Introduction: The article below was originally accepted for November publication in a small British academic review for psychology students. On the heels of its acceptance, the article was rejected by a senior editor who, for unknown reasons, decided that what I wrote and what you will read below was “over the heads” of the poor benighted students. As a consequence, I’ve been allowed to salvage my status as persona non grata to academia, a dubious but proudly worn badge of honor, and been afforded, dear reader, the opportunity to provide you with a summary of the major ills ascribed to the new DSM and a brief review of alternatives to the use of DSM or any diagnoses.
The focus of the latter will be the anti-diagnosis approach being developed by the UK Division of Clinical Psychology (DCP) of the British Psychological Society (BPS). Lucy Johnstone, one of its more prominent spokespersons and an MIA blogger, has termed their approach “psychological formulation,” which, in very short order, has been incorporated into the DCP’s training curriculum for novice psychologists. It is also the approach that the Committee to Boycott the DSM-5, for which I serve as national coordinator, will be promoting when we launch our No-Diagnosis Campaign sometime this Fall. More below and to follow.
Charges vs. the DSM-5: If you’ve been paying attention the last two years, you’ve seen the new DSM-5, as well as its predecessors, taking a beating from a variety of critics pre- and post-publication. Their observations have been pretty direct.
• Most have begun by noting the work of Kirk and Kutchins and, later, Bentall, who documented the lack of construct validity of DSM’s diagnoses, dating from the landmark DSM-IIIR in 1987. All three concluded that, given the absence of scientific evidence to support their existence, these diagnoses were less likely to represent the neurobiological phenomena claimed by the DSMs’ several authors than to be products of their collective imaginations.
• The DSM-5 Task Force itself has noted the steady decline in DSM’s diagnoses’ inter-rater reliability, i.e., the degree of concurrence among clinicians and researchers about the meanings of specific diagnoses, from one edition to the next – from DSM-III in 1980, through IIIR in 1989, IV in 1994, IV TR in 2001 and DSM-5 this year.
• Numerous American and European critics have underscored that successive editions of the DSM, culminating in #5, have moved the Kraepelinian line demarcating the normative from the presumed mentally ill considerably since 1952, when DSM I was published with 94 diagnoses, to the present and DSM-5’s 300-plus diagnoses. Their similar conclusions – that the American Psychiatric Association, via its DSMs, appears intent on pathologizing the quotidian or day-to-day life experiences of ordinary individuals, exposing increasing numbers to treatment with psychoactive medications.
• Further, the above-mentioned critics, joined by many others, have emphasized that DSM diagnoses are invariably reductive, with rich and varied human experiences consigned to codes which in no way represent those experiences; which offer no explanation for them and, consequently, no remedies for the problems and distress for which prospective patients are seeking help, and no prognoses or predictability that prescribed treatment will actually work. The critics’ conclusions: DSM diagnoses bear no resemblance to medical diagnoses and are, at best, to be regarded as class- and culturally-biased guesses.
• Finally, the APA and the DSM-5 Task Force found themselves obliged to admit under the unrelenting scrutiny to which the new DSM was being subjected that the long-awaited biomarkers, i.e., the scientific evidence which would support the existence and validity of the APA’s putative biomedical model or biological etiology of mental illness, had yet to be uncovered.
An immediate adverse consequence was the very public decision made by Thomas Insel, Director of the National Institute of Mental Health (NIMH), that NIMH would no longer utilize or support research that employed DSM diagnoses; rather NIMH will spend the next ten years developing its own nosology or disease classification. In short, the primary mental health research institution in the U.S. will not surrender its belief in a biomedical model of illness but will forego the use of DSM diagnostic categories in a continued quest for the elusive biomarkers or evidence of such a model.
Life Without the DSM: So what would life be like without the DSM and its collection of diagnoses? Would clinicians know what to do? Perhaps more importantly, does the DSM help clinicians do their jobs even now?
After the barrage unleashed above, it would surprise me if clinicians were to allege that attaching a DSM diagnosis to a user of their services actually helps them be more effective with that person. I would be immediately put off by the DSM diagnoses’ reductionism, their utter disregard for the person’s life experiences, past and present, where the source and causes of the person’s distress are to be found.
To tell a bit about myself, I administered a case management program in New York City for seventeen-plus years. I oversaw the work of fifty staff members whose job was to help folks who had been given diagnoses of serious mental illnesses re-settle in their home communities after spending varied amounts of time in the State’s and City’s prisons, jails and psychiatric hospitals. Most of the women referred to us – approximately ninety percent – had long histories of physical and sexual abuse; which, if acknowledged in the “psychosocial histories” attached to their referral packets, appeared nowhere in the treatment plans developed for them by their institutional caretakers. Their usual diagnosis was “schizoaffective disorder,” to which we paid little attention since it held no meaning for us or for our clients.
Our concern was the behaviors – drug use, prostitution, petty crimes – that would get our folks re-institutionalized, and our primary strategy to help them learn more self-protective behaviors was via the relationships that they formed with the case managers working with them. Over the course of time they told the case managers their stories, enabling the latter to become less judgmental and more empathic and facilitative. Although we never designated it as such, our case managers were engaging their clients in a rudimentary form of “narrative therapy”, which is a collaborative venture designed to help the person using the service develop a more complete narrative or richer comprehension of life events previously excluded from her/his understanding of her/his problems. As per White and Epston, who originated narrative therapy, “the person is not the problem, the problem is the problem.” Bentall, in a similar vein, stated not too long thereafter, “Once these complaints [or problems] have been explained [and understood], there is no ghostly disease remaining that also requires explanation.” In short, to quote from a piece where I referenced Bentall, “… only the “ghosts” or faint memories of their presumed illnesses will remain and there will no longer be need for diagnoses.”
