Welcome, everyone! Yes, I’m talking to you—whether you’re at the front of the crowd or the back, whether you’re in private practice or in the community clinic trenches, whether you’re a graduate student or a seasoned professor. Specifically, I’m talking to the part of you that’s intrepid, bold, and lionhearted—to your inner adventurer. Who among you hasn’t dreamt of embarking on this quest for a new diagnostic frontier?
True, you’re not the first. Many brave souls have come before you—risking, if not life and limb, then certainly failure, loss of credibility, the contempt of professional colleagues, and squandered intellectual resources, all to find a place where diagnosing can finally transcend its pathologizing legacy, where you can name and categorize a client’s suffering and take into account their humanity, environment, and the intricate relational systems that shaped them. “Believe you can,” Theodore Roosevelt said, “and you’re halfway there.”
I won’t lie to you: there have been casualties. Many a bright-eyed adventurer has charged into battle against the diagnostic dragons, goliaths, and serpents of our time, only to have their dreams snuffed out. Of course, no clinically liberating goal worth striving for is easily achieved. But don’t let fear stop you! Join me for a magically unpredictable and sometimes arduous journey, beyond the familiar shores of the DSM, beyond the well-trodden cliffs of the ICD, to a land where the space on a client’s paperwork after the word diagnosis is something you look forward to filling in!
Maybe you’re a seasoned therapist, well-acquainted with the heyday of systems therapy in the 1970s—humanistic and anti-diagnosis, some would say. Perhaps you watched in horror as the DSM-III and medical model in the 1980s, the influence of Big Pharma in the 1990s, and the supremacy of managed care in the 2000s shifted the field on its axis. As clinician Bill Doherty puts it, “Counting symptoms and labeling people with a disorder became increasingly necessary in order for therapists to get paid, and being able to pay our bills will always influence how we work.”
Or maybe you’re a newer clinician, born into the medical model but filled with a fiery resistance to the idea of putting people in a labeled box. Maybe you’ve seen firsthand the damage diagnoses can cause when people overidentify with them, or when bureaucrats use diagnoses for reasons that have little or nothing to do with helping people. Maybe you’ve always been someone who follows the money trail to make sense of things, and you’ve wondered about the link between modern-day diagnoses and the multibillion-dollar pharmaceutical industry creating and supplying the drugs that promise relief.
Either way, I can see it in your eyes—you are a crazy dreamer, aren’t you? Well, you’ve come to the right place! Grab your hiking boots and trekking poles. Start lathering on the sunblock and bug spray. If you’re sturdy and wise enough to weather the diagnostic mirages, quicksand, and false summits, maybe by the time we’re done you’ll have begun to craft your own vision for the future of diagnosing. I’ll be your guide for today, but the rest is up to you!
We’d better get started. There’s only so much light in the day, and our journey spans decades.
The Diagnostic and Statistical Manual
Ha! I see you’re slowing down already. Do your feet feel like they’re turning to lead? Frustrating, isn’t it? Don’t worry, it’s not just you. Before we can explore alternatives to the DSM, we have to go through it, and the closer you get to it, the more you’ll feel a familiar weight—the weight of 71 years of controversy, infighting, special interests, and pressure to follow a framework that so many therapists—you among them—consider flawed, narrow, pathologizing, biased, and even obsolete.
Look! Over there. See that black, swirling fog? That’s the first-ever copy of DSM-I. Don’t get too close, or you’ll be sucked into a morass of diagnostic criteria and codes.
Did you know that the precursor to the DSM, published in 1917, was known as the Statistical Manual for the Use of Institutions for the Insane? And get this: it contained only 22 diagnoses! By the time DSM-IV was released in 1994, the number had ballooned to 297! DSM-5 broke the growth trend at 298 diagnoses when it was released in 2013, but it’s still a beast, and a controversial one at that. I assume that’s why you’re here, after all.
Speaking of which, see that man over there, glaring at the morass of pages that comprise the DSM? That’s psychiatrist Allen Frances. He comes here a lot. Frances was on the 28-person APA task force that oversaw the development of DSM-5, but he’s also been one of its loudest critics. Back in 2012, he famously remarked that therapists should treat the DSM as “a guide, not a bible.” He said it was “deeply flawed,” and the changes made to DSM-IV seemed “clearly unsafe and scientifically unsound.”
