by Pat Comerford
I bought a copy of the Diagnostic and Statistical Manual of Disorders – 5th Edition (APA, 2013) in 2015 following my reading of Dr. Lynch’s (2015) book Depression Delusion. I then looked forward to reading Dr.Mullen’s (2016) article “Let’s Make Friends with the DSM”. The title of her piece tenders the belief that the reader can gain a positive frame and attitude in the use of this manual. This piece of writing is essentially an invitation to counsellors, and by extension humanistic psychotherapists, “…to become the expert...” in the use of the DSM-5 (22). Dr. Mullen’s article, contrary to its purpose, raised for me a number of serious professional and ethical concerns in the use of the DSM-5. In the current article, I will address the concerns I have for us as humanistic psychotherapists in using this manual for diagnostic purposes, and the consequent future phenomenological implications for our profession in its use.
Humanistic psychotherapists, clinicians, and diagnosticians
Dr. Mullen writes that the DSM-5 diagnostic manual is: “…recognised as the Bible of the psychology world” (2016: 20; bold type added). She comments on the practice of counsellors, that: “…my hunch is that a wide range of potential clients are being encountered and then lost, largely because of a lack of clear knowledge of how to diagnose properly” (2016: 20; bold type added). The purpose of the DSM-5 is clearly stated in its chapter on the use of the manual: “The primary purpose of the DSM-5 is to assist trained clinicians in the diagnosis of their patients’ mental disorders…” (APA, 2013: 19, bold type added).
It needs to be made clear from the outset that humanistic psychotherapists are not trained primarily to be clinicians, and diagnosticians of mental disorders, or in the use of this bible. In the code of ethics of the Psychological Society of Ireland (PSI), on the other hand, there is a specific reference to its members, who are psychologists, as being diagnosticians, amongst other roles:
Psychologists are specialists in the study of human behaviour and experience. The Preamble to the Code lists a number of professional roles which they occupy (for example, researcher, educationalist, diagnostician, psychotherapist, consultant, expert witness) and introduces the term ‘client’ to refer to those who receive professional services from a psychologist.
(PSI, 2016; bold type added)
You will not find in the code of ethics of the Irish Association of Humanistic and Integrative Psychotherapy (IAHIP, 2015) the words: specialists, diagnostician, expert, and psychologist. It is not a mandatory requirement for membership of IAHIP that we are also trained as specialists, diagnosticians, experts, and psychologists. We are accredited as humanistic psychotherapists. Advocating that humanistic psychotherapists, due to an association with the generic term ‘counsellors’, become “…friends with…” (Mullen, 2016: 20) the DSM-5 for its diagnostic aims is to misunderstand acutely the goals of humanistic psychotherapy.
Humanistic psychotherapists and car mechanics
Dr. Mullen (2016) goes to great lengths to compare particularly the DSM- 5 diagnostician to a car mechanic, a motor technical specialist. She writes that when we have car problems, we visit the car mechanic with the tools that they have, who diagnoses what the mechanical problem is and then the car is “...fixed...” by them (p.20, bold type added). It appears that Dr. Mullen is suggesting that clients attend a counsellor who uses the DSM-5 tool to diagnose their mental disorders and then they are fixed by them.
In the profession of humanistic psychotherapy, this use of the car mechanic analogy is ill fitting. Using this analogy regrettably objectifies all clients. Humanistic psychotherapists are not car mechanics, and clients are not cars or machines that need fixing. This mechanistic view of the person is the antithesis of the Humanistic understanding of the person. Hoffman, Cleare-Hoffman and Jackson (2015) clearly state that the focus of Humanistic Psychology is on: “…the holistic lived experience of the person (individual) and its implications for practice, pushing back on more mechanistic, reductionistic and dehumanising approaches” (42).
Client-centered Therapy (Rogers, 1951), and particularly the development of Existential Psychotherapy in the 1950s, were established by therapists: “…seeking to treat patients as individuals struggling with questions of meaning and choice rather than as mere sets of symptoms” (Bakewell, 2016: 282). To employ the DSM-5 as proposed by Dr. Mullen will require the humanistic psychotherapist to engage with the client with a diagnostic mindset, which, in turn, will corrode the: “…phenomenological view of reality, its emphasis…on experience, and the nature of the therapeutic relationship…seen as meaningful contact between persons” (IAHIP Code of Ethics: 2.3, 2015).
