Beyond The DSM-IV Assumptions, Alternatives, and Alterations PDF
Beyond The DSM-IV Assumptions, Alternatives, and Alterations PDF
Beyond The DSM-IV Assumptions, Alternatives, and Alterations PDF
Current diagnostic processes reflect the limitations and utility of the framework of the Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994). Clinical information in the
DSM-IV ’s 5-axis system almost exclusively focuses on weaknesses and pathology and is summarized in a flawed
categorical system. Hence, the authors describe 3 adjunctive, or alternative, means of conceptualizing behavior;
several means of altering the current DSM-IV system; and 2 future directions in the diagnosis of strengths.
Shane J. Lopez, Department of Psychology and Research in Education, University of Kansas; Lisa M. Edwards, Depart-
ment of Counseling and Educational Psychology, Marquette University; Jennifer Teramoto Pedrotti, Department of Psy-
chology and Child Development, California Polytechnic State University, San Luis Obispo; Ellie C. Prosser, Student Counsel-
ing Center, University of Texas at Dallas; Stephanie LaRue, Dwight D. Eisenhower Veterans Affairs Medical Center,
Leavenworth, Kansas; Susan Vehige Spalitto, private practice, St. Louis, Missouri; Jon C. Ulven, Counseling, Career and
Academic Support Center, St. Cloud State University. Correspondence concerning this article should be addressed to Shane
J. Lopez, Department of Psychology and Research in Education, 621 Joseph R. Pearson Hall, University of Kansas,
Lawrence, KS 66045 (e-mail: sjlopez@ku.edu).
© 2006 by the American Counseling Association. All rights reserved.
Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 259
Lopez et al.
flect facts about individuals (Barone, Maddux, & Snyder, ior, was clear in his message that it was the degree to which
1997). Barone et al. suggested that through this process di- an unconscious conflict or desire might interfere with nor-
agnoses and their representative labels are reified, and the mal functioning, not the mere presence of that conflict or
cluster of symptoms begins to be recognized more often. desire (Barone et al., 1997).
Clinicians then diagnose the disorder more frequently, and
a disorder takes on a life of its own. It is interesting that some Addressing Assumption 1: Remedying Preemptive
of these diagnoses eventually will become antiquated de- Guesswork
scriptors because changes in people’s beliefs lead to changes Reification turns the unreal into the real. In the present di-
in societal norms and values, further reflecting the descrip- agnostic framework, the reification of mental disorders di-
tors’ constructivist nature. rects attention and efforts toward the detection and treat-
Evidence of the reification of the DSM-IV categories can ment of illness. Categorically defined mental illness leads
be found when considering the ever-expanding explana- scientists and practitioners to carefully gather information
tory power of the system. Barone et al. (1997) have indi- to determine a person’s “goodness of fit” in a particular cat-
cated that the scope of mental disorders has broadened to egory. This commitment of resources to categorizing behav-
include what many would consider problems that are less iors leaves few resources for the examination of behavior
serious, such as caffeine-induced sleep disorder. Furthermore, using other approaches. Because many professionals believe
the number of clinical diagnoses has increased from 106 in the DSM-IV system is a valid tool for making meaning of
the initial edition of the DSM (APA, 1952) to 297 in the mental illness and health, its existence may have the effect of
recent DSM-IV-TR (APA, 2000; Clark, Watson, & Reynolds, preempting consideration of alternative conceptualizations
1995; Wright & Lopez, 2002). of behavior (Neimeyer & Raskin, 2000). To thwart the pre-
Due to their tenuous nature, facts about mental illness emptive guesswork that comes into play in the diagnostic
and health seem to be best represented by examining the process, clinicians must be aware of alternative construc-
degree of psychological characteristics via a dimensional tions of behavior and must be committed to entertaining the
approach. Examining individual differences in psychologi- alternatives. These alternatives could be used either in lieu
cal phenomena improves on the current dichotomous cat- of the DSM-IV framework or in conjunction with the DSM-IV
egorical system. Although research studies have not yet approach to facilitate a broader understanding of the full
pitted the dimensional system against the categorical sys- range of human behavior.
