The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) may be among the most controversial and polarizing books in the world.
Informed by the medical model, the DSM-5 is the official diagnostic manual of mental disorders authorized by the American Psychiatric Association (APA, 2013).
It has engendered debate in the public arena as well as professional circles. At the same time, it has been a best-seller on The New York Times, Amazon, and other book lists.
Often referred to as the “bible of psychiatry,” it is required reading for mental health clinicians who seek insurance reimbursement and for students in graduate courses for the mental health professions.
Yet the DSM-5 is at odds with many core values that therapists hold about clients and therapy, including an emphasis on the role of the therapeutic alliance and a wellness perspective.
Meanwhile, much of what talk therapy offers has been be lost to the field’s emphasis on the medical model.
Many therapists have also noticed that while their caseloads and paperwork have increased, their reimbursements have decreased, and they have lost control to insurance companies of making some of the key decisions in their clinical practices.
Like many therapists, I was initially struck by the idealism of being a professional helper. In the 1980s, after working in various mental health settings including psychiatric hospitals, community mental health centers, and private practice, I became disillusioned by the field’s emphasis on diagnosis and psychopathology.
In the 1990s, I shifted from a rational emotive behavior therapy (REBT) approach to a solution-focused model because I had sought alternative ways of conceptualizing clients, problems, and change.
Signs of Struggle for the DSM
The medical model holds that through scientific knowledge a physician can know the true cause of a disease, formulate an accurate diagnosis, and prescribe the appropriate treatment.
A closer examination of the DSM-5, however, reveals that its diagnoses are not accurate representations of mental disorders and they are not necessarily effective in determining what treatment approaches are best for particular disorders.
Although the DSM-5 often conflicts with therapists’ values, it is important to learn the language of diagnosis to communicate with colleagues.
At the same time, the DSM-5 lacks scientific validity and reliability and does not adequately inform treatment.
Nevertheless, insurance companies and funding agencies will not reimburse clinicians unless there is a DSM-5 diagnosis and treatment is organized around such diagnoses.
This is a catch-22 for many clinicians.
The DSM-5 lacks validity and reliability
Inhumane “treatments” based on bad science were widespread in the U.S. during the 20th century, including involuntary sterilization (Largent, 2008) and lobotomy (El-Hai, 2005)
Since psychiatric drugs were developed by the middle of the 20th century, they have become the most common form of psychiatric treatment and are also considered by some to be based on dubious scientific findings
DSM-5 diagnoses do not reflect objective brain diseases which, in turn, inform the prescribing of drugs that can ameliorate such brain diseases. Pharmacology is to a large extent a trial and error process.
A medical diagnosis is considered valid when it is an accurate understanding of a client’s condition or disorder. However, the diagnoses set forth in the DSM-5 are not objective medical conditions similar to how diabetes and heart disease are independently verifiable through objective tests
What is and is not observed by a clinician depends on many factors, especially the clinician’s tendency to look for, find, and interpret information so that it confirms their preconceptions, or confirmation bias about so-called psychopathology.
A careful review of the DSM-5 suggests it does not hold that its diagnoses are valid (APA, 2013, p. 5). The DSM-5 has stated that the APA recognizes past science did not produce valid diagnoses for mental disorders (APA, p. 5).
However, clinicians may still think of the DSM-5 as a valid diagnostic system for various reasons, including because it corresponds to the medical model which is based on a scientific view.
Confusions and seeming contradictions arise because the DSM-5 is a descriptive nosology (excluding substance-induced and medically caused conditions), yet it claims to be based on the medical model.
Field trials have also showed that the DSM-5 has poor reliability
For the DSM-5 this means that the same diagnosis will be formulated by different clinicians based on the same clinical presentations. Lack of reliability for the DSM is not new.
Based on the lack of scientific validity and reliability for the DSM-5, the National Institute of Mental Health (NIMH) largely abandoned the DSM for research purposes in 2013 because it held it does not lead to useful research.
The DSM-5 does not inform treatment
In recent years evidence-based practice has emerged as a significant trend in psychiatry and the field of mental health
However, a significant limitation of evidence-based practice is that it tends to match diagnoses to interventions in a decontextualized manner (Duncan, 2014).
Effectiveness in therapy depends less on the type of treatment selected and more on the resources and strengths of the client and the therapeutic alliance (Duncan, Miller, Wampold, & Hubble, 2009).
Research has found that client factors and therapeutic alliance factors account for 40% and 30% of improvement in therapy, respectively — the highest percentage among common change factors.
