions of the normal unfolding of the self. The mentally healthy person was now practically identical to the self-actualizing individual, while...