In 2016 and 2017, Jonathan Raskin, a psychology professor at the State University of New York at New Paltz, conducted two studies examining therapists’ attitudes toward the DSM-5. Ninety percent of those surveyed said they’d use it—likely, he inferred, because they felt they had to—but many supported developing an alternative.
Maybe you feel the same way: trapped by the DSM, but seeing no way out. That’s why most people don’t get much farther than this point in our journey. They exhaust all their energy trying to game it, to fudge it, by giving the mildest diagnoses. As Doherty says, “Clinicians have resigned themselves to this world we’re in: you have to diagnose, but you can do so in a way that keeps the focus more on people’s functioning than on their diagnosis.”
You’re not satisfied with an “adjustment disorder” workaround? I like your spunk, friend! Let’s close our eyes and think really hard about a diagnostic framework that isn’t as pathologizing, an alternative that allows us to take a more expansive view of mental health. Let’s see if that transports us somewhere a little more forward-thinking.
The International Classification of Diseases
Okay, you can open your eyes now. Take a look around. What do you see? A dense forest of brightly painted trees—interesting! It’s the International Classification of Diseases, or ICD, for short. It’s not exactly where I hoped we’d wind up, but it makes sense we’d arrive here next. After all, the DSM and ICD go hand in hand: usually when you assign a DSM diagnosis, you include a corresponding ICD code for insurance purposes. In fact, since 1979, insurance companies have required ICD codes for all Medicare and Medicaid claims.
Watch your step! It looks like someone spilled paint on the ground. In fact, you can observe the ICD creators painting the diagnostic landscape as we speak. They’re the ones wearing dirty smocks, bustling about with sloshing paint cans and dripping brushes in hand. See how they’re all lining up to make their marks? There must be over a hundred cultures represented here. Stay close to me, by the way. One wrong turn out here and you could wind up lost for weeks!
Whereas the DSM is used mostly in America, the ICD is managed by the World Health Organization for use worldwide. Today, 117 member countries use it, making it a common language for healthcare providers all over the world. The latest edition, ICD-11, was released last year, after almost a decade of deliberation by 300 specialists from 55 countries. It’s a melding of cultural perspectives, a diagnostic mural that’s been in the works for over a century.
Is the ICD a more humanistic approach to diagnosis than the DSM? Good question. It may be less of a lightning rod, but critics accuse it of being overly long, tedious, and disorganized. No wonder: since the ICD includes mental health diagnoses and disease-related diagnoses, the latest version contains almost 55,000 unique codes! Like the DSM, it’s been accused of focusing on symptoms instead of their causes. It suffers from “the problem of overspecification,” wrote Emory professors and researchers Scott Lilienfeld and Michael Treadway in 2016. They believe its criteria and algorithms are too strict—which is why NOS (Not Otherwise Specified) is among the most common diagnoses.
I hate to say it, but if we’re looking for a diagnostic framework that really breaks the mold, we won’t find it here. Brush aside that thicket of thorny branches and let’s keep moving.
The Psychodynamic Diagnostic Model
Strange! We seem to have ended up somewhere... cozy. Maybe you’d like to sit down on that reclining couch and take a break. It’s a little musty in here, almost like the smell of cigars has been marinating in these threadbare oriental rugs for generations. Those Greek, Roman, and Egyptian busts on that old wooden desk make for some interesting décor. Wait a second: this room looks familiar. Are we in Freud’s office?! Ah, we must have reached the Psychodynamic Diagnostic Model—the PDM, as it’s called.
Psychodynamic therapy may go way back, but the PDM is actually a modern creation. The first edition was put together by a small task force in 2006 comprising five major psychoanalytic organizations. The goal was to create a framework that wouldn’t just capture observable behavior and symptoms, but assess personality as well, allowing clinicians to gain a deeper sense of the individual and their biopsychosocial functioning. As the PDM states, it’s a “taxonomy of people,” not a “taxonomy of diseases,” and an effort to describe “what one is rather than what one has.” According to the task force, symptoms and problems can’t be fully understood without understanding the mental life of the person who has them. In other words, diagnosing needs context—and supposedly, the PDM provides it.