Model factors, on the other hand, only account for 15% of improvement.
There are at least two reasons the field may be obsessed with developing new therapy models despite the finding that the models used by therapists play the smallest role among common factors in bringing about change
The first reason may be that the field of mental health continues to search for the ultimate therapy model — the panacea, if you will — for all ills
In recent years, mindfulness has been lauded as the new panacea despite recognitions of its limitations.
A second reason why some therapists may remain loyal to particular therapy models is political. Powerful institutions such as universities and professional associations hold privileged knowledge and impose the prevailing therapy models in our field.
The entire profession, including clinicians, educators, researchers, and students are indoctrinated to the prevailing models, and the pressure is on to align with those models to advance in academic programs, obtain licensure and certification, and attain employment
The trend toward medicalization and evidence-based practice has often sacrificed the integrity of core values of many clinicians.
The DSM-5 engenders stigma
DSM-5 diagnoses are limited descriptions which highlight deficits, weaknesses, and problems and overlook capabilities, resources, and strengths
For many clients, however, the stigma of a diagnosis may be oppressive and in some instances worse than the mental illness.
stigma of mental illness persists and is often reinforced by the pathologizing focus of the DSM-5.
In a cautionary statement, the DSM-IV-TR stated that any given diagnosis is intended to diagnose conditions, not individuals (APA, 2000, p. x). This salient warning is curiously absent from the DSM-5.
Perhaps most important, therapists have unique opportunities to help fight stigma in their clinical relationships with clients.
Therapists can promote social justice in the fight against stigma one case at a time. This can be achieved by viewing clients as individuals with their own unique potentials rather than limited by a DSM-5 diagnosis.
Stigma of mental illness has also been perpetuated by the DSM-5 due to its lack of emphasis on the critical role of culture and diversity in understanding human problems and the phenomena otherwise associated with mental illness
The DSM-5 rightly cautions that the boundaries between normality and abnormality differ across cultures (APA, p. 14). This acknowledgment suggests that mental illness is largely culture-bound.
The pathologizing focus of the DSM-5 also distracts from many if not most of the problems of which most clients seek therapy. Research has found that the majority of problems that clients seek therapy for are relational in nature (Gottman, 1999).
But a client will rarely be covered for these unless they are given an individual DSM-5 diagnosis — a mental disorder. To be covered by insurance, you have to be sick to receive mental health care.
More-of-the-same from the DSM
While efforts to improve the DSM appear to reflect the spirit of scientific inquiry, closer examination indicates most, not all, of the changes amount to a more-of-the-same solution for the problems I have thus far identified regarding this diagnostic system.
Revisions of the DSM are sometimes made due to political and social pressure to remove archaic diagnoses.
Rather than provide an exhaustive review of changes in the DSM-5, I provide a brief review of the shift from a multiaxial system to a nonaxial system because unlike other changes, this significantly impacts use of the manual in daily practice.
What was separated on Axis I, II, and III in the DSM-IV-TR are now combined in the DSM-5 because no distinction is drawn for purposes of listing diagnoses between medical disorders and mental health conditions.
Whereas psychosocial problems were listed on Axis IV in the DSM-IV-R, these are now listed as V codes or 900 codes.
The Global Assessment of Functioning (GAF), which was used on Axis V of the DSM-IV-TR, was removed due to a lack of conceptual clarity, lack of clinical utility, and poor reliability.
The DSM-5 has introduced the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0; WHO, 2010) for “further study.” Information on the validity or reliability of the WHODAS 2.0 is not available in the DSM-5.
A potential advantage of the nonaxial system is that it may reinforce the holistic perspective held by some therapists by no longer distinguishing between medical, emotional, and psychosocial factors.
The nonaxial system also resolves some limitations and drawbacks of the multiaxial system
The DSM-5 has made numerous diagnostic changes, structural modifications, and has revised its organization.
Multiple online enhancements for the DSM-5 are provided at www.psychiatry.org/dsm5.
I suggest therapists access this online resource due to anticipated changes in the DSM-5.
To date, however, the DSM-5 has significant limitations, including that its diagnostic system
- lacks validity and reliability,
- does not inform treatment, and
- tends to engender stigma.
This last sentence implies that the DSM is fatally flawed and almost useless.
That is, useless for everything but insurance reimbursement.
Author: Jeffrey Guterman – Counselor, educator, author. Also follow @SolutionsBook about my book for helping professionals and the solution-focused approach.