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Beyond the DSM StoryReview - Beyond the DSM Story
Ethical Quandaries, Challenges, and Best Practices
by Karen Erikson and Victoria E. Kress (Editors)
Sage Publications, 2004
Review by Tony O'Brien, RN, M. Phil.
Jun 19th 2005 (Volume 9, Issue 24)

The focus of Eriksen and Kress's book is the ethical challenges presented to mental health professionals by the use of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). The authors are family therapists, and their concern is that a combination of factors, not the least of which is a requirement of insurance companies, makes their use of the DSM mandatory. This is a problem because the authors identify a range of ethical and methodological concerns about its use. After outlining in broad terms the problems of the DSM, the authors present a training exercise, three illustrative case studies, followed by a final chapter that describes an alternative assessment model. The result is a book that is stronger on critique than on alternatives. And despite the authors' obvious antipathy to the DSM they are unable, finally, to reject it. Therein lies the problem of a system of thinking that has come to dominate mental health care. Even its opponents seem obliged to accord some sort of grudging recognition.

Beyond the DSM Story begins with a long chapter that outlines ethical issues with diagnosis, then goes on to criticize the DSM, psychiatry, mainstream science, 'the medical model' and a good deal else. From the outset it is apparent that 'ethics' is used only in the broadest sense: the ethical analysis of the book extends only as far as discussing very broad ethical principles. While it is possible to agree that diagnosis carries the often unrecognized ethical problems the authors list (confidentiality, consent, conflict of interest) it is impossible to separate these issues from the whole treatment enterprise. Yet Eriksen and Kress approach these problems as if such a separation were possible. There is a certain selectiveness in the critique of psychiatry. Clinicians might be interested to learn that homosexuality and male-female relationships are some of the controversies in psychiatry that are most often in the limelight (p. 30). There is a naïve critique of science which is characterized as unable to respond to the role of values in generating knowledge, and vulnerable to the criticism that 'facts and values cannot be objectively separated' (p. 35). Yet the authors seem profoundly ambivalent about science and about the DSM. They somewhat grandly declare that their book 'is not meant to disqualify science' (p. 35) and concede that 'much of the research base for the DSM-IV is sound' (p. 41).

The second chapter is given to a review of literature critical of the DSM and psychiatry from a cultural perspective. Eriksen and Kress revisit their critique of science, cataloguing the more extravagant claims made in the name of scientific psychiatry and showing how when it comes to mental illness, there is no escaping the influence of culture. There is a list of culture bound syndromes not recognized by the DSM, discussion of cultural bias in assessment and diagnosis, and examples of the influence of ethnicity in over or under diagnosing different illnesses. In this chapter, as with the first, the authors show the same ambivalence about the DSM. They lament on the one hand its shortcomings and the impossibility of finding a neutral, value free position for assessment and diagnosis, then offer suggestions, taken up later in the book, for the recognition of an even wider range of behaviors, including some that are now excluded as cultural phenomena but not mental illnesses. Given the earlier (and well justified) critique that psychiatry, especially under the influence of insurance companies, is already over inclusive, it is hard to see how its expansion would serve people experiencing loneliness, abuse, isolation, or racism, other than to legitimize (at the risk of pathologizing) their experience through the system of insurance reimbursement. There is a strong argument for cultural awareness in mental health care, although at times it gets a little lost in the welter of examples of problematic practices in the name of mainstream psychiatry.  

Chapter Four covers feminist challenges to the DSM, and begins with a review of the abundant literature into the influence of gender and gender stereotypes on the nosological system of the DSM and on the clinical practice of practitioners. Citing extensively from this literature, the authors raise questions about why disorders which pathologies women's experience (for example premenstrual dysmorphic disorder) find a place in the DSM, whereas there are few correlates for men's experience. That's a good question, although the answer is by no means clear. A further extension of the DSM to cover a wider, more gender balanced range of disorders would achieve gender equality of a sort, but at the cost of bringing a greater range of problematic behavior under the psychiatric gaze. The alternative of using a smaller range of diagnoses that focus on features of mood and cognition, without ascribing those to a particular cause seems more rational.

