The focus of Eriksen and Kress’s book is the
ethical challenges presented to mental health professionals by the use of the
American Psychiatric Association’s Diagnostic
and Statistical Manual (DSM). The authors are family therapists, and their
concern is that a combination of factors, not the least of which is a
requirement of insurance companies, makes their use of the DSM mandatory. This
is a problem because the authors identify a range of ethical and methodological
concerns about its use. After outlining in broad terms the problems of the DSM,
the authors present a training exercise, three illustrative case studies,
followed by a final chapter that describes an alternative assessment model. The
result is a book that is stronger on critique than on alternatives. And despite
the authors’ obvious antipathy to the DSM they are unable, finally, to reject
it. Therein lies the problem of a system of thinking that has come to dominate
mental health care. Even its opponents seem obliged to accord some sort of
grudging recognition.

Beyond the DSM Story begins with a long
chapter that outlines ethical issues with diagnosis, then goes on to criticize
the DSM, psychiatry, mainstream science, ‘the medical model’ and a good deal
else. From the outset it is apparent that ‘ethics’ is used only in the broadest
sense: the ethical analysis of the book extends only as far as discussing very
broad ethical principles. While it is possible to agree that diagnosis carries
the often unrecognized ethical problems the authors list (confidentiality,
consent, conflict of interest) it is impossible to separate these issues from
the whole treatment enterprise. Yet Eriksen and Kress approach these problems
as if such a separation were possible. There is a certain selectiveness in the
critique of psychiatry. Clinicians might be interested to learn that
homosexuality and male-female relationships are some of the controversies in
psychiatry that are most often in the limelight (p. 30). There is a naïve
critique of science which is characterized as unable to respond to the role of
values in generating knowledge, and vulnerable to the criticism that ‘facts and
values cannot be objectively separated’ (p. 35). Yet the authors seem
profoundly ambivalent about science and about the DSM. They somewhat grandly
declare that their book ‘is not meant to disqualify science’ (p. 35) and
concede that ‘much of the research base for the DSM-IV is sound’ (p. 41).

The second chapter is given to a review of
literature critical of the DSM and psychiatry from a cultural perspective.
Eriksen and Kress revisit their critique of science, cataloguing the more
extravagant claims made in the name of scientific psychiatry and showing how
when it comes to mental illness, there is no escaping the influence of culture.
There is a list of culture bound syndromes not recognized by the DSM,
discussion of cultural bias in assessment and diagnosis, and examples of the
influence of ethnicity in over or under diagnosing different illnesses. In this
chapter, as with the first, the authors show the same ambivalence about the
DSM. They lament on the one hand its shortcomings and the impossibility of
finding a neutral, value free position for assessment and diagnosis, then offer
suggestions, taken up later in the book, for the recognition of an even wider
range of behaviors, including some that are now excluded as cultural phenomena
but not mental illnesses. Given the earlier (and well justified) critique that
psychiatry, especially under the influence of insurance companies, is already
over inclusive, it is hard to see how its expansion would serve people
experiencing loneliness, abuse, isolation, or racism, other than to legitimize
(at the risk of pathologizing) their experience through the system of insurance
reimbursement. There is a strong argument for cultural awareness in mental
health care, although at times it gets a little lost in the welter of examples
of problematic practices in the name of mainstream psychiatry.  

Chapter Four covers feminist challenges to the
DSM, and begins with a review of the abundant literature into the influence of
gender and gender stereotypes on the nosological system of the DSM and on the
clinical practice of practitioners. Citing extensively from this literature,
the authors raise questions about why disorders which pathologies women’s
experience (for example premenstrual dysmorphic disorder) find a place in the
DSM, whereas there are few correlates for men’s experience. That’s a good
question, although the answer is by no means clear. A further extension of the
DSM to cover a wider, more gender balanced range of disorders would achieve
gender equality of a sort, but at the cost of bringing a greater range of
problematic behavior under the psychiatric gaze. The alternative of using a
smaller range of diagnoses that focus on features of mood and cognition,
without ascribing those to a particular cause seems more rational.