tem, evidence from studies of the categorical system indi-
rectly supports the use of an alternative system. Factor Assumption 2: DSM-IV Diagnostic Labels Promote
analyses of data from a sample of individuals diagnosed Understanding
with personality disorders and a sample of individuals with
“normal” personality functioning revealed that personali- As DSM-IV categories currently exist, they describe only the
ties reflected in the two groups were more alike than differ- negative aspects of the person’s life and do not elucidate hu-
ent (see Maddux & Mundell, 1999, for a review). In addi- man strength or the process of human change (Barone et al.,
tion, neither was necessarily reflective of the criteria-based 1997). This is a concern, but it could be remedied by limiting
diagnoses in the DSM-IV. Similarly, Oatley and Jenkins preemptive guesswork and at the same time augmenting the
(1992) found that “normal” and “abnormal” emotional DSM-IV conceptualization with additional information. An
experiences were not discretely classified. Overall, it ap- even bigger, and possibly more intractable, problem is that by
pears that looking at problems within the current all-or- using the DSM-IV diagnostic system, clinicians become pre-
nothing categorical system creates false dichotomies and occupied with forcing people into negative categories, cur-
is not empirically supported. The dimensional approach tailing their attempts to understand the client (as well as his or
may offer a more valid representation of the “facts” of psy- her strengths and weaknesses) in a more comprehensive
chological phenomena. manner. Without purposeful attention toward a more balanced
Barone et al. (1997) acknowledged difficulties in human approach, clinicians run the risk of focusing primarily on nega-
functioning and clarified that although all people experi- tive attributes, thus ignoring possible strengths, and there-
ence problems, these difficulties are best represented as oc- fore may view the client as being unidimensional. By provid-
curring on a continuum. Discrete categories cannot easily ing a nonholistic diagnostic system, a conflict is created for
explain the inevitable variability of clients’ problems. clinicians, because a diagnosis “label” precludes clinicians
Barone et al. suggested that it is impossible to create a true from being able to give a full description of clients (i.e., the
dichotomy between normal and abnormal functioning, be- diagnosis becomes the characterization of the person). A sec-
cause almost every theoretical orientation acknowledges that ond problem is that although most clinicians can recognize
it is the degree of the dysfunctional behavior that dictates the faults in the DSM-IV system (and thus may place less
the distinction between normality and abnormality. Even stock in this deficit-based label), they are not the only indi-
Freud, who is often criticized for overpathologizing behav- viduals viewing the diagnosis. Other professionals who may
not be specifically trained in the system, and who are thus overlooked. By asking questions designed to elicit symp-
potentially unaware of its faults, may be less apt to view the tomatology and omitting questions regarding evidence of
diagnosis within its systemic context. Again, this may lead to optimal functioning, clinicians are often guilty of expecting
a sole focus on the negative traits the diagnostic label de- to observe dysfunctional behavior.
scribes. The labels given to these negative categories then Barone et al. (1997) contended that clinicians can also
serve as a social wedge between “the labeled” and all others. be overconfident in their abilities to diagnose. They may
Static negative labeling can create stereotypical expectations tend to elicit premature diagnoses, because clinicians seek
that influence how professionals conceptualize and interact with information that supports their hypotheses and they then
individuals as well as how these labeled individuals may think take this information as confirmation of their original ideas.
about themselves. The application of a diagnostic label can be Because clients have a tendency to agree with whatever
crippling for a client, taking away autonomy and individuality. the clinician proposes, clinicians may then accept this
Furthermore, once the label of the diagnostic group is applied, mutual agreement as further support and feel more confi-
the perception of within-group differences tends to be dimin- dent in their next encounter with a client. At this point, the
ished, and between-group differences are enhanced (Wright, narrow diagnostic focus becomes a collaborative myth
1991). Wright (1991; Wright & Lopez, 2002) asserted that infor- shared by clinician and client.
