Beyond the DSM Story

Ethical Quandaries, Challenges, and Best Practices

Karen Eriksen, Victoria E. Kress

• Publisher: SAGE Publications, Inc
• Year: 2004
• Print ISBN: 9780761930327
• eBook ISBN: 9781452235882
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

"Among many of the ethical issues clinicians encounter in their practice, diagnosing someone with a given mental disorder just for the purpose of reimbursement of services is perhaps the number one ethical dilemma.  This book is an outstanding review of the conceptual and empirical literature on this particular dilemma.  But the most important contribution of this book is that it provides an extensive discussion of clinical strategies and case vignettes that clinicians could use in diagnosing mental disorder and as the same time attending to ethical standards governing their discipline."
—Freddy A. Paniagu, University of Texas Medical Branch-Galveston 

"Eriksen and Kress offer a well-formulated discussion of problems with the American Psychiatric Association?s The Diagnostic and Statistical Manual of Mental Disoders (DSM), Including almost 800 references, this volume covers the literature in the field extremely well."
—W.P. Anderson, CHOICE

Beyond the DSM Story presents challenges to the Diagnostic Statistical Model (DSM) system from ethical and cultural perspectives, critically evaluating its fit with other professional and theoretical orientations. It offers possible solutions or best practices for addressing ethical, theoretical, and contextual quandaries, along with experiential activities that challenge the reader to think critically about both the problems and the solutions associated with DSM diagnosis. Beyond the DSM Story presents an atheoretical model for incorporating alternative models with DSM assessment. Instructors, students and practitioners will benefit from this critical appraisal of the DSM.

Features

• Addresses the philosophical discrepancies between a medical model, DSM assessment approach, and most helping philosophies.

• provides a thorough framework for utilizing the DSM in a contextually sensitive fashion

• Comprehensively reviews the challenges to the DSM system, particularly multicultural and feminist challenges and addressing ethical concerns related to using the DSM system

• Provides case studies and experiential/interactive activities that challenge the reader to consider the DSM from a contextual perspective

 

1

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The Price of Diagnosis

Mental health professionals would clearly not engage in diagnosis or use the Diagnostic and Statistical Manual of Mental Disorders (DSM; when used in this way, we are referring to any version; American Psychiatric Association [APA], 1980, 1994, 2000) diagnostic systems were it not for this model’s perceived benefits. The DSM system of diagnosis is the “gold standard” for diagnosis in mental health practice, textbooks on diagnosis and psychopathology clearly articulate its value to clinical practice and to understanding abnormal behavior, and its economic power would not have emerged without many people knowing and espousing its value. Consequently, in this chapter, we do not aim to rearticulate the dominant beliefs about the diagnosis of mental health problems nor do we intend to provide a balanced view of the benefits and limitations of the DSM system. Instead, we move quickly to discussing the DSM’s limitations after offering only a brief summary of the benefits of using the DSM diagnostic categories, both for clients and for mental health providers.

BENEFITS OF DSM DIAGNOSIS

Some of the benefits claimed for the DSM make inherent sense, and thus have face validity. For instance, the DSM’s categories reduce complex information into a form of “shorthand” that facilitates communication within and among professional groups. Also, by categorizing people’s psychological problems, researchers and theorists can compare various treatment approaches to particular problems; they can evaluate counseling, psychotherapy, and other psychiatric treatment effectiveness; and they can research underlying causal mechanisms and processes of particular diagnoses (Harari, 1990, as cited in Ivey, Jankowski, & Scheel, 1999; Hinkle, 1999; López-Ibor, 2003; Maniacci, 2002; Mead, Hohenshil, & Singh, 1997). The DSM further provides information about the course, prevalence, and cultural, gender, and familial issues related to each diagnosis—information that may be helpful to practitioners who are struggling to fully understand clients’ experiences. Additionally, DSM diagnosis can help practitioners to identify those clients whose problems extend beyond the clinician’s areas of competence (Seligman, 1990).