Having set out their critique, the authors then attempt to resolve the issues raised through the use of a number of vignettes. The vignettes are designed to highlight the issues raised so far: the need for contextualized assessment, attention to social and cultural factors, gender issues and other concerns in diagnosis. As such the chapter does not advance the authors' arguments any further, but provides a guide for managing the issues raised in clinical practice. Customized vignettes always carry the disadvantage that they are designed to illustrate certain points and so those points tend to be highlighted. In clinical practice such issues are not usually so apparent.

 The next three chapters cover individual case studies in which issues of diagnosis are discussed by a panel. The range of views introduced in these chapters adds interest, especially as the invited commentators do not always agree. The case studies cover very different clinical presentations and highlight a range of diagnostic issues, but what looms large over these chapters is the role of diagnosis in influencing clients' access to insurance entitlements. In one case a mother demands a diagnosis for her child so that she can claim reimbursement (raising issues about whether the child's 'symptoms' are manufactured by the mother); in another case, one diagnosis might validate an understandable response to trauma, another might stigmatize the client and set up negative expectations. What was interesting overall in this section was that there is little discussion of the limitations of the DSM; equally, it is clear that the DSM alone does not provide an adequate framework for understanding the complexities of mental health practice.

The final chapter proposes an alternative model of assessment, the CPSS model developed by one of the authors. The CPSS model is based on constructivist psychology, and attempts to meet the criticism leveled at the DSM, especially in terms of eliciting a more contextual 'story' than is possible with the individualist model of the DSM. However in the case study used to illustrate the CPSS model, the authors state that the DSM diagnosis of depression should be applied if the client meets the criteria. Thus although the CPSS model is presented as an alternative to the DSM, it is not a complete alternative. It is not entirely clear if the authors limit its applicability to counseling services, or see it as applicable across the spectrum of mental health services.

Early in this book Erikssen and Krass state that they 'do not intend to provide a balanced view of the benefits and limitations of the DSM' (p. 1). That is a pity, because in the end it's not clear that even a practitioner who accepts their arguments about the limitations of the DSM would feel free to abandon it. Besides the authors' muted acceptance that there are some benefits of psychiatric diagnosis and treatment (which necessitate DSM diagnosis), such a diagnosis is also necessary in order to claim insurance entitlements. Clinicians can take from this book that even where DSM diagnosis is a necessary component of practice it does not tell the whole story.

It is hard to fault the authors' initial objection that the DSM is an inappropriate diagnostic tool for family therapists given that there exist many more helpful ways of conceptualizing the clinical problems this professional group deals with. However it is another question whether other professional groups, particularly psychiatrists, would share their concerns. But they might agree that an alternative system of reimbursement for family therapy would be a reasonable part of a solution to the issues raised by Erikson and Kress.     

In the end it is hard to know whether it is the system of reimbursement that is the problem for Eriksen and Kress, or the DSM itself. It seems not unreasonable for family therapists to argue that a system of psychiatric classification is not adequate for their purposes, and that an alternative means of classifying problems would serve them and their clients better. After all, the target population of the DSM is people with mental illness, not those with problems in living. Beyond the DSM Story is an American book with a cautionary tale for American family therapists. But just as mental health clinicians need to contextualize the DSM within their own practice setting, they should also approach Eriksen and Kress's critique with caution. It may not wholly address the issues they face in their clinical practice, especially if they do not currently use he DSM. The book provides an extensive review of some familiar issues in mental health practice, and more than adequately shows diagnostic psychiatry to be socially constructed, unstable, and not always reliable. For those who have had no previous exposure to such critique the book will provide a useful introduction. Others will find the issues better covered in some of the material referenced by Eriksen and Kress, and in other critical accounts that are not referenced.       

 

© 2005 Tony O'Brien

 

 Tony O'Brien, RN, M. Phil., Senior Lecturer, Mental Health Nursing, University of Auckland


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