Why the Medical Model Fails in Psychotherapy, Part Two: People Are Not Their Labels

In part one of this article, I argued that the medical model focuses too much on the objective zone of experience, seeing illnesses rather than people. While this is much more true in medicine than in psychology, the take-over of the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the medical establishment - i.e., psychiatrists, an alarming number of whom have strong ties to the pharmaceutical industry - has pushed the diagnosis and treatment of psychological dysfunction into that same model.

A 2006 article from Psychotherapy and Psychometrics looking at the DSM-IV panel found some alarming numbers:

Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had fi nancial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%). Conclusions: Our inquiry into the relationships between DSM panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. The connections are especially strong in those diagnostic areas where drugs are the fi rst line of treatment for mental disorders.

The situation seems not to have improved much in the DSM-V process, though we may not know for sure until after the revision is finished. According to a 2009 article in Psychiatric Times:

Last year, the Center for Science in the Public Interest in its May 5 Integrity in Science publication noted that more than half of the 28 members of the DSM-V task force have ties to the drug industry. “They ranged from small to extensive. Leading the pack was William Carpenter Jr . . . who over the past 5 years worked as a consultant for 13 drug companies.”

The disclosure statements released to the public have been criticized in blogs and news articles as being remarkably spare, because they show only the existence of corporate connections—not dollar amounts or duration.

John Grohol, PsyD, founder and publisher of Psych Central, warned in his November 17 blog that the DSM-V process contained a “glaring loophole.” Appointees could make a million dollars a year for 10 years from a company before beginning work with DSM-V. He said, “All you need do is to cut off that relationship for a few years and then come back to it when you’re done.”

As long as the pharmaceutical industry has so much pull on the DSM task force, the future does not look good for a more human-based diagnostic approach.

If you don't believe me, Mojtabai & Olfson (2010) report that not only are psychiatrists prescribing a lot of drugs to their patients, but they are prescribing multiple drugs to many of their patients.

There was an increase in the number of psychotropic medications prescribed across years; visits with 2 or more medications increased from 42.6% in 1996-1997 to 59.8% in 2005-2006; visits with 3 or more medications increased from 16.9% to 33.2% (both P < .001). The median number of medications prescribed in each visit increased from 1 in 1996-1997 to 2 in 2005-2006 (mean increase: 40.1%). The increasing trend of psychotropic polypharmacy was mostly similar across visits by different patient groups and persisted after controlling for background characteristics. Prescription for 2 or more antidepressants, antipsychotics, sedative-hypnotics, and antidepressant-antipsychotic combinations, but not other combinations, significantly increased across survey years. There was no increase in prescription of mood stabilizer combinations. In multivariate analyses, the odds of receiving 2 or more antidepressants were significantly associated with a diagnosis of major depression (odds ratio [OR], 3.44; 99% confidence interval [CI], 2.58-4.58); 2 or more antipsychotics, with schizophrenia (OR, 6.75; 99% CI, 3.52-12.92); 2 or more mood stabilizers, with bipolar disorder (OR, 15.46; 99% CI, 6.77-35.31); and 2 or more sedative-hypnotics, with anxiety disorders (OR, 2.13; 99% CI, 1.41-3.22)

Those numbers are alarming at best, especially considering that no one really knows how these chemicals interact. We are creating a nation of zombies, so drugged up that they are barely conscious. This is definitely the shadow side of medicine and psychiatry.

In the Comment section of the article, the authors list some of the drug interaction concerns for both schizophrenia, where there is no benefit in combining medications, and major depression, where the evidence for benefit is limited at best.

The authors offer this conjecture:

A change in the style of psychiatric practice may have contributed to the increase in antidepressant-antipsychotic polypharmacy. Some psychiatrists may be placing greater emphasis on symptom reduction while lowering their concerns over the number of medications required to achieve this clinical goal.

This is indicative of the problems with the medical model: symptom reduction, rather than treating the cause.

The most prominent side effects of many of these medications includes metabolic syndrome and diabetes (both are associated with weight gain and increased HDL cholesterol), especially in polypharmacy for schizophrenia (Suzuki, et al , 2008).