Other claims about the DSM’s benefits are more controversial, and literature exists that espouses conflicting sides of the arguments (when we discuss the DSM’s limitations later, we explore the “con” side of the arguments). For instance, some mental health practitioners believe that diagnosis enables effective referral and/or planning of counseling, psychotherapy, and other psychiatric treatment strategies, planning that is based on accurate conceptualizations of client problems (Duffy, Gillig, Tureen, & Ybarra, 2002; Mead et al., 1997; Waldo, Brotherton, & Horswill, 1993). Other writers state that the DSM’s diagnostic system allows professionals to summarize complex information about clients for use in a variety of activities (Cook, Warnke, & Dupuy, 1993). Furthermore, just as in medicine, advocates claim that the DSM increases comprehension of the pathological processes involved in disorders, improves control over the outcomes of psychiatric disorders, and promotes prevention of the disorders (e.g., as a result of conducting research on etiology [APA, 2000]). Although the DSM does not address treatment, the APA has published many books that propose treatment guidelines that are based on the DSM criteria (see http://www.appi.org/). Consequently, identifying a DSM diagnosis allows practitioners to find and use information about empirically supported treatment and prognosis. Another reported advantage is that “the DSM’s nonetiological and descriptive nature is purposefully intended not to alienate potential users with diverse theoretical orientations” (Hinkle, 1999, p. 475). However, although the DSM does not state that its diagnoses are rooted in biological processes, many believe that it reflects a medical-model approach to helping. Therefore, it is understandable that those operating from a medical model might vouch for the aforementioned claims. However, those mental health providers who stand on different theoretical ground might, because of a different perception of what causes and “cures” problems, question whether a diagnosis reflects an accurate conceptualization of client problems or is more a reflection of the worldview of the person who conceptualizes the clients’ behaviors (Clark, Watson, & Reynolds, 1995; Nathan & Langenbucher, 2003).

The DSM may benefit clients in more personal and direct ways. For example, sometimes clients benefit from a concrete “explanation” for their behavior and experiences. They may find it freeing to have their experiences labeled (Shergill, Barker, & Greenberg, 1998; Wetterling, 2000). One client known to the first author struggled with depression for many years. A psychologist who tested her said that she would be in psychiatric hospitals for the rest of her life. During counseling sessions, she kept “thrashing” herself with messages like “I should be better,” “I shouldn’t keep struggling with this,” “I am such a loser compared with everyone else.” When the therapist shared the diagnostic labels of major depression and borderline personality disorder with her and urged her to think of these disorders as physical, like having diabetes or like being a paraplegic, the client was able to refocus her efforts toward managing the problems, coping with them, developing realistic expectations of herself, and garnering appropriate kinds and levels of support for herself. Having a label to hang onto actually freed her from the paralysis of self-blame and helped her to invest her energy more productively in activities that, in the end, were successful in keeping her out of the hospital.

Diagnostic labels may also focus clients and their families on an identified external enemy and away from blaming one another or themselves. Family members of someone who is labeled schizophrenic, for instance, may put less pressure on the one so labeled about idiosyncratic behaviors, such as social isolation. Family members who learn that a member has a psychiatric illness may increase their motivation for the therapy process as a result of decreases in mutual blame and experiences of guilt (Anderson, Reiss, & Hogarty, 1986). For instance, a family who brought their adoptive child into counseling, secondary to the child exhibiting a great deal of acting out and causing trouble in school, was worried that their parenting would be blamed for the child’s problem. In fact, the couple had struggled for a while with their own conflicts about which one of them was to blame for their son’s behavior. When the counselor diagnosed some developmental problems resulting from physical abuse and neglect in the biological family, the adoptive family breathed a collective sigh of relief and buckled down to rectify and manage the problems that they had inherited.

In another family known to the first author, an adult daughter who had recently experienced tremendous trauma was very depressed and angry, and was increasingly nasty and abusive toward the very people who were trying to help her. When family members would urge her to do things that might help her, she would become very argumentative and put down all of their ideas. When a cognitive behavioral therapist explained that she was suffering from depression, that “thought disorders” (Beck, Rush, Shaw, & Emery, 1979; Burns, 1980) were associated with depression, and that depressed people were often very persuasive in expressing these thought disorders, the family members were able to let go of trying to convince the daughter to change her mind, were able to feel less hopeless and discouraged themselves in response to her anger, and were able to redirect the conversations with their daughter toward more productive topics. Accepting the notion that their family member was suffering from depression, as defined by cognitive behavioral thought, reduced the family’s tendency to want to avoid their daughter, a tendency that would only have confirmed their daughter’s current “awfulizing” beliefs.

Furthermore, knowing that a person “bears” a clinical diagnosis may even positively change practitioners’ feelings toward those so diagnosed. In a human development course, the first author invited panels of people of various ages to come into class to talk about what it was like to “be that age.” The students found one 50-something woman quite offensive and difficult, and challenged the instructor on why the woman had been invited to the class. The next semester, when the same students were taking a diagnosis class with the first author and the same woman volunteered to come in to share her experiences with generalized anxiety disorder, their feelings dramatically changed. Of course, the woman’s conversation with the students included more than merely a diagnostic label; it included the rather vulnerable sharing of a lifetime of struggle. But somehow, when the students knew how long and hard she had struggled with the problem, they were more understanding, more forgiving, and more willing to engage with the woman.