Having set out their critique, the authors then
attempt to resolve the issues raised through the use of a number of vignettes.
The vignettes are designed to highlight the issues raised so far: the need for
contextualized assessment, attention to social and cultural factors, gender
issues and other concerns in diagnosis. As such the chapter does not advance
the authors’ arguments any further, but provides a guide for managing the
issues raised in clinical practice. Customized vignettes always carry the
disadvantage that they are designed to illustrate certain points and so those
points tend to be highlighted. In clinical practice such issues are not usually
so apparent.

 The
next three chapters cover individual case studies in which issues of diagnosis
are discussed by a panel. The range of views introduced in these chapters adds
interest, especially as the invited commentators do not always agree. The case
studies cover very different clinical presentations and highlight a range of
diagnostic issues, but what looms large over these chapters is the role of
diagnosis in influencing clients’ access to insurance entitlements. In one case
a mother demands a diagnosis for her child so that she can claim reimbursement
(raising issues about whether the child’s ‘symptoms’ are manufactured by the
mother); in another case, one diagnosis might validate an understandable
response to trauma, another might stigmatize the client and set up negative
expectations. What was interesting overall in this section was that there is
little discussion of the limitations of the DSM; equally, it is clear that the
DSM alone does not provide an adequate framework for understanding the
complexities of mental health practice.

The final chapter proposes an alternative model
of assessment, the CPSS model developed by one of the authors. The CPSS model
is based on constructivist psychology, and attempts to meet the criticism
leveled at the DSM, especially in terms of eliciting a more contextual ‘story’
than is possible with the individualist model of the DSM. However in the case
study used to illustrate the CPSS model, the authors state that the DSM
diagnosis of depression should be applied if the client meets the criteria.
Thus although the CPSS model is presented as an alternative to the DSM, it is
not a complete alternative. It is not entirely clear if the authors limit its
applicability to counseling services, or see it as applicable across the
spectrum of mental health services.

Early in this book Erikssen and Krass state
that they ‘do not intend to provide a balanced view of the benefits and
limitations of the DSM’ (p. 1). That is a pity, because in the end it’s not
clear that even a practitioner who accepts their arguments about the
limitations of the DSM would feel free to abandon it. Besides the authors’
muted acceptance that there are some benefits of psychiatric diagnosis and
treatment (which necessitate DSM diagnosis), such a diagnosis is also necessary
in order to claim insurance entitlements. Clinicians can take from this book
that even where DSM diagnosis is a necessary component of practice it does not
tell the whole story.

It is hard to fault the authors’ initial
objection that the DSM is an inappropriate diagnostic tool for family
therapists given that there exist many more helpful ways of conceptualizing the
clinical problems this professional group deals with. However it is another
question whether other professional groups, particularly psychiatrists, would
share their concerns. But they might agree that an alternative system of
reimbursement for family therapy would be a reasonable part of a solution to
the issues raised by Erikson and Kress.     

In the end it is hard to know whether it is the
system of reimbursement that is the problem for Eriksen and Kress, or the DSM
itself. It seems not unreasonable for family therapists to argue that a system
of psychiatric classification is not adequate for their purposes, and that an
alternative means of classifying problems would serve them and their clients
better. After all, the target population of the DSM is people with mental
illness, not those with problems in living. Beyond
the DSM Story is an American book with a cautionary tale for American
family therapists. But just as mental health clinicians need to contextualize
the DSM within their own practice setting, they should also approach Eriksen
and Kress’s critique with caution. It may not wholly address the issues they
face in their clinical practice, especially if they do not currently use he
DSM. The book provides an extensive review of some familiar issues in mental
health practice, and more than adequately shows diagnostic psychiatry to be
socially constructed, unstable, and not always reliable. For those who have had
no previous exposure to such critique the book will provide a useful
introduction. Others will find the issues better covered in some of the
material referenced by Eriksen and Kress, and in other critical accounts that
are not referenced.       

© 2005 Tony O’Brien

 Tony O’Brien, RN, M. Phil., Senior
Lecturer, Mental Health Nursing, University of Auckland

Categories: Philosophical, Ethics, Psychology