Diagnostic Issues

In fact, the DSM has moved increasingly toward diagnosing behaviors - not feelings or emotions (nothing subjective) - and they acknowledge this, seeing it as a more reliable approach in that it removes some of the subjective diagnostic element. This is a kind of flatland approach to the human mind and human suffering. Except there is one problem - the same person might receive five different diagnoses from five different therapists, especially in personality and dissociative disorders.

For one diagnosis, antisocial personality disorder (Hare, Hart & Harpur, 1991), the review committee objected to "the focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria" - and this was going into the DSM-IV, where the goal was to create a more objective, behavior-based diagnostic model.

Yet, this approach poses its other problems in reliability and validity, especially in the psychotic disorders where behaviors and interior states might be at odds. One of these - schizoaffective disorder (Maj et al, 2000) - is subject to removal from the DSM-V, suggesting the tenuous nature of some diagnostic labels.

Other diagnoses will also disappear or be heavily revised - autism and Asperger's (Anestis, 2009) will likely become a spectrum disorder; PTSD (Rosen, Spitzer & McHugh, 2008) is likely to be heavily revised. Other diagnoses are also subject to change and deletion, or new ones might be added.

Here are some other diagnoses under review, with citations:

Pedophilia: "The DSM diagnostic criteria for pedophilia have repeatedly been criticized as unsatisfactory on logical or conceptual grounds, and that published empirical studies on the reliability and validity of these criteria have produced ambiguous results." (Blanchard, R. The DSM Diagnostic Criteria for Pedophilia. Archives of Sexual Behavior. Sept 16, 2009)

Gender Identity Disorder: "These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent."(Cohen-Kettenis PT, Pfäfflin F. The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults. Arch Sex Behav. 2009 Oct 17)

Adult ADD: Some people want an even more rigorous medical definition of this disorder: "Future DSM field trials should assess symptoms and domains of impairment that are developmentally appropriate for adults. Symptom thresholds for diagnosis should be established with consideration of adult norms. Consistent with earlier DSM field trials, the age-of-onset criterion should minimally be increased to age 12 or—in the absence of strong empirical support—be abandoned altogether." (McGough, J.J. & McCracken, J.T. Adult Attention Deficit Hyperactivity Disorder: Moving Beyond DSM-IV. Am J Psychiatry. October 2006; 163:1673-1675)

A big issue with the DSM diagnoses is the seeming lack of consistent reliability and validity, which are defined as follows:

Technically, the reliability of a diagnosis is the percentage of the person-to-person variability in a given population that relates to the variance of the ‘true’ values of the diagnosis (Lord and Novick, 1968). Less technically, it relates to the extent to which a second independent diagnostic opinion about a patient agrees with the fi rst, and is best measured by the correlation coeffi cient between independent test–retest diagnoses for a sample of subjects from that population.

Validity, however, is the percentage of the person-to-person variability of the diagnosis in a given population that relates to the variance of the disease for which the diagnosis is meant, and is consequently always lower than the reliability of a diagnosis (Lord and Novick, 1968). To date, the DSMs have focused solely on face or clinical validity, the assertion that the diagnosis corresponds to clinicians’ subjective views of a disorder. This is a weak but necessary form of validity achieved by requiring consensus among clinicians expert in that disorder, and such consensus has to date been the primary basis of DSM modifications. Ideally the validity of a diagnosis represents the correlation between the diagnosis and a ‘gold standard’ determination of the disorder. For example, one common form of validity is expressed by the sensitivity and specificity of a categorical diagnosis relative to its corresponding disorder, where sensitivity is the probability that a person who has the disorder is diagnosed positive, and specificity is the probability that a person who does not have the disorder is diagnosed negative. (Kraemer, 2007, p. S9)

Kraemer is advocating for a dimensional model for the DSM-V, rather than the traditional categorical diagnoses, which have limited validity and reliability. Others have taken up the same issue (Brown & Barlow, 2009) for anxiety and mood disorders.