Psychological Formulation: We’ve got a long way to get to that point. The Division of Clinical Psychology of the BPS has taken the lead in the UK to get us there. They just issued their manifesto, “Time for a Paradigm Shift,” this past May, more on which below. Their counterparts in the U.S., Division 32 of the American Psychological Association, led by Brent Robbins, are about to initiate their “Diagnostic Summit Committee,” to discuss alternatives to the DSM nosology; our Committee to Boycott DSM-5 is planning to launch our “No-Diagnosis” Campaign this Fall, which will oblige us to investigate alternatives; and the Stop-DSM Committees in Paris and Barcelona, headed, respectively, by Patrick Landman and Carlos Rey, are planning similar ventures.
Lucy Johnstone and her colleagues of the DCP seem several steps ahead. As per Lucy’s several blogs that I’ve had the chance to read, they’ve been examining the issue of alternatives to diagnosis, DSM or otherwise, since at least 2006. To quote from one of her January, 2013, MIA posts, “[Psychological, as opposed to psychiatric] formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them … Unlike diagnosis, it is not about making an expert judgment, but about working closely with the individual to develop a shared understanding which will evolve over time.” She proceeds to address the role of the professional helper: “The central task of all … professionals is to work alongside service users to create meaning out of chaos and despair.”
Finally, in a subsequent post, she issues a stern caveat to prevent the concept of psychological formulation from being distorted or co-opted: “The most important and controversial issue is whether formulation is used as an addition to, or an alternative to, psychiatric diagnosis… It was for this reason that we wanted the [Psychology Training] Guidelines to draw a clear distinction between psychiatric formulation and psychological formulation – the former being an addition to diagnosis and the latter being an alternative.”
Johnstone and colleagues won their point. As she notes, “… the following best practice criterion was agreed [upon by the DCP membership]: psychological formulation as practiced by UK clinical psychologists ‘is not premised on a functional psychiatric diagnosis …’.” Ever the pragmatist, Johnstone understands that the treatment system within which we work will not readily allow individual psychotherapists to freely practice and implement psychological or what I would term collaborative formulation. In the U.S., the best individual practitioners could hope to achieve would be to use collaborative formulation as an add-on to the obligatory DSM or ICD diagnosis, precisely what Johnstone warns against. Accordingly, as a strategy, as well as a methodology, she suggests a team approach to promote the use of formulation and provide necessary support to those who want to employ it in their practice in lieu of diagnosis. The difficulty here, and part of the struggle to change, is to find a venue that will tolerate even that.
Final Thoughts: If you should insist on working with diagnoses, I would suggest you lobby for the incorporation into the next DSM – my guess is that there will be one – Bentall’s “proposal to classify happiness as a psychiatric disorder.” Specifically, he proposes in the abstract of the article he wrote under that title “that happiness … be included … under the new name: major affective disorder, pleasant type. In a review of the relevant literature, it is shown that happiness is statistically abnormal … and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains – that happiness is not negatively valued. However, this objection is dismissed as scientifically irrelevant.”
FYI: Bentall published this in 1992. Yup, this stuff’s been going on for a long time. So remember … don’t mourn … be happy, if you’re so inclined … and organize!
Bentall, R.P., “A Proposal to Classify Happiness as a Psychiatric Disorder,” Journal of Medical Ethics, Vol. 18, 1992, pp. 94-98
Bentall, R.P., Madness Explained: Psychosis and Human Nature, Penguin Books, London, 2004
Carney, J., “1984 Revisited: The New DSM,” Behavioral Health News, November 30, 2011, www.behavioral.net
Carney, J., “The DSM-5 Field Trials: Inter-Rater Reliability Ratings Take a Nose Dive,” Mad In America, March 26, 2013
Corcos, M., “How to Measure Human Distress,” 2011, www.blogs.mediaport.fr/blog/taky-varsoe/1711/lhomme-sein-le-dsm-le-nouvel-ordre-psychiatrique-essai-maurice-corcos
Division of Clinical Psychology, British Psychological Society, “Position Paper on the Classification of Behaviour and Experience in Relation to Functional Psychiatric Diagnoses: Time for a Paradigm Shift,” May, 2013,
Johnstone, L., series of blogs re DSM diagnoses and Psychological Formulation at www.madinamerica.com/author/ljohnstone:
“Time to Abolish Psychiatric Diagnosis, January 1, 2013
“Thinking About Alternatives to Psychiatric Diagnosis,” January 7, 2013
“More Thinking About Alternatives to Psychiatric Diagnosis,” January 15, 2013
“Using Formulation to Change Team Cultures,” April 7, 2013
“UK Clinical Psychologists Call for Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model,” May 13, 2013
Kirk, S.A., Kutchins, H., The Selling of DSM: The Rhetoric of Science in Psychiatry, Aldine de Gruyter, New York, 1992
Rey, C., “Otras Lecturas: Para Una Clinica Basada en la Clinica,” 2013, www.imaginarte.net/projecyts/otras-lecturas/index_v2.php
White, M., Epston, D., Narrative Means to Therapeutic Ends, W.W. Norton, New York, 1990