Evil Deeds

A forensic psychologist on anger, madness and destructive behavior.

How Psychologists Can Help Correct DSM-V: A Response

Psychology must assert more influence regarding diagnosis and treatment.
Allen Frances, M.D.
This post is a response to How Psychologists Can Help Correct DSM5 by Allen J. Frances, M.D.

Psychiatrist Dr. Allen Frances deserves congratulations and gratitude for his recent posting here at Psychology Today regarding the American Psychiatric Association's forthcoming revised diagnostic manual, the DSM-V. As he makes quite clear, the new manual has potential problems, and psychologists now have both an opportunity and responsibility to try to correct (or at least minimize) such problems prior to publication.

One problem is that the DSM-V is created and published exclusively by the American Psychiatric Association. Dr. Frances points out that now is the time to question whether it is appropriate for the American Psychiatric Association to control the contents and publication of the DSM-V. Psychiatrists are, by definition and training, physicians first. As medical doctors, they have been indoctrinated to conceptualize and treat syndromes or symptoms as medical diseases or illnesses. A diagnosis based on the DSM-V is, by definition, a psychiatric diagnosis. Despite the shift in DSM over the years toward using the term "mental disorder" instead of "mental illness," most psychiatrists still tend to take a decidedly biological view of such disorders. For this reason, the vast majority of psychiatrists being trained and practicing today have become little more than psychopharmacologists, limiting themselves to the prescription of psychotropic medications over what was once the mainstay of psychiatry--psychotherapy. Of course, the pharmaceutical companies strongly support this biochemical trend. As do the insurance companies, who resist paying for extensive (and expensive) psychotherapy. Clearly, the more psychiatric diagnoses contained in the DSM-V, the broader the definition of mental disorders, the more profit can supposedly be made by so-called Big Pharma in providing the drugs psychiatrists so often prescribe.

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While clinical psychology has to some extent leaped onto this same biological bandwagon driven by contemporary psychiatry, seeking prescription privileges, some psychologists and other non-medical mental health professionals have practically written off the relevance, value and importance of psychodiagnosis today--in part precisely due to its inherent medicalization, biological bias, dehumanizing labeling, and notorious inaccuracy. As a result, I suspect many psychologists and other psychotherapists may be less than enthusiastic about participating in improving the standardized diagnostic system they despise yet are nonetheless forced to use by the insurance companies and other third party payors. But this professional apathy is itself a big part of the problem. And such resigned passivity on the part of psychologists at the present moment would be a major mistake.

I believe it is time for the leadership of the American Psychological Association to take a far more active and public role in the revision and direction of the DSM-V. Clearly, the publication of this diagnostic manual should be a collaborative effort between the American Psychiatric Association and the American Psychological Association. Yet, one wonders exactly what, if anything, the American Psychological Association is doing about DSM-V. Or about the hypermedicalization of psychology. As Dr. Frances, former chair of the DSM-IV Task Force indicates, the next six months or so is a window of opportunity for both the American Psychological Association, clinical and forensic psychologists, and other mental health professionals to provide vitally needed feedback about the proposed DSM-V revisions. And, due to external criticism about the revision process thus far, the American Psychiatric Association is apparently more receptive than ever before to such feedback.

This is not about scrapping the DSM-V. Speaking as a clinical psychologist, psychodiagnosis can be extremely valuable in treatment planning and psychotherapy. Diagnosis is an initial, though admittedly limited and potentially limiting, way of understanding the patient, his or her symptoms, and their possible sources. (See, for example, my enthusiastically supportive previous post on the proposed DSM-V diagnosis of Posttraumatic Embitterment Disorder.) It gives the clinician a starting point in hypothesizing about the nature of the symptoms, and it provides the patient with the often encouraging and humanizing sense that his or her problem can be known, is shared by others, and will be treatable. In forensic psychology, diagnosis is an integral aspect and focal point of every forensic evaluation, especially in the field of forensic criminal psychology. A good diagnosis can aid a jury or judge in reaching difficult, far-reaching, possibly life and death decisions regarding the fate of a criminal defendant. Of course, a bad diagnosis can have disastrous consequences. And different clinicians or expert witnesses frequently disagree regarding the diagnosis after having evaluated the same defendant. Which is why it is terribly important, as Dr. Frances suggests, that the DSM-V revisions strive to make it not a less but more reliable and accurate system by carefully reviewing and choosing not only the specific diagnostic criteria required for each old and new disorder, but the language that is used in describing these criteria and the disorder itself.

The DSM-V was designed to be a primarily phenomenological and descriptive rather than etiological system of recognizing and categorizing commonly (I would say archetypally) occurring patterns of mental disturbance. It still cannot, except rarely, presume to know with any certainty the cause of any given disorder. (Though there are presently implicit presumptions in psychiatry based on their biological paradigm.) This means that just because a person, client or patient receives a DSM-V diagnosis, there is no preordained prerequisite that psychiatric medication must always be part of their treatment. Nor psychotherapy for that matter. The interpretation and particular treatment of the disorder should be left to the clinician's judgment, though that judgment must take into consideration accepted standards of competent treatment in the clinical community.

But if DSM-V were to explicitly presume etiology, as say, in the case of anger disorders like the proposed Posttraumatic Embitterment Disorder and Temper Dysregulation Disorder with Dysphoria, it would need to counterbalance biology with psychology. Psychology must aggressively reassert its influence into the understanding and treatment of mental disorders as, for the most part, primarily psychological phenomena. In this sense, psychology has an obligation to correct psychiatry's lopsided biological bias. It was Sigmund Freud who first demonstrated the powerful role of psychology and the unconscious in both the etiology and treatment of mental suffering. Prior to Freud, a century ago, mental illness was seen purely as a physiological  aberration. Today, sadly, psychiatry has come practically full circle. And many psychologists have followed suit. But despite this regressive state of affairs in both psychiatry and psychology, psychodiagnosis remains an essential and indispensable part of clinical practice, whether regarding psychological assessment, psychotherapy or forensic psychology. Simply throwing the baby out with the proverbial bathwater is really not an option as regards DSM-V. What the DSM-V and psychiatry need to re-integrate into their neurobiological paradigm is the dynamic power of psychology to both cause mental disorders and to heal them.

Stephen Diamond, Ph.D., is a clinical and forensic psychologist in LA and the author of Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity.

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