Family therapy

Okay, a bit of a rant today. In the family therapy world, I often hear criticism of the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic guide published by the American Psychiatric Association and currently on its fifth edition (DSM-5). This usually comes from students first learning about the DSM and its history, and in those students the criticism is often based more on anxiety than on any real substantive problem with the book.

Students are understandably anxious when confronted with the complexity of diagnosis and the power that comes with being able to diagnose a client as mentally ill. Unfortunately, I see too many MFTs who never get past that initial anxiety, and use it as an excuse for avoiding the DSM well into their professional careers. I don’t begrudge anyone their anxiety, I just wish people would own it for what it is (kind of like with licensing exams), instead of making up or latching onto an easily-refuted argument against learning and using the DSM appropriately.

The arguments against DSM use that I hear in the MFT world tend to reflect poor understanding of both the DSM and family therapy. Those arguments typically fall into three groups, listed here with their easy counters:

1. “The DSM is based on individuals, and I work with families.” The DSM offers labels for common sets of symptoms. That is, it gives you a quick name for sets of problematic behaviors that often occur together. It is agnostic about the source of those symptoms. It does not, contrary to some therapists’ opinions, make a presumption that the source of suffering lies within the individual. The way the DSM is written, depression could be caused by something within an individual, by problems in couple or family functioning, or by aliens. You’re free to maintain your systemic ideas about how depression often originates and is sustained (ideas I agree with, just so we’re clear) without any concern that these ideas conflict with the DSM. They don’t. Furthermore, a good systemic therapist does not ignore individual functioning; indeed, one needs to be keenly aware of how individuals are functioning within a system in order to understand the system itself.

2. “A diagnosis is just a label, and I don’t like labeling people.” Nonsense. Any time you call someone by their name, you are using a label for them. Labeling is a good and healthy and awesome thing that we do in human societies to keep language relatively efficient. If you really hate labels, and prefer to capture the whole essence of things (many of those I have heard say they avoid the DSM say that they do so to better capture the “whole person”), then when you go home tonight I want you to announce to whomever is close by that for dinner you will be having semolina, flour, eggs, and water, all formed, cut into long needle shapes, and dried, and then resoftened in boiling water for a few minutes, topped with pulverized tomatoes that have themselves been heated and mixed with spices and possibly some kind of meat or cut mushrooms. Served steaming hot! Then you can take pride, when they tell you “um, that’s spaghetti,” that you have captured the entire essence of the pasta. You’ve also needlessly wasted everyone’s time.

   Listen, use of a label doesn’t constrain you to only using that label, nor does it mean the label is all there is of someone. I hope that when doing therapy, you really do maintain a thorough sense of your clients’ strengths and resources and personalities far beyond what you can gather from a simple diagnosis. But use the label too. It is essential for other health care providers, who may need to know the nature of someone’s symptoms very quickly (like in an emergency), that you know enough about symptoms and diagnoses that you can tell them, without taking the next 15 minutes to describe someone’s essence as a human being.

3. “The DSM is pathologizing, and I try to focus in therapy on depathologizing behavior.” I have the most empathy for this argument, as family therapists are particularly inclined to see even diagnosable behaviors as adaptive to their context. But it still falls pretty flat. Yes, the DSM is pathologizing, insofar as it describes symptom clusters as mental disorders. Expanding criteria for mental illness contributes to what Szasz labels the medicalization of everyday life. And there is much to be said about the misuse of DSM diagnoses across cultures.

   But go back to the first argument here. Remember, the DSM is agnostic as to the source of symptoms. The fact that the behaviors that together add up to a diagnosis of, say, depression are actually adaptive responses to family dysfunction does not make the diagnostic label incorrect — the individual really is displaying those symptoms — and it doesn’t mean that the individual should not receive treatment. Indeed, one of the upsides of broadening diagnostic criteria is that they allow people to receive treatment, often paid for by their insurance company, when they previously could not have. In other words, that individual diagnostic label (which, again, is just a description for a symptom set, not a theory about the cause of the symptoms) is often the very thing that allows you to treat the system.

There are larger debates to be had about the role of the DSM in mental health care, and even more broadly, how our entire health care system is structured around diagnosis and dysfunction rather than a foundation of keeping people well. And there certainly is plenty to criticize about the DSM. But for where we are now, let’s all agree that (1) diagnosing is important enough that it’s okay to be anxious about it, and (2) the act of assessing and diagnosing an accordance with the DSM is in no way inconsistent with family systems work. In fact, it’s a requirement for doing that work well.

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