Most practitioners with whom we have had conversations, however, seem more aware of the financial and occupational benefits of using the DSM. That is, the DSM has become the most widely used system for the diagnosis of mental disorders. As a result, various governmental agencies use the DSM categories for census purposes, for specifying target populations whose treatment may be funded by grants, and for determining who is eligible for specially funded programs (Holden, Santiago, & Manteuffel, 2003; Regier, First, & Marshall, 2002). Almost all settings in which mental health providers work currently require a Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) diagnosis for reimbursement of services (e.g., hospitals, private practices, community mental health agencies, and residential settings; Mead et al., 1997; Sperling & Sack, 2002). Consequently, without knowledge of diagnosis, mental health providers may lose credibility and status in their professional fields, may not be able to fulfill their employment requirements, and may lose credentialing opportunities (Chambliss, 2000; Sperry, 2002a; Waldo et al., 1993). Students in the first author’s diagnosis course, when challenged to think critically about the DSM system of diagnosis, responded, “Look, we have to use the DSM. We don’t have a choice. What good does it do to think about it? We just do it and get it over with so that we can have the funds to treat the clients in the best ways that we know how.”

It is clear that the DSM has positive uses, and is the dominant story about mental health diagnostic classification. It also appears that the DSM system of diagnosis is “here to stay” (Hinkle, 1999, p. 45; Hohenshil, 1993; Schwartz & Wiggins, 2002). Yet despite its staying power and benefits, the DSM has many limitations that should be considered and addressed. Those who espouse different stories about diagnosis, assessment, and treatment often bring these limitations to light. Perhaps considering the DSM to be one story among many can help practitioners to open up to other stories that might, in certain circumstances, add breadth and depth and helpfulness to assessment and to mental health practitioners’ attempts to benefit their clients.

LIMITATIONS OF DSM DIAGNOSIS

Some of the limitations of DSM diagnosis were mentioned in the introduction to this book; the remainder of this chapter expands on the introduction. The concerns about the DSM as a diagnostic system that are overviewed in this chapter and discussed further in chapters that follow can be categorized as the following:

• The DSM diagnostic system fails to predict treatment outcomes or to promote understanding of underlying pathology.
• DSM diagnostic categories can lead people to accept a self-fulfilling prophecy that their situation is hopeless and that they are sick.
• DSM diagnoses can narrow a mental health professional’s focus by encouraging the professional to only look for behaviors that fit within a medical-model understanding of the person’s situation.
• DSM diagnosis fails to include a full understanding of contextual factors that may more aptly illuminate both etiology and helpful treatment.
• The application of diagnostic labels has historically stigmatized and hurt those who are different from the mainstream. This practice continues today.
• Serious problems exist in the “science” of the DSM diagnostic process.
• DSM diagnosis implies the imposition of a certain set of values on clients and the counseling process.
• Diagnostic categories can minimize peoples’ individual uniqueness.
• The diagnostic process takes the focus away from clients’ reality and understanding of their problems by directing clients away from an internal and subjective way of understanding their experiences, instead putting the focus on external conceptions about them.

This chapter offers brief explanations from the literature to help provide an overview of these concerns. Future chapters offer more in-depth literature reviews on these issues, analyzing each of them from practical and ethical perspectives.

Communication, prevention, prediction, and understanding. Spitzer (1975), an advocate of properly used diagnosis and a central figure in the development of many editions of the DSM, claims that, although diagnosis has been somewhat effective in enabling professional communication and quite helpful in predicting the usefulness of particular treatments for particular diagnoses, it has, as of yet, been woefully inadequate in helping practitioners to comprehend the pathological processes involved and to prevent the disorders from developing (see also Albee, 1999; Tsuang & Faraone, 2002; Tsuang & Stone, 2000). In fact, Spitzer recommends against the use of diagnostic categories for outpatients who are not seriously ill. Sarbin (1997) counters some of Spitzer’s claims, indicating that there is actually a weak connection between psychological diagnosis and treatment choices (that is, in predictive value), despite the stronger connection between medical diagnosis and treatment, the paradigm upon which the founding notions of the DSM diagnostic system are based. Seligman et al. (2001) indicate that predictive value (that is, the degree to which patients receive a certain treatment based on a particular diagnosis) is higher for some disorders than for others. For instance, those patients who are diagnosed with bipolar disorder generally receive a drug such as lithium as treatment. Clients who suffer from premature ejaculation tend to receive and respond well to specific behavioral and social learning treatments. “In these instances, the diagnosis indicates a treatment that has a high probability of succeeding. However, in most diagnostic situations, merely having a diagnosis is of limited use” (Seligman et al., 2001) in dictating a helpful or particular course of treatment with a predictable outcome (Acierno, Hersen, & Van Hasselt, 1997; Clarkin, Kernberg, & Somavia, 1998; McWilliams, 1998; Ogrodniczuk, Piper, & Joyce, 2001). Although some authors indicate that connections between the DSM and treatments will be made in the near future (Gunderson & Gabbard, 2000), others consider a search for such connections to be misguided (Sarbin, 1997).