Stigma

A very different issue, however, is how these diagnoses impact the person who then carries the label. When people accept and internalize their "medical diagnosis," they are more likely to be depressed, according to Sonja Grover (2005).

Consider in this regard that there is evidence that internalizing the medicalization of one's DSM-defined "mental health problem/disorder" is a strong predictor for depression (White, Bebbington, Pearson, Johnson & Ellis, 2000). Further, it has been found that those who accept explanations of their experience as one of having experienced a "psychotic episode" are also more prone to depression than those who resist integrating the experience in this way (Jackson et al., 1998). One is safe to assume that the client had acceded to the DSM label, to the extent they did, in the hopes that the entire process would alleviate psychological distress. (p. 78)

Grover, who is writing specifically on confidentiality issues, goes on, however, to make the following important points about the validity and reliability of DSM diagnoses:

The fallaciousness of reifying DSM diagnostic categories is evidenced, for instance, by the fact that the validity of various long-established DSM categories such as schizophrenia has been attacked in part due to the non-specific nature of many of the attributed symptoms (Gallagher, Gernez, & Baker, 1991). The scientific status of other "conditions" such as "post-traumatic stress disorder" (PTSD) has also been held suspect since there is no certain way to distinguish between the alleged genuine disorder and simple malingering of symptoms. (p. 79)

And . . .

In addition, the validity of DSM categories in general has been challenged on the basis that often the categories cannot be reliably measured and therefore their validity also cannot be assessed (reliability here referring to mental health workers independently reaching the same conclusions regarding diagnosis when using the same DSM eligibility criteria and the same assessment tools [Kirk, 1994]). Due to such evidence as the foregoing, it is therefore not reasonable to hold DSM categories to be relatively accurate and definitive statements about the nature of the person so diagnosed. (p. 79)

In Grover's opinion, to give someone a label, especially one that defines them psychologically, is to remove their freedom to self-define and to stigmatize them in their social context. She is not alone in her concerns - others have found the same results in their studies (Rosenfeld, 1997; Link, et al, 1997). We've known for decades that mental illness carries a powerful social stigma, but we are beginning to get clear that labels impact the person being labeled, as well.

In narrative theory, such a powerful label can create a "monological" self-narrative, one devoid of diversity and prone to repeat itself over and over again (Singer & Rexhaj, 2006). Healthy psyches have dialogical self-narratives, meaning multiple perspectives. But when these heavy labels are being carried, the self-narrative often (not always) narrows to one centered on the label.

Individuals should not have to carry stigmatizing diagnostic labels, either against their will or willingly - either way, they will carry that label and self-define with that label for the rest of their lives in many cases. We can treat people without these harsh labels.

Finally, there were some efforts to construct an alternative to the DSM model, for many of the reasons presented here.

When drafts of the DSM (4th ed.; DSM–IV;American Psychiatric Association, 1994) were being circulated, it became clear to a number of researchers that the DSM influence was getting more strongly entrenched in several ways. First, economically the mental health care delivery system was increasingly dependent on the DSM as a way of classifying patients for getting reimbursement. Second, the scientific community was being increasingly constrained to organize its research around the DSM. Journals, grant agencies, conventions, and even talk among colleagues was increasingly reifying diagnostic categories. This would not be bad if the DSM had earned this considerable influence on a level scientific playing field. Instead, this was and is happening despite the fact that the DSM has not been particularly successful as an organizing principle for guiding science, and its assumptions about how to interpret behavior seem inadequate from many perspectives. (Follette, 1996)

The Journal Of Consulting And Clinical Psychology (1996 Dec; Vol. 64 (6)), did a special issue, the introduction of which was the source of the previous quote, devoted to looking at the other options. That was 14 years ago - clearly, they have not been successful. Another approach has been offered more recently (Andrews, Anderson, Slade & Sunderland, 2008), one that seems promising (or at least a move in the right direction, though still burdened with labels) if enough professionals support it.

But we have options in how we relate to our clients. We do not need to burden them with labels. Many therapists working with parts or subpersonalities, such as Richard Schwartz (who I mentioned in part one) do not even used diagnostic labels. His patients get well without them.

