What the DSM and the Medical Model are For

ketchupThe “medical model of mental illness” and the new fifth edition of the DSM (DSM-V) have been kicked around by a lot of people recently. But let’s not lose track of the fact that the DSM serves a useful purpose. Most people wouldn’t put ketchup on everything, but they won’t claim that ketchup is useless, either. So, too, with the DSM.

Let’s keep in mind that DSM stands for “diagnostic and statistical manual,” and its main purpose is to allow different professionals to talk to each other with an agreed-upon vocabulary, and for records and statistics to be kept that had an agreed-upon meaning. This function is essential!

For example, suppose a guy goes on the rampage and breaks 57 windshields with a baseball bat because (he claims) this is the only way to keep the vampires at bay. After the sound of broken glass dies away, any number of people want to know, “Now what?” — starting with “jail or hospital?” and continuing on down the line. What to do depends on what’s going on with this dude, and that’ll influence actions by the cops, the courts, the hospital, the health-insurance company, the prosecuting and defense lawyers, his placement or probation if found guilty, and on and on.

So a lot of people’s professional decision-making will be helped if this guy can be accurately accurately diagnosed with a problem with an agreed-upon definition, such as “intoxicated with a blood-alcohol level of 0.25%” or “schizophrenia.” Then the various professionals can plan accordingly.

Same for keeping statistics. The DSM is symptom-based, with the idea that people who arrive with the same symptoms will get the same diagnosis. That helps keep the reckoning straight.

But, to use a medical analogy, suppose two people arrive at a hospital with the same symptoms, but have two different underlying problems — one has indigestion while the other has appendicitis. This is a fundamental limit of a symptoms-based approach.

Why do it that way? Because it’s the best we’ve got. If mental-health issues could be pinpointed by an X-ray or a blood test, everybody would instantly switch to doing that. But the necessary technology hasn’t been developed yet. Heck, this is true of many purely medical conditions as well. When the available tools improve, the classification system will change.

Implications for Alternative and Unlicensed Practitioners

Now, every kind of nomenclature and every system of classification suffers from incompleteness and inaccuracy. The world is so complicated that every statement is an oversimplification, including this one. The DSM uses a particular approach for a particular purpose. The closer your purpose is to the DSM’s, the better it will work for you. If your purpose is significantly different, the DSM will be less useful, and possibly not useful at all.

For example, those of us in the unlicensed/alternative side of things are generally in private practice,  aren’t contributing to formal statistics-keeping, aren’t involved with cases like the guy with the baseball bat, and often don’t even accept insurance (another constituency that loves official labels).

So we’re outside the DSM’s sweet spot, maybe to the point where we don’t find it helpful. Not because there’s anything wrong with it, but because it solves problems that we don’t have.

For example, as a hypnotherapist, I’m a one-trick pony. My clients come to me because they’ve decided that it’s time to give hypnosis a try on some problem or other. Since I don’t take insurance or work in an institutional setting, my clients select me on their own initiative, arrive under their own power, and pay out of their own pocket. In short, they’re self-selected, self-motivated, and high-functioning. Many are successful professionals and business owners. They typically don’t have a DSM diagnosis and don’t want one.

Sometimes the most important issue for a client is not being labeled with a diagnosis.

I’ve discovered that knowing a client’s DSM diagnosis, if any, does not help me do my job. Why? Because the people who put together the DSM expended precisely zero energy on making it a useful tool for hypnotherapy.

When a client does report a diagnosis, I ask them to sign a release so I can communicate with their doctor. For example, I had a client once who told me he was schizophrenic (he wanted help with something else), so I had him sign a release and called up his psychiatrist, who said, “Hey, good idea! Go for it. And you’ll enjoy working with him: he’s a great guy.” And so it proved. He resolved the problem he came in for in just three sessions.

This doesn’t mean that I have any special talent with schizophrenics. I’m sure I don’t! it just means that anyone who is sufficiently functional, motivated, and determined to find me on his own, show up on time, and pay out of his own pocket has plenty going for him. This rules out people who are impaired beyond a certain point. I don’t expect many catatonics to walk through my door! And it rules out people who don’t really care. For example, when someone drags in a family member for me to work with, the results tend to be disappointing. All the motivation and determination in the world aren’t of much use if they reside in someone other than the client!

So by the standards of many conventional practitioners, including ones who are working with severe mental illness or the justice system, I’m getting a whole different spectrum of clients, ones for whom being labeled “mentally ill” would usually be inappropriate. So it’s not an apples-to-apples comparison.

Which is not to say that my clients’ problems aren’t causing them serious difficulty and deep suffering, because they often are. But few of my clients even have a current DSM diagnosis. I’ve probably seen more health-care professionals. And I’m sure this is true of many alternative/unlicensed practitioners.

From the unlicensed/alternative practitioner point of view, the biggest point of friction may be that DSM-speak has entered into the everyday conversation of the man on the street, including us, so it’s hard to remember to treat these increasingly generic terms as if they were sacred and unutterable by all but the licensed few!

 Aren’t DSM Terms Necessary to Attract Clients?

Surprisingly, based on the traffic to my Web site and other sources of information, DSM terms are lousy Internet keywords. People don’t search on these terms anywhere near as often as you’d think, and the mainstream industry uses them (and advertises them) so heavily that you just become lost in the crowd, like Where’s Waldo with a cloak of invisibility. So even if DSM terms weren’t regulated in Oregon, they wouldn’t be worth your time. Even though clients use terms like “OCD” freely in ordinary conversation, they’re not focusing strongly on DSM terms.
Instead, use terms that are less clinical and more personal, and avoid jargon as much as you can.



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