An Alternative to DSM

Last month (May 31), National Public Radio (NPR) ran an interview on Science Friday with Thomas Insel, MD, Director of NIMH, Jeffrey Lieberman, MD, President of the APA, and Gary Greenberg, PhD, practicing psychotherapist.

I didn’t hear the interview, but I have read the transcript.  Doctors Insel and Lieberman were spinning the barrage of criticism directed at psychiatry in recent months, while at the same time clinging desperately to the notion that the problems that psychiatrists “treat” are real illnesses.  It’s become a familiar theme, and there was nothing new.

What interested me, however, was a remark by Dr. Greenberg.  Here’s the quote:

“I think, you know, one of the things to consider here is we’re dealing with the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions. Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos. And I don’t think anybody wants to go back to that. I don’t think anybody right now has an alternative for clinical use…”

I was surprised to read these words, because I had always had the impression that Dr. Greenberg was opposed to the widespread spurious medicalization of human problems.

Let’s take a closer look at what he said.

“…the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions.”

As an example here, let’s consider the case of a young man who goes to a therapist and says: “I worry a lot about germs, and I wash my hands about 100 times a day.”

To my way of thinking, this is perfectly clear and perfectly understandable.  Gary seems to be suggesting that assigning this man a “diagnosis” of obsessive compulsive disorder somehow enables the therapist to understand the presenting problem.  In other words, the preoccupation with germs and the frequent hand-washing are explained by the “diagnosis” of obsessive compulsive disorder.  The reality, however, is that the “diagnosis” (unlike real medical diagnoses) has no explanatory content.

Let’s apply the acid test:

Client: Why do I worry about germs and wash my hands so much?
Therapist:  Because you have a mental illness called obsessive compulsive disorder.
Client:  How do you know I have obsessive compulsive disorder?
Therapist:  Because you worry about germs and wash your hands so much.

The “diagnosis” explains nothing.

Back to Dr. Greenberg:

“…And to make clinical decisions.”

I can’t even imagine how replacing the client’s very clear, very specific problem statement with a more general statement, which has no explanatory value, can help in making clinical decisions.

Dr. Greenberg continues:

“Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos.”

Well I can remember back then, and it didn’t seem like chaos to me.  We asked the client what was troubling him or her; sought clarification and details as necessary; listened as carefully as we could for nuances; and worked collaboratively with the client towards solutions.  In the hypothetical case mentioned above, the help provided would be along the general lines of stimuli identification, and graduated exposure adapted creatively to the individual needs and concerns of the client.

Also, we didn’t call these kinds of problems mental illnesses.

“I don’t think anybody right now has an alternative for clinical use beyond what the DSM is providing.”

Behavior therapy since at least the 60’s has used the client’s own statement as the treatment “target,” not as a result of any great insight or study, but simply because it made sense.

In addition, Peter Kinderman, PhD, on May 15 posted So…What happens next? on DxSummit.org.  In this article he proposes the use of a client problem list and psychosocial formulations as a rational substitute for a DSM “diagnosis.”

Psychiatric “diagnoses” were invented by psychiatrists to promote the pretense that they are real doctors, and to legitimize the prescribing of mood and behavior altering drugs.  These “diagnoses” not only don’t help, they are a hindrance.  They have no advantage over the client’s own statement.

I know the advantage to psychiatrists:  without a “diagnosis” they can’t prescribe their drugs.  But why would a therapist find these spurious “diagnoses” useful?

Dr. Greenberg continues:

“So it’s easy to criticize this and to say it’s not a perfect document.”

We have been hearing this a lot from psychiatrists lately.  They say, in effect:  we know the DSM isn’t perfect, but it’s the best we’ve got and we’re working hard to improve it.  This whole line of reasoning misses the point of what the anti-DSM contingent is saying.  We’re not saying that the DSM is an imperfect document in need of tweaking.  We’re saying that it’s rubbish!  It has no validity and serves no useful purpose.  And, in that it legitimizes the pushing of dangerous pharmaceutical products for an increasingly wide range of human problems, it is very destructive rubbish.

The purpose of this post is not to attack Gary Greenberg.  But I have commented favorably on Gary’s writing in the past, and I didn’t want there to be any perception that I was in harmony with some of the positions he took on the NPR interview.

 

 

  • Steven Johnson

    While I agree with some of your points the exchange between the client and the therapist is flawed.

    Client: Why do I worry about germs and wash my hands so much?

    Therapist: Because you have a mental illness called obsessive compulsive disorder.

    Client: How do you know I have obsessive compulsive disorder?

    Therapist: Because you worry about germs and wash your hands so much.

    The exchange should be

    Client: Why do I worry about germs and wash my hands so much?

    Therapist: Because you have a mental disorder called obsessive compulsive disorder

    Client: How do you know I have OCD?

    Therapist: OCD is just the name we give to your particular mental disorder. I know you have a mental disorder because you wash your hands more than needed. This is likely caused because you can’t tell when your hands our actually clean since you can’t see the germs. How do you know when a cup is full? You can see it. Would you hold a cup there in the sink watching water spilling over the top wondering if its full? Probably not. With washing your hands, how do you know? Most people don’t worry about it. They use soap and water and dry off and forget about it. However you don’t forget about it. Quite the opposite – You obsess and that obsession will not go away until you perform the compulsive behavior. But even then it really doesn’t.

    Here’s a fun joke. You know how OCD people flick the light switches on and off? What did they do before electricity? Light the candle, blow it out, light the candle, blow it out.

  • Phil_Hickey

    Steven,

    Thanks for coming in. The scenario that you describe is interesting, but it is not what actually happens.

    In the real world of psychiatric practice, the “mental illnesses” are routinely adduced as the explanations for the problems, even though, as you point out, they are merely labels. I have never encountered a psychiatrist who would concede that their various “diagnoses” are merely labels.

    In fact, the use of the terms “symptoms” and “mental illness” in psychiatry clearly imply that the former are caused by the latter, as is the case in real medicine.

    In psychiatry, the “mental illnesses” are considered to have the same kind of ontological status as pneumonia and diabetes, and the same kind of explanatory value. Since the 70’s, I have never encountered a psychiatrist who displayed even the slightest interest in exploring genuine causative factors.

    Best wishes.

  • Steven Johnson

    I’ve never been to a psychiatrist, but if that’s how they do it, that is horribly inaccurate.

    Rudolf Driekurs once said, when asked if a psychiatrist is a psychologist, “Yes, but really bad ones”.

    This is further proof of that.