We need to emphasize our clients' humanity, not their illness. If we can reconstruct their sense of identity to revolve around the Self, we will have taken a huge step toward both their healing and their evolution as human beings.



References:

Andrews, G., Anderson, T., Slade, T., & Sunderland, M. (2008). Classification of Anxiety and Depressive disorders: problems and solutions. Depression & Anxiety (1091-4269), 25(4), 274-281.

Anestis, M. D. (2009) The fate of Asperger's syndrome in DSM-V: A follow-up to last week's article. Psychotherapy Brown Bag. Nov. 10: http://2a1w.sl.pt.

Brown, T.A. & Barlow, D. (2009) A Proposal for a Dimensional Classification System Based on the Shared Features of the DSM-IV Anxiety and Mood Disorders: Implications for Assessment and Treatment. Psychological Assessment; Sep;21(3):256-271.

Cosgrove, L., Krimsky, S., Vijayaraghavan, M., & Schneider, L. (2006) Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry. Psychother Psychosom. 75:154–160.

Follette W.C. (1996) Introduction to the special section on the development of theoretically coherent alternatives to the DSM system. Journal Of Consulting And Clinical Psychology. Dec; 64(6):1117-9.

Grover, S. (2005) Reification of Psychiatric Diagnoses as Defamatory: Implications for Ethical Clinical Practice. Ethical Human Psychology and Psychiatry, Spring;7(I):77-86.

Hare, R., Hart, S. & Harpur, T. (1991) Psychopathy and the DSM—IV Criteria for Antisocial Personality Disorder. Journal of Abnormal Psychology. August 1991. 100(3): 391-398.

Kaplan, A. (Jan i, 2009) DSM-V Controversies. Psychiatric Times. Vol. 26 No. 1: http://w.dc.sl.pt.

Kraemer, H.C. (2007) DSM categories and dimensions in clinical and research contexts. Int. J. Methods Psychiatr. Res. 16(S1): S8–S15.

Link, B.G., Struening, E.L., Rahav, M., Phelan, J.C. & Nuttbrock, L. (1997) On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behavior. Jun;38(2):177-190.

Maj, M., Pirozzi, R., Formicola, A.M., Bartoli, l. & Bucci, P. Reliability and validity of the DSM-IV diagnostic category of schizoaffective disorder: Preliminary data. Journal of Affective Disorders. Jan; 57(1): 95-98.

Mojtabai, R. & Olfson, M. (2010) National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry. Jan;67(1):26-36.

Rosen, G.M., Spitzer, R.L. & McHugh, P.R. (2008) Problems with the post-traumatic stress disorder diagnosis and its future in DSM V. Br J Psychiatry. Jan;192(1):3-4.

Rosenfeld, S. (1997) Labeling Mental Illness: The Effects of Received Services and Perceived Stigma on Life Satisfaction. American Sociological Review. August; 62:660-672.

Singer, J.A. & Rexhaj, B. (2006) Narrative Coherence and Psychotherapy: A Commentary. Journal of Constructivist Psychology. 19:209–217.

Suzuki T, Uchida H, Watanabe K, Nakajima S, Nomura K, Takeuchi H, Tanabe A, Yagi G, Kashima H. (2008) Effectiveness of antipsychotic polypharmacy for patients with treatment refractory schizophrenia: an open-label trial of olanzapine plus risperidone for those who failed to respond to a sequential treatment with olanzapine, quetiapine and risperidone. Hum Psychopharmacol. 23(6):455-463.

Tags: identity, Psychology, self concept, therapy, Why the Medical Model Fails in Psychotherapy, Part Two, People Are Not Their Labels, Diagnostic and Statistical Manual of Mental Disorders, DSM, DSM-IV, DSM-V, psychiatrists, medical model, pharmaceutical industry, drugs, psychotropic medications, polypharmacy, reliability, validity, Diagnostic Issues, behaviors, diagnostic criteria, Self, self-narrative, dialogical self