Self-fulfilling prophecies, contextual factors, narrowing the provider’s view. The potentially negative impact of diagnostic labeling on both the clients and the caregivers is also troubling. For instance, the results of Rosenhan’s famous experiment (Rosenhan, 1973; Seligman et al., 2001) challenge us to carefully consider the self-fulfilling prophecy and contextual nature of diagnosis. He and his colleagues were admitted to psychiatric hospitals after pretending to have a single symptom. They claimed to have “heard voices that said ‘empty,’ ‘meaningless,’ and ‘thud.’ From the moment they were admitted, these pseudo-patients abandoned that symptom and acted the way that ‘normal’ people do. However, Rosenhan and his colleagues were labeled as crazy and ‘treated that way’” (Seligman et al., 2001, p. xv). As a result of this experience, Seligman and Rosenhan concluded that the setting in which diagnoses are made influences what diagnoses are ascribed to clients. For example, the hospital context (the site of their experiment), in which all residents were assumed to be abnormal, contributed to interpreting all patient behaviors or verbalizations in light of the patients’ diagnoses. This bias toward abnormality subsumed other observations to the point that “normal behaviors” were overlooked or misinterpreted. Additionally, once a diagnosis was given, it was very difficult for the client, the mental health professional, or the hospital staff to shift their focus away from that diagnosis. Russell (1986b) indicates that this sort of a situation reduces a client’s self-esteem. In the Rosenhan experiment, then, the diagnosis created its own reality for all involved, influencing others’ perceptions of the patient and the patient’s behavior, despite later evidence that contradicted the initial diagnosis. However, the array of complex stimuli that surround hospital mental patients, stimuli that many would consider to be quite “sick,” are typically ignored in diagnostic systems (Rosenhan, 1973). Rosenhan concludes that because the DSM model locates the sources of aberration within the individual, once those diagnosing believe that they have an understanding of the patient, it is difficult for those around the patients, or even for the patients themselves, to concede that their behavior has changed, or to entertain alternative or different views. Rosenhan challenges mental health personnel instead to consider anyone who actually “fits into” dysfunctional systems—such as these hospitals—to have a disorder.

Similarly, Jensen and Hoagwood (1997) discuss the inaccuracies and contextual nature of the DSM assessment process. For instance, they claim that as the practitioner obtains diagnostic information, the information shapes the ensuing assessment process. Furthermore, clients engage in their own shaping process. During the initial assessment, they are usually in an exploratory mode. They probably begin an initial session by thinking that only certain revelations are relevant. As they hear their own voices revealing certain symptoms, clients shift what they consider necessary to reveal. Their revelations are further shaped by the questions that the practitioner asks. White and Epston (1990) call the process by which the client and assessor create an assessment storying, and write that “the sense of meaning and continuity that is achieved through the storying of experience is gained at a price: that is, a narrative can never encompass the full richness of our lived experience” (p. 11). Therefore stories require a selective process in which “we prune . . . those events that do not fit with the dominant evolving stories that we and others have about us” (pp. 11–12). Those selections, in turn, shape our future stories (see also Denton, 1990; Jones, 2003). Such storying clearly affects all assessment and treatment procedures, not merely DSM diagnosis. However, those who hold the more narrative theoretical perspectives do not claim that these stories reflect “reality,” and are not searching for “truth.” Instead, they evaluate a story on the basis of its helpfulness to the client or the therapeutic process. If it is not helpful, practitioners assist the client to rewrite the story into one that might be more helpful (not more true or closer to reality; Neimeyer & Raskin, 2000). In contrast, the DSM developers’ and users’ pursuit of truth and accuracy promotes a reification of the diagnostic category, that is, using it inflexibly whether or not it is helpful to the client or to the treatment (Duffy et al., 2002).

As Rosenhan’s (1973) experiment illustrated, Jensen and Hoagwood (1997) also claim that beyond the behavior and contexts brought into the assessment process by the practitioner and the client are the expectations brought to bear by the assessment “setting” (e.g., agency, hospital). Organizations design procedures that specify the length of time available for assessme...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1. The Price of Diagnosis
• 2. Ethics Meets Diagnosis
• 3. Multicultural Challenges to the DSM
• 4. Feminist Challenges to DSM Diagnosis
• 5. Toward Resolving the Quandaries and Pursuing Ethical and Contextually Sensitive Diagnostic Practice
• 6. The Case of 9-Year-Old Janelle and Her Mother
• 7. The Case of Ana and Mark
• 8. The Case of Ellen
• 9. A Developmental, Constructivist Model for Ethical Assessment (Which Includes Diagnosis, of Course)
• Afterword
• References
• Index
• About the Authors
• About the Contributors