Amidst the considerable controversy regarding the publication of the new Diagnostic and Statistical Manual (DSM) -- 5th Edition, I have found myself curiously disconnected from the heated debate.
When I was in graduate school, I memorized the DSM-IV when it came out. I tagged all relevant categories of mental illness and learned all of the criteria in preparation for my clinical work. Yet, I never thought of the DSM as the Bible of mental illness. Instead, I saw it similar to a Chinese food menu of signs and symptoms -- I could pick and choose what seemed to fit in order to make a diagnosis that was required by insurance companies. None of my patients ever squarely fit into any DSM category. Human behavior always seemed much more complicated and nuanced than what psychiatric signs and symptoms could offer.
Indeed, every revision of the DSM has been controversial. Those of us in training who were more mindful of history knew that older versions of the DSM used to consider homosexuality as antisocial behavior. As if this was not enough for us to be suspicious of our supposed "diagnostic manual," I remember learning that the diagnosis of personality disorders (when not using structured clinical interviews) had an inter-rater reliability coefficient of .30. This means that among all people trying to diagnose an Axis-II disorder using the Bible of psychiatry, only one-third of clinicians agreed to a diagnosis based on the same DSM criteria. In case my memory is not enough, consider an article by Jack Carney; field trials regarding DSM-V have not done much better for both Axis I & II diagnoses.
It was only much later in my training that I realized that psychoanalytic clinicians were not interested in the DSM at all. Psychoanalytic diagnosis has long been operating in isolation. Ultimately, this led to the Psychodynamic Diagnostic Manual: (PDM) in 2006. This publication attempted to offer another way to view human psychopathology. Using more complex understandings of behavior and motivation, it offers a better comprehension of diagnostic criteria.
But even the PDM is not enough. For those of us conducting therapy everyday, no diagnostic system really explains the depths of human suffering. The fact is that psychotherapy is hard to define and hard to explain.
Yet, as doctors, we are hired to treat symptoms. When we are confronted with patient complaints, even if we are psychoanalytic, we need to provide treatment. I recently consulted with someone who had spent 10 years in analytic therapy and no one had told this person about another Bible -- that of cognitive-behavioral therapy for depression -- Feeling Good, by David Burns.
While the American Psychiatric Association may be propagating nonsense with the new DSM, we psychoanalytic clinicians need to take a better look at our own outcomes. It is incumbent upon us to provide symptom reduction and we need to use all tools we have access to. As psychoanalytic clinicians, we need to treat symptoms, like any other doctor.
While the DSM seemingly operates in exclusion of psychotherapists, analytic clinicians need to stop pretending they offer a treatment that is in isolation of other therapies that address patient complaints. Analytic clinicians need to use Cognitive-Behavioral therapy and employ medications when needed. Treating symptoms does not mean that patients will leave therapy; it just means that fewer symptoms will make analytic therapy more tolerable.
American psychoanalysts seem to be suffering the same fate as those who wrote the 5th edition of the DSM. One manual does not fit all. Psychoanalytic treatments can offer a lot, but not when we pretend that we know more than anyone else. After all, aren't we all just on the front line in trying to make people better?
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