On family therapists who oppose using the DSM-5

Doctor discussing diagnosis with patientOkay, 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.

# # #

Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed. You’ll also find a some very insightful comments on this article over on my Facebook page.

Announcing the Self-Injury Institute

KISI logo, (c) 2013 Kahn Institute for Self-Injury, used by permission. Any external use requires separate permission.Non-suicidal self-injury is newly in the DSM-5, which is a welcome change reflecting a new scientific understanding of the phenomenon. It just isn’t where you might expect it, as I wrote last week on the new blog for my friend and colleague Angela Kahn’s new institute: The Self-Injury Institute.

I’ve been lamenting over the past few months that as the dynamic first-generation leaders in the family therapy profession have been passing on, there really haven’t been loud, passionate voices ready to take their places. Kahn, however, is just such a voice. She offers a full-throated defense of family-based treatment for most cases of self-injury. The crowded rooms and warm receptions she has received at conferences put on by NAMI, AAMFT-CA, and AAMFT show just how much of a hunger there is for her work and her insight.

Based in Los Angeles, SII was born partly out of necessity. There are few places in the country specializing in self-injury treatment, and few if any of them seem to offer what Kahn does: An understanding and treatment of self-injury based in family dynamics. As word of her family-based treatment has spread, she has found herself with more clients than she can take on — and no one who provides similar local services who she could refer clients to.

The Institute is starting with trainings and treatment. KISI offers family-based, outpatient therapy for self-injury through Kahn and several registered MFT interns. The first official KISI training for mental health professionals will be July 12 in Los Angeles, with Kahn herself as the instructor. Complete information and registration is at www.selfinjuryinstitute.com.

In the interest of full disclosure, I’ve been assisting the Institute in getting started, and hold the title of Fellow there. But it’s a volunteer role, and I would be happily cheering SII on even if I weren’t directly involved. This institute will be great for the family therapy profession, and more importantly, for the many families struggling with self-harm who have spent far too much time with diagnoses that don’t really match their problems, and in treatments that, far too often, don’t work.

Welcome to the world, SII. We need you.

# # #

Your comments are welcomed. You can post them in the comments below, or email me at ben[at]bencaldwell[dot]com.

There will never be a lab test for some mental health disorders

Because they aren’t really “disorders” when you consider the “symptoms” in context.                                                                                                                                                                                                                                                                                                            


One of the first things any new student in family therapy learns about is the genius of the acting-out child. Children are keen observers of the world around them: If they learn that one kind of scream or cry or tantrum gets their parents’ attention where another kind does not, they are quick to do what works and give up on what doesn’t.

Children are also, for obvious reasons, incredibly observant of their parents’ relationship (whether to each other, or in blended or single-parent families, to the new partner). For kids, seeing their parents fighting can be utterly terrifying.

Some kids, in the midst of a parental argument, learn to stay out of the way. Other kids learn, even by accident, that a very good way to get the parents to stop arguing with each other is to break rules, scream, or otherwise behave inappropriately. Here is where acting out is so smart: if both parents get angry at the kid for misbehaving, at least they stop arguing with each other for a while.

For a child, the pain of having your parents angry at you may be far preferable to the terror experienced when watching them fight each other.

Of course, parents are often reluctant to see this. They may instead perceive such a child as “hard to handle,” “defiant,” or otherwise broken. In the worst cases, health care professionals buy into the parents’ descriptions, slapping diagnostic labels on the child. Labels like “attention-deficit hyperactivity disorder” or “oppositional defiant disorder” may accurately describe a child’s behavior, but they ignore the cause, and tend to focus attention on the child as the problem.

A skillful family therapist will assess not just the child but also the child’s entire social environment, including their family, to see whether the acting-out behavior is actually smart. If it is, then therapy focuses not on “curing” the acting out, but instead on making it no longer necessary. The family therapy field is rife with stories of children diagnosed with attention-deficit disorder, childhood bipolar disorder, or other mental illnesses who are rapidly “cured” once their parents start coming in to therapy sessions — especially if the parents are willing to work on their relationship with each other.)

Of course, we don’t stop being impacted by our social worlds when we become adults. Just as the acting-out child is often behaving in a way that is quite smart given their environment, adults who appear to have mental illnesses may be responding intelligently to the world around them. This may mean their behavior is a response to the work environment, social circle, family, or even larger society. For example, William Glasser suggests that at least some of the higher prevalence of depression among women might actually be a wise response to the impossibly high demands placed on women to be successful at work, at home, and socially, always with a smile on. For women who experience that pressure intensely, and do not feel they have a reasonable way of escaping or easing it, depression can be a quite reasonable way of checking out of that chase without having to actively fight social norms. (For clarity, Glasser is not suggesting blaming the depressed for their depression; he does argue that depressive behaviors are sometimes chosen, but goes on to say these choices are often not conscious. Depression may be an adaptive response to difficult circumstances, Glasser says, but it certainly is not ideal.)

Ultimately, whether we are talking about children, adolescents, or adults, it is often true that behavior that might look troubling or even “ill” in one context is actually quite helpful in another. In fact, sometimes taking on behaviors that appear crazy to others is actually the smartest thing to do. It’s evidence of good health and adaptability, not an underlying problem with the brain or body that any lab test could detect.

That’s why, for as much as I support the National Institutes of Mental Health’s effort to usher in a new era of hard science in mental health diagnosis (and usher out the behavior-based diagnoses of the DSM-5), I wonder who it will leave out in the cold. The simple fact is that many people who now (appropriately!) receive diagnoses and are eligible for insurance-covered treatment for mental disorders are not, in any physiologically-testable way, disordered. They are actually quite healthy. Their behavior makes perfect sense when understood in context.

# # #

Your comments are welcomed. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

National Institutes of Mental Health abandons DSM-5

Just weeks before the new diagnostic manual is released, NIMH cites “lack of validity” and says “patients with mental disorders deserve better.”

PET-imageIn a surprising announcement just weeks before the scheduled release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the US government’s mental health research arm has announced plans to stop using DSM categories in its work.

The National Institutes of Mental Health (NIMH) is the single largest funder of mental health research in the world. In his announcement last week explaining the decision, NIMH Director Thomas Insel wrote that “Symptoms alone rarely indicate the best choice of treatment.” While diagnositic categories based on clusters of symptoms — like the categories in the DSM — provide a common language that mental health care providers and researchers can use, these categories are more about that consistency in usage (i.e., reliability) than they are about clinical or research validity. Such symptom-based diagnosis, Insel argued, is now outdated in most other areas of medicine.

So NIMH is scrapping DSM categories when funding future research and is developing its own framework to “transform diagnosis by incorporating genetics, imaging [such as the PET scan pictured above], cognitive science, and other levels of information to lay the foundation for a new classification system,” according to Insel. For now, the new classification system is just a framework for research. But the clear intention is to make the DSM obsolete.

As a family therapist, I find the DSM-5 categories to be both useful and limited in the ways Insel described. They are a good tool for communicating with other professionals, but not especially useful for clients, beyond establishing that others may have similar suffering. I like the idea of a new classification system for mental disorders based on biology and verifiable laboratory tests (indeed, I think it’s overdue), and think it quite likely that such a system will strongly support systemic and relational therapies. The brain is a social organ, after all, and therapy creates verifiable physiological changes in the brain.

# # #

Your comments are welcomed. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.