Dissecting DSM

By John Soderlund

 "We can't service this claim until you provide us with a diagnosis," the claims administrator recited in a flat, tired tone. Like many medical insurance schemes, this one was becoming more insistent about having a detailed diagnosis before paying a claim. And not just any diagnosis would do.

At our next session, I put it to my client: "Adjustment disorder, with depressive mood (DSM 309.0) is how I think it most appropriate to classify the problems you're having," I explained. "But I can never be sure that they will reimburse for this. It depends on the case manager and whether he or she feels it appropriate that you are seeking protracted therapy for your difficulties at work."

The alternative, I explained, would be to stretch the diagnosis, say my client is depressed and be more sure of reimbursement. But labels stick. "I have real problems with these diagnostic schemes because I don't believe they tell anything near the full story. But we have to work within the system if you are to continue to receive a therapy benefit from your insurance," I continued.

We were stuck in the same web, an elaborate triangle comprising me, my client and his medical scheme which was extracting substantial sums of money from him in monthly premiums and promising support in return if we worked by its rage to order the puzzles of life satisfaction and its absence.

The slowly turning tide

But this rage to order has been attracting growing column inches of bad press in the past few years. Now, more than ever since the advent of the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other mental health professionals are beginning to question the utility of a diagnostic system which seems such a poor cousin by comparison to the medical diagnostic systems it tried to emulate.

That said, the ubiquitous influence of DSM is hard to miss. In a hard-hitting and powerfully argued critique of DSM, the Citizens Commission on Human Rights (CCHR) argues in an article entitled The quackery of labels (http://psychextortion.cchr.org/eng/page12.htm) that undermining the widespread influence of DSM is nigh an impossible task.

"Carefully honed and marketed by psychiatrists for over four decades, the DSM/ICD now feature heavily as diagnostic tools, not only for individual treatment, but also child custody battles, discrimination cases based on alleged psychiatric disability, court testimony, education, and more. In fact, wherever a psychiatric opinion is sought or offered, the DSM/ICD are presented and increasingly accepted as the final word on sanity, insanity, and so-called mental illness.

Not surprisingly, our everyday culture is so infused with the language of DSM that clients frequently present their own diagnoses with confidence that this will ease the task of the practitioner in effecting a treatment. Ironically, though, this link between diagnosis and cure is a critical area in which DSM has failed most patently.

Not only are the "softer" diagnoses arguably not the purview of a scheme of "mental illness", but many of them offer little guidance to how to they should be "treated". Robert Spitzer, himself an ardent backer of DSM, is quoted by the CCHR as saying "our current diagnostic criteria are 'limited' as guides to the need for treatment." And yet, once the diagnosis is made, attempts at treatment - usually in the form of psychiatric drugs - are only a few steps behind.

It's this cosy relationship between diagnosis and drug manufacturers which led prominent psychiatrist Loren Mosher to resign from the American Psychiatric Association (APA) in despair late last year, saying he felt it more appropriate to say he was leaving the American Psychopharmacological Association. After 30 years in the organisation, he charged in his letter of resignation that psychiatrists had become the "minions of drug company promotions". (New Therapist 11, January/February 2001). Mosher goes on to lambaste DSM:

"DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so, although its brief apologia is rarely noted. DSM IV has become a bible and a money making best seller -its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don't, and can't, because there are no external validating criteria for psychiatric diagnoses. "

Notwithstanding the criticisms of Mosher and a growing band of anti-diagnosticians, the use of DSM as a validation for the use of various treatment approaches continues. A powerful example is that of Attention Deficit Hyperactivity Disorder (ADHD), which has also come under its fair share of fire in the past couple of years.

Peter Breggin, a vocal American psychiatrist, said in an article in the Boston Globe entitled Kids Are Suffering Legal Drug Abuse (9/26/99), that our response to energetic and difficult children is a telling example of the abuse that DSM perpetuates.

"We are the first adults to handle the generation gap through the wholesale drugging of our children. We may be guaranteeing that future generations will be relatively devoid of people who think critically, raise painful questions, generate productive conflicts, or lead us to new spiritual and political insights."

Despite Breggin's prognostications, there is no shortage of people who skipped the Ritalin generation and are thinking critically and raising painful questions about the ease with which diagnoses are dispensed to people who have little knowledge about the stickiness of the labels they are taking on.

Amongst these critics are the growing ranks of narrative, postmodern and social constructionist theorists, the bulk of whom have rallied against the deficit model on which DSM is based or, put simply, the fact that DSM is only really concerned with what it can show is abnormal, dysfunctional or wrong.

Kenneth Gergen, in a trialogue on diagnosis with Lynn Hoffman and Harlene Anderson (http://www.swarthmore.edu/SocSci/kgergen1/text5.html) notes that the reach of these diagnostic labels has been extensive to the point of being ridiculously over-inclusive:

"At the present time, one may be classified as mentally ill by virtue of cocaine intoxication, caffeine intoxication, the use of hallucinogens, voyeurism, transvestism, sexual aversion, the inhibition of orgasm, gambling, academic problems, antisocial behaviour, bereavement, and non-compliance with medical treatment."

Herb Kutchins and Stuart Kirk, authors of the 1997 book Making Us Crazy, maintain that " there are plenty of problems that we all have and a myriad of peculiar ways that we struggle... to cope with them. But could life be any different? Far too often, the psychiatric bible has been making us crazy when we are just human."

 

Continued on the next page ...

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