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Practice & Theory

Beyond the DSM-IV: Assumptions,


Alternatives, and Alterations
Shane J. Lopez, Lisa M. Edwards, Jennifer Teramoto Pedrotti,
Ellie C. Prosser, Stephanie LaRue, Susan Vehige Spalitto, and
Jon C. Ulven

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.

Traditionally, psychodiagnosis has focused on symptoma- Assumptions About Psychodiagnosis


tology and dysfunction—that which is not working in a
person’s life. Within the framework of the Diagnostic and and the DSM-IV
Statistical Manual of Mental Disorders (4th ed.; DSM-IV;
In this section, we hope to establish that reification of and
American Psychiatric Association [APA], 1994) and the later
reliance on the DSM-IV system are grounded in the assump-
text revision (the DSM-IV-TR; APA, 2000), each diagnosis
tion that clinicians are getting the “whole picture” of a client
represents a negative syndrome comprising a cluster of symp-
from a diagnosis based on the DSM-IV system. This is not the
toms associated with clinically significant impairment or
case. Failure to acknowledge the assumptions that undergird
distress. Rather than addressing these syndromes as envi-
the DSM-IV system and the associated limitations of this mean-
ronmentally or situationally determined, the developers of
ing-making tool will perpetuate the disconnect between di-
the DSM-IV framed mental disorders as dispositional (i.e.,
agnosis and treatment. (See “Stopping the Madness” by
something that is within the individual and part of his or her
Maddux, 2002, for a detailed deconstruction of illness ideol-
psychological makeup). This focus on negative aspects has
ogy that served as the intellectual stimulus for this article.)
occurred at the expense of identifying the strengths of indi-
viduals and their environmental resources and of assisting
Assumption 1: Mental Illnesses Are “Facts” and
people in their pursuit of optimal human functioning.
Can Be Classified in Discrete Categories
In this article, we identify limitations in current psychodi-
agnostic practices and the DSM-IV framework and offer al- The DSM-IV’s (APA, 1994) and the DSM-IV-TR’s (APA, 2000)
ternative means for conceptualizing behavior. More spe- diagnostic system is based on the assumption that “mental
cifically, we address unsubstantiated assumptions about illness” reflects “facts” about people struggling in the world.
mental illness and psychodiagnosis that undergird the use “Disorders” are created based on reports of complaints and
of the DSM-IV. We then offer three adjunctive, or alternative, functional disturbances, with arbitrary distinctions being
means of describing behavior and mental health. Finally, we drawn between types of dysfunction. Once these distinc-
discuss ways to alter the DSM-IV’s five-axis system so that tions are made, the cluster of symptoms is given a name and
strengths and resources can be detected and described within is thereby transformed into a real entity. In this way, it may
the existing framework. be said that illnesses are created and do not necessarily re-

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

260 Journal of Counseling & Development ■ Summer 2006 ■ Volume 84


Beyond the DSM-IV

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

Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 261


Lopez et al.

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.

262 Journal of Counseling & Development ■ Summer 2006 ■ Volume 84


Beyond the DSM-IV

mensions of personal and family developmental history,


community and multicultural issues, and physiology” Personality Personality

(p. 486). Understanding the individual requires gaining infor- Style Disorder
mation about him or her along numerous contextual dimen-
sions (see Table 1), and developing treatment plans that are Conscientious ➤ Obsessive-Compulsive
Self-Confident ➤ Narcissistic
sensitive to contextual resources requires an in-depth un- Dramatic ➤ Histrionic
derstanding of the social context in which the client lives. Vigilant ➤ Paranoid
Specifically, conceptualization within the Ivey and Ivey Mercurial ➤ Borderline
Devoted ➤ Dependent
(1999) system involves building a framework of informa- Solitary ➤ Schizoid
tion. For example, when working with someone who has Leisurely ➤ Passive-Aggressive
experienced childhood trauma, Ivey and Ivey would gather Sensitive ➤ Avoidant
Idiosyncratic ➤ Schizotypal
information about what they referred to, in the terminology Adventurous Antisocial

