After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology
Part I. The Context: Overwhelmingly Negative Reactions to Publication of DSM-5
This week, the American Psychiatric Association is holding its annual convention in San Francisco, and this is not your ordinary gathering of psychiatrists. This convention inaugurates the launching of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5. If you have been following the Facebook page of the Society for Humanistic Psychology, you are all too aware that I have been closely monitoring news coverage of the DSM-5 launch (my apologies if your news feed has been unduly littered by DSM-5 related news).
One thing is abundantly clear: The news coverage of the DSM-5 is, almost without exception, overwhelmingly negative press. The journalistic headlines and story angles paint a clear picture that the DSM-5 is anything but a document to be celebrated. The tone, rather, is that we have a guidebook on diagnosis that is fraught with controversy. For example, Dave Templeton interviewed me for a story in the Pittsburgh Post-Gazette , and he also interviewed DSM-5 Chair, David Kupfer. In the interview, I felt I gave a very nuanced and fair reading of the state of the field, and refrained with professional restraint from any kind of polemics. Yet, what was the headline? “Critics blast new manual on mental disorders.” Is this sensationalism? Absolutely not. If there ever was a truth to news, the journalists have it right: Just about everyone hates the DSM-5.
Among the critics, perhaps the most influential has been Allen Frances , Chair of the DSM-IV Task Force and Thomas Insell, Director of the National Institute of Mental Health. Francis has been relentless in his criticism over DSM-5’s lowering of diagnostic thresholds, reckless inclusion of new diagnostic categories with little empirical support, and embarrassingly poor reliability and validity. Thomas Insell rocked the world of psychiatry several weeks ago when he announced that DSM-5 diagnostic categories lack scientific validity, and that NIMH would no longer support research based on DSM classification (see here). Most commentators rightly viewed this as a death blow to the future of the DSM approach to classification (see for example Hank Campbell’s blog post here).
These critics are important because, unlike other legitimate critics, they cannot be easily dismissed as “anti-psychiatry” or as mental health professionals in a “guild dispute” with psychiatry. They are psychiatrists, and they represent mainstream psychiatric institutions – the DSM-IV and NIMH, respectively. It would be ludicrous to suggest they are trying to discredit the field of psychiatry. Quite the contrary, they are trying to save it from ruin.
Likewise, a very important moment in the growing negative attitude toward DSM-5 was the “Open Letter to DSM-5,” which was sponsored by the Society for Humanistic Psychology, Division 32 of the American Psychological Association. The “Open Letter” was endorsed by over 50 international mental health institutions, and signed by about 15,000 individuals, the great majority of whom are mental health professionals. Another important and influential voice was the British Psychological Society, which was among the first in the world to author a systematic critique of the DSM-5 in their own letter to the American Psychiatric Association. These voices have now joined together both in critique of the DSM-5 and in the generation of international dialogue to explore better alternatives to current diagnostic practices. The DSM-5 Response Committee , which is spearheaded by Peter Kinderman and myself, is focused on the critique of DSM-5, and the International Diagnostic Summit Committee , led by Frank Farley and Jonathan Raskin, is focused on creating forums for international dialogue on better alternatives to current diagnostic practice. Note that the websites for these efforts contain a wealth of information—so make sure to check them out.
These examples are the tip of the iceberg. News story after news story, blog after blog by professional commentators, overwhelmingly converge in universal condemnation of the DSM-5. The emerging consensus is that the DSM-5 lacks scientific reliability and validity, which compromises public safety. Yet, what is the alternative? What we have, basically, is a diagnostic vacuum. What will fill the vacuum?
Part II. The Future of Diagnosis in Clinical Psychiatry and Psychology
On my radar, I have identified four different major projects that are getting underway, and each telegraphs the future of diagnosis in clinical psychiatry and psychology.
First, Allen Frances is playing a major role in a MOOC (Massive Open Online Course) designed to help minimize damage from the DSM-5. The MOOC has been developed by Thomas Nickel, Director of Continuing Education at Alliant University. I’ve been in touch with Nickel, and we are working on ways that Society for Humanistic Psychology’s initiatives can contribute to, and be informed by this MOOC project. I already did a short interview with Nickel that is available on the website. But I think, beyond that, there may be some very creative ways to use this forum to help foster international dialogue to help those who are required to use the DSM-5. Information and forums for discussion can serve as potential ways to help minimize possible damage that could result from mis-use of the DSM-5 manual, such as iatrogenic side effects from unnecessary medication of the over-diagnosed.
