Psychiatrist Glen Simblett reflects on what DSM diagnosis might mean in the consulting room and offers the unusual metaphor of dance to think about how we might best help people.
Bring up the topic of DSM 5 and you are immediately engulfed in controversy. It is an intensely polarising topic with people either challenging the relentless medicalisation and drug treatment that it seems to represent, or conversely pointing to the many examples when people have found DSM diagnosis and drug treatment helpful. DSM does tend to pull people into particular positions in relationship to it, and in the process, often produces conversations that collapse us all into argument and challenge of the “opposing” viewpoint. Rather than engage in debate about whether DSM is good or bad for people, as a therapist I am a lot more interested in exploring different questions. Here’s a question that has meant more to me:
‘What types of relationships and conditions are needed for DSM knowledge and practices to add to personal agency and assist people in reclaiming their lives from problems?’
To answer this, I have to understand some of the dangers that lurk within DSM knowledge and practices. Then, I think I need to develop some different understandings and ways of working in order to counter those dangers. I have to understand how I can dance with DSM in different ways and different styles as a person, a therapist and psychiatrist.
A view and language become more dangerous as their certainty increases and claims to truth dominate other possible explanations. It is easy to forget that ‘truth’ is always historically and culturally embedded in discourse. The greater the certainty of the discourse, the less the possibility of discovering alternatives and practising personal agency. It is important to remind ourselves that DSM 5 is simply a collection of ideas that a relatively small group of professional experts can agree upon at a particular moment in history in one country. The very public disagreement of other professional experts around the world is testimony to that. That uncertainty is rarely reflected in the office or therapy room, however, and most of us practice as if we know that bipolar affective disorder, schizophrenia and personality disorders are real ‘things’ that can be assessed, measured in severity and modified with treatment. It can be hard to hold instead to the idea that these ‘things’ represent a current way of thinking about some human problems and distress that may have other alternative and more useful explanations. So dancing with DSM tip number one is: hold onto your DSM partner lightly unless you are absolutely certain that dancing the DSM tango is the best way to assist the person or family sitting in front of you.
But how do we know what is best?
Another danger is that discourse determines what can be said or done, and who can say or do it; and as such determines power relations between people. For example, in DSM 5 discourse it is the trained clinician who holds the authority to assess and determine which DSM 5 diagnosis can be applied to which person at what time. It is the expert that is granted the authority to ask questions of the person, rather than the person of DSM. But we can change the dance style and jive with our DSM partner rather than tango. We can collaborate with the person or family sitting before us and explore how closely DSM descriptions match their own personal experience. We can help them understand which aspects of their experience are not well captured by those descriptions. We can look together at the limits and uncertainty of those categorisations. We can treat them as possible explanations worth exploring together rather than absolute, unshakeable truths. This is an approach that can have real utility with problems that DSM categorises as depression, anxiety, bipolar disorder or obsessional disorder. It is one I always fear using with personality disorders, since that particular categorisation sits dangerously close to the possibility of the co-creation of pathological identity. However, at times we have even ventured there when an official diagnosis of borderline personality disorder opened up a possibility of accessing a publicly funded dialectical behavioural therapy programme that the person wanted to try.
We can also choose to disrupt the dance. Hijacking is when the person following the dance lead takes charge for a brief period of time. In dancing, it is regarded as poor style. In relation to DSM it should be an essential skill. A simple hijack I regularly use, is the stubborn refusal to site problems and disorders inside human beings in both my thinking and my language. Instead, I ask questions in relational ways. Here is an example:
‘How has this diagnosis of bipolar affective disorder got you to make sense of your life differently? Has it ever got you to examine your relationships and experiences for evidence of its influence? Is there any risk that you may come to see all joy, daring, spontaneity or angry outbursts as evidence of mania? How could you tell if it was mania driving those things?’
But sometimes hijacking isn’t enough. Sometimes we need to backlead our DSM partner. Backleading is when the follower steals the lead and takes over entirely. When I am working with people captured by eating disorders, I refuse to categorise either them or the disorder using DSM criteria. I do this because of my deep concern that processes of DSM categorisation and the required measurement practices to establish the DSM diagnostic category, are diminishing of the person and often strongly supportive of the eating disorder. Instead, I backlead the DSM dance into alternative steps developed from other understandings gathered from people with lived experience and documented in post-ana and anti-anorexiabulimia movements. I use deliberately irreverent and counter-cultural descriptions of the problem such as abxy, anorexiabulimia or whatever-we-happen-to-be-calling-it-this-particular-DSM. I strive to understand the problem much more intimately than the DSM categorisation dance allows, remaining strongly connected to insider knowledge held by the person. But I don’t lose touch with DSM practices entirely – instead we discuss very carefully the effects of weighing and evaluating practices before deciding if or how we engage in them. We seek agreement of which ones are necessary and how and when they will be done. We search for the most anti-abxy way of practising them together.
When working with someone fighting an eating disorder I do not use force or compulsion (although I did once when we both agreed it was the best way to get her through the doors of an inpatient unit whose programme she wanted to try). I never make continuing to work with the person contingent on following those measuring practices or the results of them. Instead, we search for ways past barriers that work for both of us. I never, ever confuse the problem with the person.
Finally, we can simply decline to dance with DSM at all. Unfortunately as a practising psychiatrist subject to audit, peer review and the restraints of ‘best practice’, this is rarely a position that I can afford to take. Not only that, but in the taking up of that dance position I have to let go of an entire body of knowledge and practice from modernist scientific research about the effects of medication and researched talking treatments on populations of people with DSM categorised disorders. This has always seemed to me too big a loss to contemplate, although I have always respected and admired those who do decline DSM’s dance.
If you would like to read more about my thoughts on this, backed up with a great deal more theory and examples of the positions I take in my practice take a look at my recent article in the Australian & New Zealand Journal of Family Therapy available free online here.