Academic journal article Journal of Counseling and Development : JCD

Beyond the DSM-IV: Assumptions, Alternatives, and Alterations

Academic journal article Journal of Counseling and Development : JCD

Beyond the DSM-IV: Assumptions, Alternatives, and Alterations

Article excerpt

Traditionally, psychodiagnosis has focused on symptomatology and dysfunction--that which is not working in a person's life. Within the framework of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) and the later text revision (the DSM-IV-TR; APA, 2000), each diagnosis represents a negative syndrome comprising a cluster of symptoms associated with clinically significant impairment or distress. Rather than addressing these syndromes as environmentally or situationally determined, the developers of the DSM-IV framed mental disorders as dispositional (i.e., something that is within the individual and part of his or her psychological makeup). This focus on negative aspects has occurred at the expense of identifying the strengths of individuals and their environmental resources and of assisting people in their pursuit of optimal human functioning.

In this article, we identify limitations in current psychodiagnostic practices and the DSM-IV framework and offer alternative means for conceptualizing behavior. More specifically, we address unsubstantiated assumptions about mental illness and psychodiagnosis that undergird the use of the DSM-IV. We then offer three adjunctive, or alternative, means of describing behavior and mental health. Finally, we discuss ways to alter the DSM-IV's five-axis system so that strengths and resources can be detected and described within the existing framework.

* Assumptions About Psychodiagnosis and the DSM-IV

In this section, we hope to establish that reification of and reliance on the DSM-IV system are grounded in the assumption that clinicians are getting the "whole picture" of a client from a diagnosis based on the DSM-IV system. This is not the case. Failure to acknowledge the assumptions that undergird the DSM-IV system and the associated limitations of this meaning-making tool will perpetuate the disconnect between diagnosis and treatment. (See "Stopping the Madness" by Maddux, 2002, for a detailed deconstruction of illness ideology that served as the intellectual stimulus for this article.)

Assumption 1 : Mental Illnesses Are "Facts" and Can Be Classified in Discrete Categories

The DSM-IV's (APA, 1994) and the DSM-IV-TR's (APA, 2000) diagnostic system is based on the assumption that "mental illness" reflects "facts" about people struggling in the world. "Disorders" are created based on reports of complaints and functional disturbances, with arbitrary distinctions being drawn between types of dysfunction. Once these distinctions are made, the cluster of symptoms is given a name and is thereby transformed into a real entity. In this way, it may be said that illnesses are created and do not necessarily reflect facts about individuals (Barone, Maddux, & Snyder, 1997). Barone et al. suggested that through this process diagnoses and their representative labels are reified, and the cluster of symptoms begins to be recognized more often. Clinicians then diagnose the disorder more frequently, and a disorder takes on a life of its own. It is interesting that some of these diagnoses eventually will become antiquated descriptors because changes in people's beliefs lead to changes in societal norms and values, further reflecting the descriptors' constructivist nature.

Evidence of the reification of the DSM-IV categories can be found when considering the ever-expanding explanatory power of the system. Barone et al. (1997) have indicated that the scope of mental disorders has broadened to include what many would consider problems that are less serious, such as caffeine-induced sleep disorder. Furthermore, the number of clinical diagnoses has increased from 106 in the initial edition of the DSM (APA, 1952) to 297 in the recent DSM-IV-TR (APA, 2000; Clark, Watson, & Reynolds, 1995; Wright & Lopez, 2002).

Due to their tenuous nature, facts about mental illness and health seem to be best represented by examining the degree of psychological characteristics via a dimensional approach. …

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