of Masterson (1981), as environmental or biological insults. Self-Sacrificing ➤ Self-Defeating
They would then test hypotheses regarding the connection Aggressive ➤ Sadistic
Serious ➤ Depressive
between the insult and stress and pain and between the sub-
jective experience of stress and pain and sadness and de- FIGURE 1
pression (which might occur because of threatened attach-
Oldham and Morris (1995) Dimensional
ment security and safety). Next, the nature of defending
Conceptualization of Personality Disorders
against negative mood would be examined, and the current
use of defensive structures would be considered. With all Note. From J. M. Oldham & L. B. Morris (1995). New Personality
Self-Portrait: Why You Think, Work, Love, and Act the Way You Do.
these data garnered, personality style and its manifestation
New York, Bantam. Reprinted with permission.
in and out of session can be described. How this personality
style helps a person navigate current relationships then de-
termines the course of treatment. The developmental diag-
nostic framework needs to be fleshed out a bit more, but in Morris, may find that possessing this quality allows him or
its current form, it serves as an intriguing meaning-making her to be responsible and reliable. A person with features of
alternative to the DSM-IV system. narcissistic personality disorder may find that certain as-
pects of this disorder allow him or her to be self-confident
New Personality Dimension and therefore able to function at a superior level. It is only
Oldham and Morris (1995) provided particular support for when these characteristics become extreme that they are no
the dimensional approach with their unique conceptualiza- longer beneficial to the client.
tion of personality disorders. These two authors contended This personality continuum can be used to differentiate
that each of the 14 personality disorders listed in the DSM- between individuals possessing more, or less, florid symp-
IV can be viewed as lying on its own continuum of adapta- tomatology in their daily lives. With the current DSM-IV
tion. Less acute presentations of these personality types lie conceptualization, an individual must possess a majority of
at one end of these continua, with the actual manifestations the criteria delineated to be diagnosed as “having” the dis-
of the personality disorders (e.g., borderline, paranoid, his- order. An individual who has one less than the specified
trionic) at the other end. Oldham and Morris posited that an number of criteria may still be experiencing quite a high
individual may move along this continuum, depending on level of stress and yet may not receive services because of a
the environmental and endogenous stressors in his or her lack of a specific diagnosis. The Oldham and Morris (1995)
life at any one point in time. In this conceptualization, an conceptualization leaves room for individuals to be diag-
individual may exhibit behaviors more indicative of the nosed according to the degree of dysfunction or maladaption
actual disorder at times of high stress, whereas clinical pre- as well as to the degree of positive use of resources. In addi-
sentation may resemble a less intense version of the disorder tion, it may provide more client-friendly terminology to use
in times of less stress. Thus, an individual may meet criteria when discussing personality disorder diagnoses during ses-
for histrionic personality disorder during extremely stress- sions, allowing clinicians to help clients identify strengths
ful periods but might merely be described as dramatic at times as well as weaknesses in their set of behaviors.
of low stress in his or her life. As another example, someone
who may appear to have obsessive-compulsive personality Levels of Well-Being
disorder in stressful situations may be described as consci- Conceptualizing individuals based on well-being and posi-
entious on the lower end of the continuum (see Figure 1). tive functioning represents an alternative lens through which
These characteristics may, in fact, be quite helpful to the to view human behavior. Theories of subjective well-being,
individual on the nondisordered end of the continuum. A such as the model posited by Diener and others (Diener,
person who is conscientious, as described by Oldham and 1984; Diener, Suh, Lucas, & Smith, 1997), suggest that indi-

Journal of Counseling & Development ■ Summer 2006 ■ Volume 84 263


Lopez et al.