Humanistic psychotherapists, the DSM-5 and Shakespeare
To be familiar with the symptoms as listed in the DSM-5 is useful for being aware of psychiatric symptoms. Dr. Mullen (2016), however, issues an explicit invitation to counsellors with “…diplomas…to become the expert” in the list of psychiatric symptoms and thereby the diagnosis of mental disorders (21-22). She writes: “The DSM identifies traits and lists specific criteria needed to diagnose accurately the individuals we have coming to see us” (21; bold type added). In the later part of her article, she makes the following recommendation:
Then look at the list of criteria and, more importantly, how many need to be ticked in order to warrant the diagnosis. Then take a client that you feel meets a lot of the criteria and carefully attempt to match their specifics with the listed descriptions.
(22; bold type added)
This invitation to diagnose betrays a sharp misunderstanding about the role of humanistic psychotherapists. This is the case irrespective of the standard of graduation, be it at the diploma, degree, or postgraduate level. In this invitation to specialise, there is the risk of reducing clients to mere sets of symptoms. We further risk dehumanising the person through defining them by their particular diagnostic and psychiatric label(s). Labelling theory, an explanation of a systemic response to perceived challenging difference, has stated that the process of labelling confirms the person in their role as being ill, possibly for their lifetime, and then they potentially become problematised, excluded, or defined as “Outsiders” (Becker, 1963).
William Shakespeare (1994) addressed the tragic consequences of having the wrong name, a negative label, in his play ‘Romeo and Juliet’. Juliet speaks:
’Tis but thy name that is my enemy….
What’s in a name!
That which we call a rose
By any other name would smell as sweet.
(Act 2, Scene 2)
The psychiatric/medical diagnosis or label could, but must not, become our enemy in our relationship with clients.
Humanistic psychotherapists and the motion
To consider incorporating this diagnostic tool as a core feature of our practice is to undermine significantly the philosophical and phenomenological underpinnings of the humanistic framework of all our psychotherapeutic relationships, that essential sweet smell! It is in this context that Dr. Coleen Jones was prescient in presenting her motion for the AGM of IAHIP (2016), which all members were e-mailed: “That IAHIP reaffirm, that in an age increasingly dominated by specialism and technique, IAHIP’s understanding of humanistic and integrative psychotherapy remains fundamentally generic” (C. Jones, personal communication, February 24, 2016).
For humanistic psychotherapists to engage in the specialist skill of DSM-5 diagnosis without appropriate accredited training is to breach seriously the code of ethics for IAHIP accredited psychotherapists: “Psychotherapists should actively monitor the limits of their own competence through supervision and/or consultative support” (IAHIP Code of Ethics: 8.1, 2015; bold type added). “It is an indication of the competence of psychotherapists that they recognise their lack of training or experience to work with a client and make appropriate referrals” (IAHIP Code of Ethics: 8.3, 2015; bold type added).
I do support that humanistic psychotherapists and counsellors are aware and alert to psychiatric symptoms and, in turn, to bring their concerns to supervision or to one who is trained particularly in this clinical field. Humanistic psychotherapists, however, must not lose sight of the fact that they cannot employ the DSM-5 as a diagnostic tool unless they are also accredited clinicians and diagnosticians. Even then, Gerard Staunton (2016), an IAHIP member, has expressed the following considered and insightful view in the use of the DSM-5:
I actually consider that even if the therapist were trained in diagnostic procedures, it would still be completely unethical to advance or endorse any specific opinion in such a respect (just as were he or she trained as a lawyer or a broker, it would be unethical to advance or endorse a legal opinion or an investment prospect).
(personal communication, March 16, 2016; printed with author’s permission)
As IAHIP accredited humanistic psychotherapists, we do not need to rush blindly into being an expert in the DSM-5, or any other type of specialism or technique on offer. In doing so we may inadvertently dilute, or at worse undermine, our core humanistic beliefs and values.
Dr. Mullen (2016) correctly points out that in the historical development of the DSM-5: “…over time the committees moved to encompass more of a medical model” (21). In the training of humanistic psychotherapists, the medical model is not used. Does then the invitation to become the expert in the use of the DSM-5 also require current and future humanistic psychotherapists to shift more towards a medical model in their practice and training? To make this shift will necessitate humanistic psychotherapists and IAHIP itself to move away from a fundamental humanistically philosophical and phenomenological framework as their start point.
