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Article Excerpt
Many of the values, assumptions, and philosophies inherent in the DSM diagnostic system conflict with those of the mental health counseling profession. This article describes these conflicts; provides clinical practice suggestions for addressing these issues when using the DSM system; and offers strategies for bridging the divide between mental health counseling's professional identity, and the DSM system of conceptualization.
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The influence of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR; American Psychiatric Association, 2000) assessment system on the mental health field has been profound. In fact, it is difficult to overstate the magnitude of the DSM's presence in the mental health profession (Eriksen & Kress, 2005; Hinkle, 1999; Seligman, Walker, & Rosenhan, 2001; throughout this article "DSM" will be used to refer to the system of diagnosis described in the various editions of the Diagnostic and Statistical Manual). The DSM's multiaxial assessment system has become the primary language of communication regarding client problems, offering a way of reducing complex client-related information into a manageable form (Seligman et al., 2001). Also, the DSM, by categorizing people's psychological problems, aims to assist researchers and theorists in comparing various treatment approaches to particular problems. Further, researchers may investigate underlying causal mechanisms and processes of particular diagnoses, which in turn may allow for prevention and improved control over the outcomes of psychiatric disorders (American Psychiatric Association [APA], 2000; Hinkle, 1999; Maniacci, 2002; Mead, Hohenshil, & Singh, 1997). In addition, the DSM provides information about the course, prevalence, cultural, gender, and familial issues related to each diagnosis--information that may be helpful to counselors who are struggling to fully understand their clients' experiences. This understanding, in turn, may enable effective referral and/or planning of counseling, psychotherapy, and other psychiatric treatment strategies (Duffy, Gillig, Tureen, & Ybarra, 2002; Mead et al., 1997; Waldo, Brotherton, & Horswill, 1993). DSM diagnoses may also help mental health counselors to identify those clients whose problems extend beyond the clinician's areas of competence (Eriksen & Kress, 2005).
The DSM may also benefit clients in more personal and direct ways. For example, sometimes clients benefit from an ostensibly concrete explanation of their behavior, and experiences. Labeling clients' behaviors and experiences may offer them freedom from self-blame and the ability to invest their energy more productively in resolving or managing their problems (Eriksen & Kress, 2005; Houts, 2002; Shergill, Barker, & Greenberg, 1998). Houts (2002) states that receiving a diagnosis may be "personally comforting" to some people as it provides a "kind of 'explanation' for behaviors or feelings that are upsetting" (p. 48). Diagnostic labels may also focus families of those diagnosed on an identified external enemy or cause, and away from blaming one another or themselves (White, 2002). Furthermore, believing that a client bears a clinical diagnosis may even positively change counselors' feelings towards a client, enabling them to be less critical and more supportive (Eriksen & Kress, 2005).
Mental health counselors may be particularly aware of the financial and occupational benefits of using the DSM because third-party reimbursement for services requires the ascription of a diagnosis (Eriksen & Kress, 2005). For instance, various governmental agencies use the DSM categories for census purposes, for specifying target populations whose treatment may be funded by grants, and for determining who is eligible for specially funded programs like Medicaid, Social Security Disability Income, benefit programs for veterans, and Medicare (Kutchins & Kirk, 1997; Regier, First, & Marshall, 2002). Almost all settings in which mental health counselors work currently require a DSM diagnoses for reimbursement of services (Mead et al., 1997). Consequently, without knowledge of diagnosis, counselors may lose reimbursement, may lose credibility and status in their professional fields, may not be able to fulfill their employment requirements, and may lose credentialing opportunities (Sperry, 2002a; Russell, 1986; Waldo et al., 1993). Because of its economic power, influence, and popularity, it has been said that the DSM "is the key to millions of dollars in insurance coverage for psychotherapy, hospitalization, and medications" (Kutchins & Kirk, 1997, p. 12). Essentially, entry into almost any service in the mental health care delivery system requires the ascription of a DSM diagnosis.
However, limitations of DSM diagnosis and potential harm to clients that may emerge from such limitations call on mental health counselors to use the DSM carefully and to consider ethical challenges related to its use. The limitations that have been cited include the following:
* The DSM diagnostic system fails to predict treatment outcomes or to promote understanding of underlying pathology (Sarbin, 1997)
* DSM diagnostic categories can lead people to accept a self-fulfilling prophecy that their situation is hopeless and that they are sick (Rosenhan, 1973)
* DSM diagnoses can narrow a counselor's focus by encouraging the counselor to only look for behaviors that fit within a medical-model understanding of the person's situation (Ivey & Ivey, 1998; Malik & Beutler, 2002; White, 2002)
* The act of diagnosing may preclude a focus on the client's narrative construction of his or her experience (Goncalves, Macahdo, Korman, & Angus, 2002)
* DSM diagnosis fails to include a full understanding of contextual factors that may more aptly illuminate both etiology and helpful treatment (Maracek, 1993; Shields, 1995)
* The application of diagnostic labels has historically stigmatized and hurt those who are different from the mainstream. This practice continues today (Caplan, 1995)
* Problems exist in the science of the DSM diagnostic process (Jensen & Hoagwood, 1997; Houts, 2002; Malik & Beutler, 2002; Szasz, 1974)
* DSM diagnosis implies the imposition of a certain set of values on clients and the counseling process (Woolfolk, 2001)
* Diagnostic categories can minimize peoples' individual uniqueness (Denton, 1989)
* The diagnostic process takes the focus away from clients' reality and understanding of their problems by directing clients away from an internal and subjective way of understanding their experiences, instead putting the...
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