mation consistent with the diagnostic label would be remem-
bered more easily than inconsistent information. Thus, by sim- Addressing Assumption 2: Widening the
ply applying the negative label, clinicians may tend to seek out Diagnostic Focus
information about individual deficits rather than strengths. This Labels provide the common language that facilitates commu-
process thus decreases the accuracy of a conceptualization of a nication; however, the development of a shared view does not
person’s complete psychological makeup. guarantee shared understanding. Specific labels communi-
There are a myriad of negative social consequences asso- cate different things to different people. Regardless of this
ciated with a diagnostic label that might obfuscate the true lack of shared understanding, the bearers of a particular label
meaning of a categorical tag and bring harm to the bearer of are grouped together and their within-group differences are
the label. Public knowledge of a diagnosis can result in so- underestimated. Imagine if 20 clinicians were asked to iden-
cial alienation, ostracism, loss of employment, harm to fam- tify 20 children with whom they had regular contact and whom
ily, and reduced social status. These consequences may be they would label “at-risk.” These 20 hypothetical clinicians
due to the fundamental negative bias associated with label- would identify 400 people who carried the same label. Due to
ing. Wright (1991; Wright & Lopez, 2002) explained that if the label, fellow professionals would infer that the 400 chil-
something regarded as negative occurs in a vague context dren were more alike than they were different, thereby curtail-
and is then made known about an individual (i.e., a diagno- ing efforts to gather more information about individual chil-
sis), then that diagnosis guides the subsequent perceptions dren in the group. This label would then be perpetuated be-
made about that person. She noted that clients are able to cause it was shared with other laypersons and clinicians. With-
conceptualize their own behavior as stemming from a num- out a comprehensive examination of these children, they have
ber of factors and possess the ability to identify the posi- been reduced to a single entity.
tives in addition to the problems of their situation. Outsid- Widening the diagnostic focus involves consideration of
ers, however, may tend to have a more limited view, attribut- the psychological strengths, environmental influences on
ing the behavior to dispositional aspects of the diagnosis— behavior, and developmental forces that affect the manifes-
aspects that are independent of the environment. tations of weaknesses and strengths. If the focus is widened,
Negative labels lead the clinician to having a set of nega- clinical confusion may result because the amount of infor-
tive expectations. Another error that can occur in clinical mation needed to make diagnostic determinations may be
judgment is the confirmatory bias (Barone et al., 1997). Hy- initially overwhelming; however, ways of incorporating this
potheses are often formed based on diagnostic categories wealth of information are available.
into which the client is placed. These assumptions are that
(a) the client will present with symptoms characteristic of a Assumption 3: DSM-IV Diagnosis and Treatment
mental disorder and that (b) the symptoms will cluster and Are Connected
can be categorized and labeled. Clinicians must choose hy- The goal of the use of any psychodiagnostic system is to
potheses associated with an existing set of diagnoses to best understand the person’s needs and resources and facilitate
account for these assumptions. The tendency is to look for the implementation of helpful therapeutic interventions.
information that supports their hypotheses and results in the Focus on negative categories does not provide the insight
application of one of these labels. Again, clinicians may at- necessary to identify ways of enhancing client adjustment.
tend more to the negative confirmatory evidence and fail to In fact, the DSM-IV (APA, 1994) only has four lines of text
recognize information inconsistent with their original hypoth- (e.g., “to formulate an adequate treatment plan, the clinician
eses or diagnoses. In this process, clients’ strengths are often will invariably require considerable information about the
person being evaluated beyond that required to make a DSM- more, the information clinicians do get from DSM-IV diag-
IV diagnosis” [p. xxv]) that address treatment. This suggests noses does not necessarily direct them to the treatment se-
that DSM-IV diagnoses offer little information from which a lection. Alternative (or adjunctive) conceptualizations of
clinician would logically derive an intervention. Ivey and behavior are available, but preemptive guesswork that cur-
Ivey (1998) contended that the “DSM-IV becomes a poten- tails the use of other systems must be overcome. The systems
tial barrier to client growth and change due to the absence of described subsequently vary in the comprehensiveness with
linkages useful for the therapeutic process” (p. 335). which they address pertinent psychological phenomena.
Maddux (2002) pointed out that the utility of a classifi- Thus, we would suggest that the developmental counseling
cation system is closely linked to its ability to lead sub- and therapy (DCT; Ivey & Ivey, 1998) system and the New
scribers to the development and selection of effective treat- Personality (Oldham & Morris, 1995) conceptualization be
ment. This aspect of the DSM-IV’s utility has been repeat- considered “replacements” for the DSM-IV framework. In ad-
edly questioned (see, e.g., Raskin & Lewandowski, 2000; dition, models of well-being could augment the weakness-
Rigazio-DiGilio, 2000). This limited utility may be attrib- focused information gathered in the DSM-IV system. Although
uted to the atheoretical nature of the DSM-IV. A system that these alternatives vary in scope, all incorporate a dimensional
does not explain connections between the environment, approach to describing personal characteristics and function-
culture, behavior, thoughts, emotion, external supports, and ing while at the same time emphasizing the connection be-
functioning can only hint at implications for treatment. The tween conceptualization and treatment.