viduals’ appraisals of their own lives capture the essence of TABLE 2


well-being. Objective approaches to understanding well-
Diagnostic Criteria for Flourishing in Life
being have been proposed by Ryff (1989) and Keyes (1998),
both of whom provided a useful framework for conceptual- Flourishing in Life
izing human functioning. A. Individual must have not had an episode of major depression
Ryff (1989) posited that the categories described by pro- in the past year.
B. Individual must possess a high level of well-being as indicated
ponents of positive psychology can be integrated into six by the indivdual’s meeting all three of the following criteria.
main areas of psychological well-being. Self-acceptance, or 1. High emotional well-being, defined by having 2 of 3 scale
holding positive attitudes toward oneself, is a central fea- scores fall in the upper tertile
a. Positive affect
ture of mental health. Environmental mastery is the second b. Negative affect (low)
domain of Ryff ’s model of well-being. This involves the c. Life satisfaction
ability to select or generate environments most conducive 2. High psychological well-being, defined by having 4 of 6 scale
scores fall in the upper tertile
to an individual’s goals. The third aspect of well-being is a. Self-acceptance
positive relations with others. This area emphasizes the need b. Personal growth
for satisfying interpersonal relationships. Having a purpose c. Purpose in life
d. Environmental mastery
in life is the fourth essential element of mental health. The e. Autonomy
fifth element, personal growth, describes the way individu- f. Positive relations with others
als fully realize and grow toward their potential. Finally, 3. High social well-being, defined by having 3 of 5 scale scores
fall in the upper tertile
autonomy is the sixth essential element. Autonomous indi- a. Social acceptance
viduals use an internal locus of evaluation; they are inde- b. Social actualization
pendent and self-deterministic. This model of well-being c. Social contribution
d. Social coherence
has been investigated in numerous studies, and findings e. Social integration
indicate that the six dimensions of well-being are indepen-
dent, although correlated, constructs. Specifically, Ryff and
Keyes (1995) conducted an analysis of the six-part well- being. Limitations of the categorical system (e.g., categoriza-
being model and found that the multidimensional model tion does not necessarily promote understanding, categories
was a superior fit over a single-factor model of well-being. are not discrete yet they suggest a clear distinction between
Keyes (1998) suggested that just as clinicians categorize normal and abnormal behavior, categories can cloud clinical
the social challenges evident in an individual’s life, so should judgment) must be considered when adopting this approach.
they assess the social dimensions of well-being. He pro-
posed that these dimensions are coherence, integration, ac- DSM-IV Alterations
tualization, contribution, and acceptance. His model of well-
being addresses both social well-being and intrapsychic func- The DSM-IV diagnostic framework comprises five axes: Clini-
tioning, because the individual is able to move from dys- cal Disorders and Other Conditions That May Be a Focus of
function to satisfaction in both domains. Clinical Attention (Axis I), Personality Disorders and Mental
Keyes and Lopez (2002) suggested that complete mental Retardation (Axis II), General Medical Conditions (Axis III),
health can be seen as a syndrome comprising high levels of Psychosocial and Environmental Problems (Axis IV), and Glo-
emotional well-being, psychological well-being, and social well- bal Assessment of Functioning (Axis V). Diagnosis and
being. Individuals with these high levels are said to be “flourish- conceptualization within this framework are grossly incom-
ing” (see the criteria in Table 2). Individuals without mental plete because environmental resources, well-being, and psy-
illness but who have low levels of well-being are described as chological strengths are not addressed. Because the DSM-IV’s
“languishing.” (We have found that informal assessment of lev- place in the field of psychology is firm, working within this
els of well-being provides valuable information about the range diagnostic framework is, however, necessary. Alterations to
of functioning between flourishing and languishing.) This the system could serve to emphasize the positive side of hu-
conceptualization of incomplete mental health describes a syn- man functioning and provide a greater wealth of information
drome of symptoms that might be amenable to intervention tech- that could be incorporated into a more comprehensive
niques aimed at increasing levels of emotional, social, and psy- conceptualization of personality and functioning.
chological well-being; thus, conceptualization and treatment
Broadening Axis IV
are well-connected in this model. (For more information about
well-being therapy, which is based on Ryff’s, 1989, model, see When addressing Psychosocial and Environmental Problems
Fava, 1999; Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998.) (Axis IV), clinicians log the problems that serve to add some
It should be noted that the Keyes approach to describing context to the psychological disorders diagnosed along Axes
flourishing and languishing incorporates the DSM-IV categori- I and II. The DSM-IV developers indicated that problems
cal system as well as a new set of categories to describe well- experienced would affect the diagnosis, prognosis, and treat-

264 Journal of Counseling & Development ■ Summer 2006 ■ Volume 84


Beyond the DSM-IV

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

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Lopez et al.

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-
courages clinicians to actively look for clients’ personal References
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Regarding the future of this approach, Wright (1991) called cal manual of mental disorders. Washington, DC: Author.
for the creation of four separate diagnostic manuals— a manual American Psychiatric Association. (1994). Diagnostic and statistical
for each of the four fronts. We believe that a fifth manual manual of mental disorders (4th ed.). Washington, DC: Author.
would be necessary to guide the clinician in the incorpora- American Psychiatric Association. (2000). Diagnostic and statistical manual
tion of data and the connection of conceptualization and of mental disorders (4th ed., text rev.). Washington, DC: Author.
treatment. Although it might be cumbersome, five manuals Barone, D., Maddux, J., & Snyder, C. R. (1997). The social cognitive
would cover all the bases of diagnosis. If the arduous task of construction of difference and disorder. In D. Barone, J. Maddux, &
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opment of a single, condensed volume highlighting the four- rent domains (pp. 397–428). New York: Plenum.
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The VIA Classification of Strengths (Peterson & Seligman, Diener, E. (1984). Subjective well-being. Psychological Bulletin,
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that although members of the counseling field currently Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. (1997). Subjective well-
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ogy to use in speaking about the strengths of individuals. Fava, G. A. (1999). Well-being therapy: Conceptual and technical
The VIA Classification of Strengths provides them with this issues. Psychotherapy and Psychosomatics, 68, 171–179.
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