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Dissecting the DSM contd ...


The prognosis for diagnosis

So, let's suppose the deficit model falls into further disfavour. What then? Is there another, more salutatory character waiting in the wings to take up the anti-deficit model as the crowd gestures a pathogenic DSM to left of stage ? The short answer is no - not so much because nobody can rise to the challenge, but because the challenge is a dubious one in the minds of those most disappointed in psychiatry's history of attempting to categorise and pigeonhole the human condition.

There have been a number of previous bids to break with this approach. The idea of a more socially contextualised diagnostic system is one of the most prominent of such attempts. In 1957, psychedelic drug proponent Timothy Leary published a book entitled Interpersonal Diagnosis of Personality: A functional theory and methodology for personality evaluation. In it, he outlined the notion of a functional concept of personality and how we can understand people and their difficulties in terms of their interactions.

Commenting on the outlook for diagnosis, Leary saw two possible directions in which diagnostic systems could move:

" the first is that direct interpersonal terms will replace the disorganized nosology of present-day psychiatry; the second is that the current terms will be redifined in interpersonal terms."

Following 22 years of work on these ideas, in the January 1979 edition of American Psychologist, Clinton McLemore and Lorna Benjamin drew together a considered critique of DSM and proposed an interactional alternative, replete with examples of equivalent diagnoses for DSM conditions. They noted the DSM's overreliance on the medical model, its stigmatisation of patients, inadequate reliability and validity, its dehumanisation of the client-therapist relationship and its biases towards pathology.

However, despite their delineation of the type of work that needed doing to make this kind of diagnostic system more solid, attempts to take it further which could earn the approval of establishment psychiatry and psychology never quite made the grade.

As the interactional approaches to diagnosis progressed, they did so almost as if in a parallel universe as DSM became entrenched as the lingua franca of the psychiatric world. The most obvious difference was that the DSM succeeded in hanging onto its favoured-status relationship with the funders of healthcare and the proponents of a black-and-white medical model.

Amongst the alternative approaches which were proposed are a handful of systemically oriented approaches, including the classic schizophrenogenic family taxonomy of Gregory Bateson, and a lesser known assessment approach by Karl Tomm (Beginnings of a "HIPs and PIPs" approach to psychiatric assessment, The Calgary Participator, Spring 1991).

Postmodernism goes post-diagnosis

But the enthusiasm for a new labelling system began to wane quickly as postmodern approaches made their presence felt in academic psychotherapy circles. The rage to order began to carry the stigma of a simplistic and reductionistic approach to what should be seen as more nuanced and ill-defined.

Lynn Hoffman, who travelled a windy road through all the most exciting interactional alternatives to conceptualising human behaviour over the past 30 years, states her present position:

"Gathered under the medicalized roof of DSM IV, we find an attempt to enumerate and describe all existing problems of behaviour: life problems, death problems, mind problems, disease problems, poverty problems, class problems, violence problems, sex problems, work problems, love problems. At the same time, I think this may be the good fortune of family therapists. Conditions that are 'merely' relational have been exempted from inclusion in DSM IV, except for a brief nod to a relationship-oriented axis that may not even be reimbursed. So perhaps we have been rescued from the 'rage to order' Only by remaining the one health industry that does not give people labels or diagnose conditions, can it represent an important stream of evolution in the field. That is my position too." (http://www.swarthmore.edu/SocSci/kgergen1/text5.html)

Increasingly, anti-diagnosticians are also noting that the process of deciding where to draw the lines in any new diagnostic system would probably be as arbitrary as it was in the DSM approach.

Paula Caplan, in her 1995 book They Say You're Crazy, points out that DSM has been drafted over the decades on the basis of votes by psychiatrists about what stays and what goes. A psychologist attending a DSM-III-R hearing is quoted as saying:

"The low level of intellectual effort was shocking. Diagnoses were developed by majority vote on the level we would use to choose a restaurant. You feel like Italian, I feel like Chinese, so let's go to a cafeteria. Then it's typed into the computer."

Such was the case with the sensitive diagnosis of homosexuality. In 1973, the APA voted 5,584 to 3,810 to cease calling "homosexuality" a mental disorder after gay activists picketed the APA conference.

Where to from here?

So, how are DSM and its opponents likely to square up in the coming decade? A tough call, say most commentators, but most seem to agree that the stranglehold DSM has on the "truths" of people's emotional and behavioural lives, the controllers of the purse strings of psychiatric services and the popular conception of "mental illness" won't be loosened for a long time to come.

One scenario sees small branches of parallel approaches to treatment developing for self-paying clients who feel a discomfort with mainstream psychiatry. A second sees the possibility for the DSM evolving into less of a deficit oriented diagnostic model. But this will be resisted by many service providers, the most vocal of whom would like to see every discomfort falling within the ambit of their expertise, their drugs and their therapies.

Ken Gergen hopes for a "multiplicity of self-accounts" in which alternative ways of defining oneself and one's condition spray out, offering alternatives to the hegemony of DSM (New Therapist 5, January/February 2000).

Others hope to continue to work within the status quo without succumbing to its quasi-medical reductionism. But as managed care tightens its grip on psychological services, the latitude for diagnosis-free claims and systemic or interactionally-based formulations will become increasingly narrow.

For the time being, the state of play is, in the words of cybernetician Heinz von Foerster, a case of 'believing is seeing'.


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