DSM-IV system can only “suggest somewhat vaguely what
DCT
needs to be changed, but it cannot provide guidelines for
how to facilitate change” (Maddux, 2002, p. 20). Ivey and Ivey (1998) suggested that one of the first steps
toward transcending pathology is to change the language used
Addressing Assumption 3: Connecting Diagnosis, to describe client functioning. This step includes seeking out
Conceptualization, and Treatment and specifically addressing the positive aspects of a client’s
Neimeyer and Raskin (2000) asked, “How can we conceptual- life. The emphasis should be expanded to include discovery
ize this client’s struggles in a way that is therapeutically useful of what is working and ways to capitalize on clients’ strengths.
and still communicate intelligibly with colleagues and case Ivey and Ivey (1998) described DCT as a here-and-now
managers?” (p. 4). Assessment and diagnosis serve as the starting conceptualization of client strengths as viewed within a
points for making meaning of a client’s presentation. A compre- cultural and historical model. They proposed a develop-
hensive, and preferably theory-based, conceptualization of all mental approach in order to understand the unique circum-
forces that bear on a client’s functioning provides a framework for stances of each client’s experiences and environment that
understanding that can lead to the development of a treatment have contributed to current dysfunction, noting that behav-
plan that is sensitive to the cultural context of clients. ior considered pathological within the DSM-IV system is
often a logical response to developmental history. (Aspects
Alternative Conceptualizations of the developmental focus and the DSM-IV diagnostic sys-
tem are juxtaposed in Table 1.)
of Behavior In framing their approach, Ivey and Ivey (1999) encour-
Mental disorders are socially constructed, are based on opinion aged clinicians to accurately understand the client as a whole.
and value, and have strong negative connotations. Further- They stated that the “contextual self includes relational di-
TABLE 1
DSM-IV: The Contrast Between Traditional and DCT Meaning-Making Systems
Traditional Pathological
Issue DSM-IV Meaning Developmental Meaning
Locus of problem Individual Individual/family/cultural context
Pathology Yes No, logical response to developmental history
Developmental and etiological
constructs Peripheral Central
Culture Beginning awareness Culture-centered
Helper role Hierarchy, patriarchy Egalitarian, coconstruction
Cause Linear, biology vs. environment Multidimensional considers both biology and environment
Family Not stressed Vital for understanding individual development and treatment
Treatment Not stressed Central issue
Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; APA, 1994); DCT = developmental counseling and theory (Ivey
& Ivey, 1998). From “Reframing DSM-IV: Positive Strategies From Developmental Counseling and Theory” by A. E. Ivey and M. B. Ivey, 1998,
Journal of Counseling & Development, 76, p. 336. Copyright 1998 by the American Counseling Association. Reprinted with permission.
ment of mental disorders. In essence, the problems might would be reflective of severely impaired functioning, good
initiate or exacerbate dysfunction. health, and optimal functioning, respectively. Having this
On reviewing the nine categories of problems listed in type of assessment built into the diagnostic system would
the DSM-IV (see Table 3), we were struck by the notion that encourage clinicians to recognize, and hopefully use,
if these everyday problems serve as initiating and exacer- strengths within clients and their environments.
bating factors of disorder, then everyday resources could
serve as protective factors that would prevent the develop- Creating Axis VI
ment of disorder or reduce its impact on an individual. Many A third option for revising the 1994 DSM-IV categorical
of the resources listed in Table 3 can be measured with psy- system is the inclusion of an additional axis. This axis, per-
chometrically sound tools. haps titled Personal Strengths and Facilitators of Growth,
Our recommendation for using a broadened Axis IV is to would present an individual’s strengths along dimensions,
try to contextualize the view of the client and his or her thereby allowing the development of a more comprehensive
functioning by considering psychosocial and environmen- picture of the client. In this way, Axis VI would be designed
tal resources. Listing these resources alongside the prob- to tap the psychological strengths associated with therapeu-
lems might facilitate the conceptualization of the ways in tic change and positive functioning, thus serving the added
which the client copes and solves problems in his or her life. function of creating a connection between diagnosis and
treatment. To determine a client’s position on this axis, a
Reanchoring Axis V clinician would present the client with a brief packet of mea-
Axis V of the DSM-IV was incorporated into the diagnostic sures designed to assess such factors as hope (Adult Hope
system to assess clients’ functioning. This is the only axis that Scale; Snyder et al., 1991), satisfaction with life (Satisfac-
does not focus exclusively on pathology, but it remains lim- tion With Life Scale; Diener, Emmons, Larsen, & Griffin,
ited in accurately assessing clients’ strengths. It is our conten- 1985), optimism (Life Orientation Test–Revised; Scheier,
tion that Axis V must be reorganized so that it is capable of Carver, & Bridges, 1994), and personal growth initiative
capturing the absence of functional deficits and the areas of (Personal Growth Initiative; Robitschek, 1998). A cover page
optimal living. To create a functioning baseline, the current would be attached to this packet with three basic questions:
Global Assessment of Functioning (GAF) level 100 (absence (a) What are your specific goals for treatment? (b) Who are
of symptomatology) would be rescaled as the midpoint (50) of the people in your life you will turn to for support while
the GAF scale. Levels 51–100 would be reserved for increas- making changes in your life? and (c) What are your personal
ing levels of functioning. The GAF anchors of 1, 50, and 100 strengths? After clients had answered these questions, the
clinician could then plot the client’s scores, from low to
TABLE 3 high, on a separate continuum for each of the above-listed
Broadening Axis IV of the DSM-IV System traits. In this way, a graphic description of these positive
characteristics could be seen, thus creating a baseline from
Psychosocial/Environmental Psychosocial/Environmental which to work in therapy.