The DSM-5 is reviewed unfavourably by Lynch (2016) in his book on depression. He makes the following statements:
“Mental disorders are deemed to exist by consensus agreement in the absence of any objective scientific verification. In no other medical speciality does anything like this occur” (16). Psychiatrist Dr. Frances (2016) describes the DSM-5 as “deeply flawed” and goes on to write that the “DSM-5 is (a) guide not (a) bible” (bold type added). The British Psychological Society has expressed its own doubts about the efficacy of the DSM-5, and the thrust of: “…psychiatry’s predominantly biomedical model of mental distress – the idea that people are suffering from illnesses that are treatable by doctors using drugs” (Doward, 2013).
In the case of depression, which Dr. Mullen cites as an example (2016: 22), Dr. Lynch (2015) has ably demonstrated the myth of the biomedical explanation or model of “brain chemical imbalances” in his thorough review of the scientific literature (1).
To approach the DSM-5 as a bible, and that is as a biomedical bible, rather than as a guide, means that we as humanistic psychotherapists also risk exposing clients to the pessimistic opinion that they are formed and shaped as persons by their mental disorder, and their biology, with little room for being in charge of personal change. When it is legally incumbent upon us to accept or recognise a DSM-5 medical model label we need to resist, in turn, any temptation to define clients solely in these terms, because failure to do so means we have then succumbed to a form of “biofatalism”, which is: “…a broad pessimism about the prospects for social change that…is…based on a particular set of presumptions about the biological underpinnings of human behaviour” (Barker, 2015: 3). IAHIP’s (2015) code of ethics, on the other hand, asserts that: “…persons are self-regulating, self-actualising and self-transcendent beings, responsible for themselves…” (2.1) .
Humanistic psychotherapists, legal parameters and the DSM-5
The Mental Health Act of 2001 defines ‘mental disorder’ as follows: “In this Act ‘mental disorder’ means mental illness, severe dementia or significant intellectual disability...” (2001a: Part 1, Section 3(1): 9). To establish the presence of mental disorder requires an “examination” and: “examination…means a personal examination carried out by a registered medical practitioner or a consultant psychiatrist of the process and content of thought, the mood and the behaviour of the person concerned”
(2001a: Part 1, Section 2(1): 8; bold type added).
It is because mental disorder is framed as a mental illness in the Act that it is then the consultant psychiatrists and registered medical practitioners who are the legally prescribed examiners and consequently the medical diagnosticians. The Act begs the question: is the DSM-5, and its lists of mental disorders, a handbook of medical mental illnesses? Using the Act’s own frame of reference, it would suggest that it is. Diagnosis, then, is not within the remit of counsellors and humanistic psychotherapists. In other words, using the medical model-shaped DSM-5 for diagnostic reasons, does mean that the diagnoses made are considered medical in kind. Against the background of the Mental Health Act (2001a), the counsellors and humanistic psychotherapists who are not legally prescribed or accredited diagnosticians or examiners must not make ‘medical in kind’ diagnoses because they run the risk of falling foul of these legal parameters.
This is particularly pertinent for those humanistic psychotherapists in private practice and who do not work as part of a multi-disciplinary team, which is led by a “clinical director” who is a “consultant psychiatrist” (2001a: Part 6, Section 71(1): 50). Some of us, as humanistic psychotherapists, may not necessarily subscribe to ‘mental illness’ as a workable psychiatric or medical frame (Szasz, 1974). We do need, however, to respect the legal parameters of the land and remain committed to our core humanistic values.
The Act furthermore states that in cases of “involuntary admission of persons to approved centres” it can only be a “recommendation” to a “registered medical practitioner”, made by an “authorised officer” (2001a: Part 2, Section 9(1): 11; bold type added). Again, it is the registered medical practitioner who is the final diagnostician and not the counsellor or humanistic psychotherapist.
In an amendment to the Mental Health Act, it is stated:
For the purposes of section 9 of the Mental Health Act 2001, the rank and grade of “authorised officer” is hereby prescribed as Local Health Manager, General Manager, Grade VIII, Psychiatric Nurse, Occupational Therapist, Psychologist or Social Worker.
