I recently read an article on the new Diagnostic and Statistical Manual (DSM). In response, I have some thoughts. Here they are below.
As a practitioner myself, I find that when I sit with my clients, particularly those who are not White Americans, the DSM fail terribly. Not to say all of them can’t fit into the DSM diagnoses when they are clearly distressed and dysfunctioning in life, but there is significant number whose symptom presentations just don’t fit the diagnoses. In addition, for anyone who has worked in non-profit agency work or serving lower income clients, it is clear that their life circumstances and socio-economic stress have huge impact on their symptoms. DSM does not seem to addresss this in the diagnosis criteria, despite having some sort of afterthought consideration of Issues of Clinical Attention or psychosocial stressors indicators in Axis I or Axis IV respectively. But what if the client fits a particular diagnosis only due to these stressors and when they have move to better conditions in their lives, the symptoms alleviate, can it be called a clinical disorder then? Or is it more accurate to say the client has somehow embodied the disorder of their socieities at that period in time? I like to think more in a systemic and developmental perspective when assessing clients and their “diagnoses”, which to me, is more about at this point in time, given the client’s chronological age, where is he or she in the developmental phase – is it congruent with age and client’s expectation and life history, culture, and current context? What is the pattern of symptoms that reflect any incongruency? What level of support or intervention is needed for client to overcome this incongruency so that the client can become functional and in equilibrium again in most aspects of his or her life, such as in intrapersonal and interpersonal domains in thoughts, behaviors and emotions, and in his or her work role in society. This is how I diagnose, often not using DSM, unless I bill insurance, or it is clear that the client easily fits a DSM criteria.
I am not wilfully coming up with this diagnostic approach. My training in psychological theories and techniques, mostly from psychodynamic, but also solution focused, multicultural, family systems, existential, and cognitive-behavioral schools of thought influence how I understand human development and human response to stress or trauma, and the dynamics of human cognition, behavior and emotions in context of the previous two components. More importantly, I count on what the client is coming in with, their presentation and circumstances, than some prescribed notion of what is wrong, as DSM inevitably forces the practitioner to do.
As for the current trend in understanding how newer, faster therapies are changing what mental health care looks like and what diagnostic criteria are valid, that often goes against the traditional psychoanalytic approach that focuses on development of disorders and prescribed treatment of personal transformation over a long period of time, I personally think if something hasn’t been happening for a long time, it’s not wise to call it a disorder. Humans naturally go out of equilibrium when a major event happens in life, and it will take some readjusting to it. This readjutment is not a disorder. How easily that happens is based on the person’s support system and resources. Where I see the difficulties is when the client has insufficient support system or resources, then it becomes a problem, which is still not a clinical disorder, unless one is diagnosing the society as a whole, which need a very different treatment or intervention that is beyond psychiatry or psychotherapy. At best, in the most micro level, it may require family therapy. If the client has sufficient external resources, yet unable to return to equilibrium, then, most likely this person has very little internal resources. Only when this happens can we start to think of a disorder. Even so, it is not a character flaw but a result of the person’s learning, whether through family upbringing, trauma, socio-cultural experiences, etc. This will mean it is a long term thing in making, thus going back to the personal transformation necessary in psychoanalytical theory, and something faster newer therapies are not set up to do as they focus on symptom alleviation instead of transforming the personal script and personality make up of that person. Freudian psychoanalytic theory may suggest character flaw, but subsequent psychodynamic theories perceive it more of an internalization of a deficient learning environment than inherent character flaw. If one actually carefully studies Freud, one will notice that he has perceived the character flaw more of a developmental task than pre-determined disposition.
Frankly, outside of managed care, whether insurance, government or other instituitions, I do not see DSM as very helpful tool. Thus leading to the question of the political aspect of the use of DSM and its link to another interest group, i.e. pharmaceuticals. I’m not against medications. In fact, I just recently urged my client to go for a psychiatric evaluation and to consider medications, because I believed her depression to have physiological nature. But to think it’s the only way or the best way discounts all the other components of psychological distress I’ve mentioned above. And it also invalidates client’s legitimate worry about side effects and their values or worldviews around medication use. To me, THAT is paternalistic, more so than the commonly held belief these days that the psychoanalytical stance of analyzing what the client expresses and exhibits as paternalistic. Clients come to professionals because they need or want the other person, either objective or reflective, view of their problems because often times they feel too stuck in it to see clearly what’s going on or what to do next. And sometime they just need someone reliable they can depend on when everything else in their lives seem to be falling apart.
Dependency is not a bad thing in itself, as long as it is not exploitative or obsessive. We depend on family and friends to be supportive, so why not a professional who will have emotional neutrality, especially if the client is feeling unsafe or experiences pressures from family and friends around their issues? No man is an island. It is a fallacy to think we can be completely independent. We go to primary care physicians, specialists, dentists, attorneys, tax accountants, etc and entrust them with their knowledge to take care of the respective tasks, so why shouldn’t it be the same with the psychological and emotional wellness? For any mental health care system to not recognize the relational aspect of care and value the care providers, it is failing the client. Dehumanizing mental health, such as focusing only on economic efficiency and symptomatology, will reduce practitioners to commodities and clients to outcomes.
When I sit in the room with my client, I do not see the dollar bill or a paper list of symptoms. I see a real human being facing, often times, very existential suffering. That is the most important diagnostic criterion I need.