Stressors Resources
As the field of psychology shifts to a balanced model
Problems with primary support Attachment/love/nurturance focusing on mental illness and mental health, clinicians and
group with primary support group
Problems related to the social Connectedness/empathic
researchers must move beyond traditional deficit diagnosis.
environment relationships/humor-filled The modifications to Axes IV and V and inclusion of an Axis
interactions VI are potential directions for growth.
Educational problems Accessible educational
opportunities and support
Occupational problems Meaningful work/career Future Directions
satisfaction/self-efficacy
Housing problems Safe housing with essential Challenging faulty assumptions about psychodiagnosis and
elements that foster healthy
development the DSM-IV system remedies the preemptive guesswork that
Economic problems Financial resources adequate keeps clinicians mired in one incomplete explanation of func-
to meet basic needs and tioning. Alternative conceptualizations help clinicians to tran-
beyond
Problems with access to Access to high quality/reliable scend pathology and entertain the full range of psychologi-
health care services health care services cal functioning. Finally, alterations to the 1994 DSM-IV sys-
Problems related to interaction Contributions made to society tem could provide a revised framework within which clini-
with the legal system/crime via donation of resources
and time cians and researchers can make sense of human behavior.
Other psychosocial and Other psychosocial and Recent developments in classifying the full spectrum of
environmental problems environmental resources human functioning hold much promise for rounding out the
Note. DSM-IV = Diagnostic and Statistical Manual of Mental Dis- view of the pathology-to-optimal-functioning continuum.
orders (4th ed.; American Psychiatric Association, 1994). In this last section, we discuss Wright’s (1991) approach to
developing a comprehensive conceptualization of a person’s cation of Strengths system—wisdom, courage, humanity, jus-
weakness and strengths and of the influence of environmen- tice, temperance, and transcendence—and these are thought to
tal stressors and resources. The Values In Action (VIA) Clas- represent universal and cross-cultural virtues. This classifica-
sification of Strengths is also described. tion system may become the gold standard for classifying the
positive aspects of human life.
Wright’s Four-Front Approach
One useful framework for assessment and diagnosis is Wright’s Concluding Remarks
(1991; Wright & Lopez, 2002) four-front approach. In this
approach, clinicians gather information about (a) strengths Diagnosing along the DSM-IV axes is a standard practice in
and assets of the client, (b) deficiencies and undermining clinical work. The five-axis framework and its related codes
characteristics of the client, (c) resources and opportunities in provide a common means of communication among clinicians
the environment, and (d) deficiencies and destructive factors and between clinicians and third-party payers. This diagnostic
in the environment. Clinicians can use multiple methods, system, however, is limited in numerous ways, and it does little
including observation, interviews, informal assessments and to encourage a focus on human strengths and environments as
standardized measures, to gather this information and should resources and does not foster a connection between diagnosis
attempt to include the four-front data that are gathered in and treatment. Hence, we hope that the recommendations to go
reports and clinical records. Using this balanced approach beyond the DSM-IV provide clinicians with ideas needed to
to psychodiagnostic assessment helps to counteract de- enhance diagnosis.
individuation and other clinician biases, and it also en-
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