For my first blog entry I thought I’d write a bit about the current state of psychology, psychiatry, and psychotherapy – where it’s been, where it is now, and the direction it seems to be going in. More specifically, I want to address the hot topic as of late that is the Diagnostic and Statistical Manual (DSM) of Mental Disorders – what it is, what it does, criticism, etc. – and how it applies to clinical work. Many people have heard or read bits and pieces about the DSM, but despite the amount of research they may have done I still get asked about what I think as a clinician in regards to the newest edition: the DSM 5.
First of all, I want to preface this article by stating that I have not yet personally read, seen, or used the DSM 5. It is a brand new document that just came out in May of 2013 and, partly due to its controversial reputation, is taking some time to catch on in the clinical world. I have, however, done a fair amount of research on the text, and am quite familiar with varying schools of thought around differing philosophies of diagnosis and have used the soon-to-be-old version that is the DSM-IV-TR rather extensively.
For those of you who are unfamiliar with the history of the DSM, you can learn more by clicking here.
In short, the DSM is essentially the clinical ‘Bible’ for diagnosing mental illnesses and disorders. It started off with 106 diagnostic categories in the DSM-I in 1952 to a now whopping 1,000 page encyclopedia of disorders in 2013. So the question now becomes: why such a dramatic increase in the amount of diagnosable mental illnesses and disorders in just under sixty years?
Some would argue the reason that the DSM has evolved as it has is because our knowledge and research in the field is yielding new and more advanced results. While this certainly holds a degree of truth, I would argue that this is a rather incomplete answer.
Perhaps the most widely known criticism of the DSM 5 is that it overly pathologizes human behavior. In other words, it makes many perfectly understandable and reasonable human behaviors seem like symptoms of a mental illness or disorder. For example, the new edition lists grief over the loss of a loved one as a symptom of major depression. Oddly enough, the most depressing thing about this is the fact that we are being led to believe that there is something wrong with us whenever we feel profound and debilitating sadness when in fact sadness, much like joy, is a natural part of life. It deludes the painful reality that is mental illness to make it seem like a mind over matter equation rather than an inescapable reality. This Daily News article does a fairly good job of explaining a bit more about the pathologizing nature of the DSM and the ensuing problems it raises for the field.
For me, all the discussion circulating around the DSM really raises the bigger philosophical question of: what is a mental illness versus a ‘normal’ reaction to an ‘abnormal’ environment? Though there is no easy or clear answer to this question, the DSM 5 certainly doesn’t seem to be pointing us in a helpful direction to facilitate such a discussion.
A bigger problem with the DSM 5 is that by overly and incorrectly pathologizing us as people the DSM skews our understanding of what it really means and is like to have a mental illness and downplays its significance. It defines what is “normal” and “abnormal.” It occludes how we understand mental suffering. It perpetuates the stigma against the mentally ill that there is something wrong with them or that they should just ‘snap out of it’ rather than approaching them with the serious empathy and care that they need and deserve. It makes it seem like the eccentricities, quirks, behaviors, and feelings that make us who we are symptomatic of an illness or disorder rather than a normal response to one’s contextual environment and living experience. It gets people to buy into the idea that there is something wrong with them and that they need medication when in fact they may not. Fortunately, though, it is starting to be considered best practice for those taking psychotropic medications to supplement their treatment with talk therapy to have their mental health closely and regularly monitored by a mental health professional. This is not to suggest that talk therapy is the remedy to everyone’s “issues,” but rather that it may be a more appropriate method of treatment for certain individuals (who have been inappropriately diagnosed with an illness or disorder) instead of medication. All in all, what the DSM does is obscure our understanding of the human experience of both the “worried well” and the mentally ill.
So when people ask me how I feel about the DSM 5 as a clinician, my answer is that I really try not to pay attention to it. It’s not helpful to the work that clients come to me to do. The only time that I as a therapist use the DSM is when a client’s insurance provider asks for a diagnosis to justify why one of their consumers is utilizing my services. I can go into more detail about insurance companies in mental health care, but that is a rather lengthy topic that I think I’ll save for another post.
For more information on the DSM please click on the links provided throughout this article. To see the DSM’s website please click here.