This, the argument goes, will—must!—happen not just to the DSM, the mere tip of the iceberg of outmoded thinking, but to psychiatry itself. According to the dissenters, psychiatry is stuck in its infatuation with scientific positivism, the belief that the only really true truth is found in objective, physical science. In fact, the argument most often made against DSM is that it’s not scientific enough, whereas the model Thomas Insel of NIMH holds up as a replacement is a new diagnostic template—Research Domain Criteria—based largely on the bald assumption that “mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.” And that settles that.
But—even if you could analyze the profoundly complex mental suffering of human beings in terms of the even more profoundly complex workings of the brain with its billions of neurons and trillions of synapses, and then encapsulate that knowledge into some sort of diagnostic system—the completion of such a project is decades, maybe centuries, away. If the old saw is true that a system can never fully understand itself, and the human brain can never fully “get” the human brain, the completion date gets pushed back to never. Besides the inherent difficulties of such a task, it does seem to underplay a few other small variables in human life, including class, economics, race, social, cultural, and political context, education, geography, systems of belief and ideology, and physical health, not to mention the sheer unpredictable cussedness that lurks within us all, individually and collectively. After all, probably the best psychotherapists do not, and will not, worry much about determining a correct diagnosis, once the reimbursement question has been settled. Instead, they focus on patients and their problems, carefully observing, questioning, reassuring, trying to understand and help this or that unique and complicated person, regardless of what official diagnostic criteria he or she meets.
All this being said, at least for the time being, it looks as if therapists will have to bumble along as they always have, make of DSM-5 what they can, use it when they must, and make plenty of room on their bookshelves (or computers) for it and all its assorted gear: desk reference, pocket guide, clinical case examples, updates, and so forth. Meanwhile, it can’t hurt to be prepared for that morning some time in the future when we look out our window and see there on the eastern horizon the glorious rising of the new paradigm in the sky!
Mary Sykes Wylie, PhD, is a senior editor of the Psychotherapy Networker.
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