DSM-5 focuses on drugs, not talk therapy

Posted: October 20, 2013

In The Inquirer and elsewhere, you may have read about the confusion and anger arising from the American Psychiatric Association's new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

This 992-page tome, called the DSM-5, classifies mental illnesses, and will be used to make care availability and insurer funding decisions.

For the first time in the manual's history, psychiatric researchers, not clinicians, dominated the proceedings. And the deciders did not include representatives from other mental health professions in their deliberations, even though most of these seeking care do not see psychiatrists.

The researchers are trying to organize psychological reactions through biomedical, genetic, and neurological markers. This so-called brain disease model will encourage the development of new drugs to treat what is often normal emotional distress.

The manual, for example, now tries to categorize many unsettling but normal life events, such as death, in much the same way that medical science categorizes physical illnesses.

There is a high likelihood that this misleading approach will cause therapists to spend even less time talking with patients, and to recommend more drugs in our overly drug-dependent society.

Please understand, I am not saying medication is bad. In serious psychiatric illness such as schizophrenia and bipolar disorder, it is a necessary, permanent mainstay. And it can be used in the short term to feel better and cope.

What I am saying is that drugs are not always necessary, and long-term medication should be a well-considered option, not a first and automatic one.

Plus, the DSM-5 overlooks the fact that patients have the best chance to improve when treated as human beings, not as "walking diagnoses."

Pure researchers may not grasp the impact of loneliness, betrayal, connivance, personal vulnerability, and cultural differences on mental health, or the value of being heard and helped by informed experience.

Those who work with patients can offer endless examples of this dangerous disconnect. I have seen one partner drive another into clinical depression through tactics of humiliation, emotional deprivation, and shame; and I have seen the most powerful member of a marriage insist that the partner take heavy meds prescribed by a caregiver who had no understanding of family dynamics.

I have seen adult sons and daughters, determined to receive as much inheritance as possible, deprive aging parents of a decent life and in doing so induce psychiatric illness.

If you or a loved one needs psychiatric care or advice, there are many fields to choose from: psychiatry, psychology, social work, marriage and family therapy, nursing, the ministry. A trusted family doctor, a religious leader, or a good friend who has sought help are excellent resources. Make sure the clinician you choose is licensed or is being prepared for licensure through close supervision.

Discuss clinical orientation. Two of the predominant approaches today are cognitive therapy, which helps one to identify and alter self-defeating thoughts, and psychodynamic therapy, which focuses on the root of the problem. Many therapists today are eclectic, selecting the approach they think can be the most effective based on a client's personality and needs.

If you or your therapist believe medication is indicated, make sure you have a clear discussion and agree on its necessity and timing.

If you have insurance, the number of approved visits may be fewer than necessary. But many excellent clinicians will accept payment on a sliding scale when a patient is motivated. Or they can refer you to another therapist who will.

And here is a crucial tip. Make sure you feel comfortable with your clinician. Healing most easily occurs when you believe you have found a therapist who understands your world, and when you believe your work together can improve your life.


SaraKay Smullens is a clinical social worker, family therapist, and writer in Philadelphia. SaraKay1710@gmail.com.

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