(2001b: (Authorised Officer) Regulations 2006, bold type added)
In this refined definition of “authorised officer”, if counsellors and humanistic psychotherapists take on this role of recommending, but not diagnosing, they must be at Grade VIII. This means they must have an Honours Bachelor’s Degree and/or Higher Diploma (National Framework of Qualifications, 2016). This educational requirement far exceeds Dr. Mullen’s (2016) acceptable minimum of a “diploma” (21) in the use of the DSM-5 for “diagnosis” (22).
Dr. Mullen does recognise that: “…we need the diagnostic equipment (in our case the DSM) in order to assess accurately the presenting issues” (20; bold type added). The most counsellors and humanistic psychotherapists are legally permitted to do is an “assessment” (Mental Health Commission, 2009: 25; bold type added), but this is not diagnosis. Even if these conditions of the particular legal parameter of “authorised officer” are satisfied, it is not the role of humanistic psychotherapists to engage in the task of clinical assessment.
Dr. Mullen’s (2016) invitation to learn the clinical skill of “how to diagnose properly” (20) means that in the use of the biomedically shaped DSM-5, that counsellors and humanistic psychotherapists are also entering into the legal arena of medical jurisprudence. The DSM-5 is clear on this point: “DSM-5 is also used as a reference for the courts and attorneys in assessing the forensic consequences of mental disorders” (APA, 2013: 25; bold type added).
To use the DSM-5 for the purpose as advocated by Dr. Mullen will blur the boundaries in our professional role as humanistic psychotherapists and in our professional relationships with psychiatrists and registered medical practitioners. This will be a consequence of blindly pursuing “specialism and technique” (C. Jones, personal communication, February 24, 2016).
Humanistic psychotherapists, the DSM-5 and referral
We may indeed meet with clients who present with “tragic dimensions of human existence” (IAHIP, Code of Ethics: 2.1, 2015) which are beyond our training or experience. It is then that the DSM-5 could be a guide to assist us to make appropriate referrals. This might include diagnosis by a psychiatrist, and/or registered medical practitioner, in order “…to provide an opportunity for the client to work towards living in a more satisfying and resourceful way” (IAHIP, Code of Ethics: 2.5, 2015). Dr. Mullen (2016) has also written: “If only to define our true scope of practice, in order to know when we should refer a client, we need a working knowledge of the DSM” (21; bold type added).
An awareness of psychiatric symptoms is useful. We have a duty of care to be informed, so that we can make the appropriate referrals for the well-being of the client. This, however, does not require humanistic psychotherapists to become experts in “how to diagnose properly” (Mullen, 2016: 20) medically regarded mental disorders, while using a “deeply flawed” instrument (Frances, 2016).
I accept that Dr. Mullen (2016) is an advocate in the use of the DSM- 5 for diagnostic purposes. I, however, urge real caution in humanistic psychotherapists incorporating the regular use of this biomedical diagnostic tool. To exercise this caution is essential among those of us who are not legally accredited clinicians and diagnosticians. To circumvent the regular use of the DSM-5 for diagnostic reasons is also necessary so as not to contravene our own code of ethics, and not to be in conflict with our national professional medical bodies. In addition, in the context of Staunton’s (2016) astute viewpoint and within the humanistic framework, I would also proffer the same degree of caution to those members of IAHIP who are legally accredited clinicians and diagnosticians.
Simply put, it is both professionally good practice and ethical that those who are legally ‘prescribed’ are the diagnosticians and never humanistic psychotherapists per se.
An invitation to renewal and self-affirmation
In the context of Dr. Mullen’s (2016) invitation to counsellors to become the expert, I believe, as humanistic psychotherapists, however, we need to discuss openly and urgently Dr. Jones’ (2016) important motion. I regard this motion as a wonderful opportunity, and an alternative invitation to the IAHIP membership, to take time and create space to explore this matter, of becoming technically the expert, for the sake of our own professional and personal renewal, and for self-affirmation in our profession. This motion also reflects the “(e)motion” and ethos driving us as humanistic psychotherapists (Comerford, 2015: 44).
I believe it is also worthwhile to engage in a shared, inclusive conversation and “debate” (Inside Out Journal Ethos; see page 2) since there are significant implications challenging us professionally in how we continue to identify, define and represent ourselves as Humanistic Psychotherapists, as distinct from counsellors, in the future, especially “…in an age increasingly dominated by specialism and technique…” (C. Jones, personal communication, February 24, 2016).
Pat Comerford is a humanistic psychotherapist working in private practice in psychotherapy and supervision in Cork.
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