Postmodern Counselling: Some thoughts on Labeling and the DSM-5

The practice of psychotherapy is quite a modern phenomenon, beginning as we know it with Sigmund Freud and his “talking cure” in the late 19^th century Vienna.  Various psychotherapies grew from this inception ground, framed within the modernist paradigm and concentrating on the functioning of the individual.  When we consider traditional therapies, such as Freud’s psychoanalytic therapy with the concept of “ego functioning,” Roger’s humanistic ideas of self-development, Jung’s various concepts of personality, and Beck’s self-talk, we notice how modern therapy has embraced the grand cultural narrative about “self” (Neimeyer, 2003).  These therapies privilege the individualistic, singular, essential, stable, and knowable self, with the underlying assumption that we are encapsulated beings.  The focus of therapeutic transformation becomes the inner working mind of the individual.  In addition, traditional therapies hold to a standard of normality.  As part of the therapeutic process, the level of abnormality of an individual is assessed based on agreed upon characteristics.  The goal of traditional therapy has been to remediate pathology and bring the client into the range of normal functioning.  McNamee states,

Psychotherapy as a series of authoritative technical procedures to bring about self-change would focus chiefly on disorders of individuals that impair adaptation and then treat them in such a way as to enhance the client’s self-actualization, self-control, self-efficacy, and the like. (1996)

The standard for clinical diagnosis in therapy is the DSM-5,  the catalogue of all abnormalities which details associated features, culture, age, and gender features, prevalence, course, and familial pattern of mental disorders,  and is referred to as the essential diagnostic tool for disorders used to promote effective diagnosis, treatment, and quality of care.[1]  The DSM, which Dr. Karl Tomm M.D. (1990) critically refers to as the “Bible of Psychiatry,” explicitly holds a strong individualistic bias.  Each of the disorders or syndromes occurs within the individual, with no perspective taken on the influence of social phenomena.  Individuals evaluated based on diagnostic criteria receive prescribed therapy with the goal of treatment to bring the individual into the arena of “normal” functioning.  This medical style model places pathology solely with the individual (e.g. Schizophrenia, ADHD, depression.) without the social context considered.  Tomm writes,

The authors seemed oblivious to the theoretical significance of their individualistic presuppositions. There was no mention of the possibility of another point of view. They simply ignored the body of knowledge based on an alternative assumption, namely that the human behavior, the mind, and its disorders may be more fundamentally grounded in social phenomena than individual phenomena. (Tomm, 1990)

In addition, Tomm states, My major concern is that there is so little cognizance of the fact that the DSM has evolved to become such an authoritative document for classifying and labelling persons with mental problems (Tomm, 1990).   Allen Frances M.D., chair of the DSM-IV task force, in his recent book, Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, And The Medicalization Of Ordinary Life (2013) reflects on the impact of the DSM-IV,

We failed to predict or prevent three new false epidemics of mental disorders in children, autism, ADHD, and bipolar disorder. And we did nothing to contain the rampant diagnostic inflation that was already expanding the boundary of psychiatry far beyond its competence.  If a cautiously and generally  well done, DSM-IV had resulted in more harm than good what are the likely negative effects of the DSM-5 driven by its grand, but quixotic ambition to be “paradigm shifting. (2013, p. xiv)

Neufeld and Maté describe unprecedented numbers of children and adolescents receiving diagnosis and corresponding prescriptions to treat depression, anxiety, or a host of other diagnosis.   They feel what is so objectionable is the reducing of “childhood problems to medical diagnoses and treatments to the exclusion of the many psychological, emotional, and social factors that contribute to how the problems arise” (2005, p. 56). Subsequently, the challenge in working with children/girls is the temptation to pathologize and label, training the focus of therapists and counsellors toward levels of inadequacy rather than toward areas for growth and development.  For example, the labelling of ADHD has become somewhat epidemic (Mark L. Wolraich, 2013).  On the website[2] for the Centre for Disease Control and Prevention a timeline outlines ADHD diagnostic criteria, prevalence and treatment over time. The Centre cites studies reporting the  number of children in the USA with a diagnosis of ADHD is increasing and reports that 10-16% of the child population been diagnosed with ADHD.

The first national survey that asked parents about ADHD was completed in 1999. Since that time, there has been a clear upward trend in national estimates of parent-reported ADHD diagnoses. It is not possible to tell whether this increase represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed. Perhaps relatedly, the number of FDA-approved ADHD medications increased noticeably since the 1990s, after the introduction of long-acting formulations.  [3]

Widely accepted, the DSM represents only a form of reality and is essentially only one way of understanding.   Postmodernists challenge whether this authoritative way of understanding is beneficial, and challenge the DSM being accorded such gravity (Frances, 2013; McNamee, 1992; Tomm, 1990). McNamee, (2002) argues diagnosis is never value neutral.  Labelling has a significant price.  Once labelled with ADHD, a child may never be treated the same again.  Teachers and parents begin to view a child through a certain set of lenses with certain kinds of expectations about behaviours and abilities.  In addition, the child will never see herself in just the same way.  This price to pay for diagnosis and labelling becomes “identity defining” (Tomm, 1990).  The postmodern approach is to steer away from labelling, pathologizing, and measuring, by honouring the individual as distinct from a collection of symptoms.