Secondly, in a development that I believe has great promise, The British Psychological Society, and Peter Kinderman in his blogs at the International Diagnostic Summit, are calling for a problem-based, case formulation alternative to the DSM approach to diagnosis. Allen Frances has already criticized this initiative by claiming that BPS is prioritizing psychosocial etiology over against bio-medical etiologies (see here. I have been working very closely with Kinderman, and it is clear to me that Frances has misunderstood the BPS proposal, at least as it is has been articulated by Kinderman.
A problem-based approach does not reject all bio-medical explanations, nor does it endorse one. It is a theoretically neutral approach which does not presume etiology – therefore, it endorses neither a purely biological nor a psychosocial approach. Rather, it is empirically and pragmatically driven. What it rejects are unreliable, invalid diagnostic categories based on a syndrome model in which symptoms that co-occur are presumed to point toward an underlying disease. As Insel at NIMH has noted, the science does not support that claim.
A problem-focused approach begins with a description of the client’s problem, such as hearing voices, being afraid to leave the house, or suicidal thoughts, for example. Once a problem is identified and formalized, a case formulation approach can investigate potential antecedents, which may be biological, psychological or social in nature – or some combination of these – and the conclusions regarding etiology should drive treatment decisions. If that is what the clinician is doing, the addition of a diagnostic label is completely unnecessary, and in fact, may be quite likely to obscure the matter. The addition of a label runs the risk of creating an explanatory fiction that masquerades as an explanation of the problem when, in fact, it is just a re-branding of the problem in different terms with the presumption of an underlying disease process that is attributed to a psychological or biological flaw in the person. A problem-based approach can be open to that possibility, but it will also be receptive to the likelihood that a person’s problem may not be attributable to the individual, but rather to that person’s situation. Sometimes the person who appears abnormal is actually reacting normally to an abnormal situation.
For example, a person who is grieving is not flawed in any way, but is reacting in a typical and expected way to the loss of an attachment figure. The person likely will need support and care because they are suffering with the problems of bereavement, but it would be superfluous and even an assault on the bereaved person’s dignity to presume grief was attributable to some flaw in the person’s psyche or soma.
Among the current directions in diagnosis, I am inclined to say that the problem-based, case formulation approach holds the most promise for a scientifically sound, theoretically open-ended, and inclusive approach to diagnosis that could be embraced by all mental health professions. The approach also lends itself quite well to a client- or patient-centered model of care, as well as recovery models of mental health, which are on the ascendancy in the United States and abroad – much to the credit of decades of hard-fought victories by humanistically-oriented mental health practitioners and consumers.
Also, very important to mention: really, isn’t a problem-based, case formulation approach the way most effective clinicians actually practice their craft in the real world? And isn’t it true that in most cases, a diagnostic label is an after-thought with the primary function being to justify reimbursement from insurance companies, or other bureaucratic systems within which we work? If so, let’s stop lying about what we do, and articulate in a clear, systematic way what we are really doing when we help people who are suffering.
The third initiative is the Research Domain Criteria (RDoC) project, which is the focus of the NIMH. Like the problem-based approach advocated by BPS, the RDoC also rejects the DSM syndrome model approach to diagnosis, and agrees that DSM categories lack scientific validity. However, whereas the problem-based approach is theoretically neutral and open-ended, NIMH presumes a biologically reductive approach to diagnosis and a bio-medical etiology of psychiatric problems. I feel strongly that NIMH’s project is doomed to failure, but I will leave that argument for a future blog. Suffice it to say for now: Of course there are biological dimensions of all psychological processes. But how does the NIHM decide when biological differences are normal or abnormal? That decision is impossible without understanding the psychological and social context in which a person’s biology is functioning. What may appear biologically functional in one context may be dysfunctional in a different context. I will have more to say on that later in a future blog.
And last but not least: Helen B. Hansen, Assistant Professor of Psychiatry and Anthropology at New York University, and a group of like-minded colleagues are calling for an independent review of social and population variation in mental health in order to improve future DSM revisions, or presumably any alternative system of diagnosis that may appear on the scene in the future. Such a group would pay attention to the many, often ignored factors that can influence the way diagnoses are framed and applied, including, for example, pharmaceutical marketing and advertising, insurance reimbursement, socio-economics, sexism, racism, and guild disputes. I applaud their efforts, and pledge that, as President of the Society for Humanistic Psychology, I would support and participate in any such effort with great enthusiasm, and I encourage others to do the same.
These are all important developments that point toward likely future directions in the field. I, for one, will be keep a close eye on all of these developments. We are indeed living in an exciting and interesting time for mental health diagnosis. Many years from now, I have no doubt, generations will look back on this moment as a pivotal age when psychiatric and clinical diagnosis took a radical turn. Let’s not just hope it turns out well – let’s work together to make sure it does.