Here’s the thing, though: much of the PDM pulls from psychoanalytic tradition—and that perspective might not appeal to all therapists. It has chapters on concepts like reality testing, ego strength, affect tolerance, and self and object constancy. It conceptualizes anxiety disorders as resulting from Freud’s “four basic danger situations.” It considers mental health as it relates to various stages of development, reflected in its four major sections: Infant and Early Childhood Disorders, Child and Adolescent Mental Health Syndromes, Adult Mental Disorders, and Conceptual and Empirical Foundations for a Psychodynamically Based Classification System for Mental Health Disorders. That last one sure is a mouthful! Well, get this: it’s actually a compilation of 12 solicited essays, 456 pages long—half the book!
See that woman by the window flipping through Freud’s books? That’s Nancy McWilliams. She was on the PDM task force and recently retired after 40 years of teaching psychodynamic therapy and psychoanalytic approaches to psychopathology. After she got her license in 1978, she worked at a community mental health center where she was swept away by the power of psychodynamic therapy. “It was a much more dimensional process than what we see today,” she says. “The work was contextual. You didn’t diagnose somebody as paranoid if they were in a situation that would make anybody paranoid. But that’s essentially what the DSM does. Two people may meet the exact same criteria for depression but have very different subjective experiences for very different reasons.”
McWilliams may be a vocal advocate of the PDM, but what role does she see it playing in the future of diagnosis? “Just follow the money,” she says. “The DSM makes gazillions of dollars for the APA. I’m a temperamental optimist about the future of diagnosis, but an intellectual pessimist.” Plus, the PDM task force never intended for it to compete with the DSM or the ICD. Rather, it was designed to complement them by taking a “multidimensional approach” and focusing on “the full range of mental functioning.”
Well, fellow traveler, I’m glad we got to rest in this cozy spot for a bit, but we’ll need to move on if we want to find a viable alternative to the DSM and ICD. Tug on that copy of Civilization and Its Discontents and take a breath—a hidden door behind the bookshelf will swing open momentarily.
The Hierarchical Taxonomy of Psychopathology
Ah, finally! No menacing black fog, no harried researchers slinging paint, and no cigar smoke. Welcome to the Hierarchical Taxonomy of Psychopathology, or HiTOP. Is your head swimming in acronyms yet? Does it make you wish you could turn back? I understand, but we’ve come too far to abandon hope. Don’t worry, you’ll get used to the disappointments, false starts, and unexpected detours. After all, we have something rather stunning here. Look up, friend! There are dozens of colorful orbs circling overhead. See those six large spheres rotating above the others? Those are HiTOP’s six spectral dimensions, representing thought disorders, emotional detachments, antagonistic externalizing (which includes narcissistic and borderline personality disorders), disinhibited externalizing (which includes substance-related disorders), internalizing (which includes fear, distress, and mania), and physical symptoms. Those below them are their subfactors, and below those are their traits and symptoms.
HiTOP is a new kid on the block. It was developed in 2015 by a small consortium of mental health professionals from around the world, many of them university professors. Robert Krueger, a psychology professor at the University of Minnesota and one of its chief architects, says the model is a remedy to what he calls the “Byzantine” DSM, and unlike its conventional counterpart, doesn’t rely on decisions by committee. It pulls from contemporary science and takes into account genetic, environmental, and neurobiological factors when settling on a diagnosis.
Why are the orbs changing hues, you ask? Good eye! Remember how the DSM looked like a swirling black mass, making its morass of criteria and codes almost indistinguishable from one another? This is where HiTOP excels: it puts mental illness on a spectrum. Whereas the DSM has a single category for social anxiety disorder, for example, HiTOP gets specific. It claims that a client’s presenting problem exists on multiple continua, and within each, they might score low, high, or somewhere in between. Under HiTOP, a client’s social anxiety isn’t so black and white. It differentiates between, say, mild discomfort in a handful of social situations to being fearful any time the client is in public, and diagnoses accordingly. Proponents say it’s precise and doesn’t have strict boundaries like the DSM and ICD, which translates to personalized, specific interventions.
It sounds like maybe, just maybe, we’ve found a framework that’s easily understandable yet varied, one that takes a whole-person approach to diagnosing. Ah, but not so fast! Although HiTOP uses mutually exclusive diagnostic categories and views diagnosis as existing on a spectrum, it still defines pathology as residing within the individual. That’s not the only issue. In 2021, a cadre of psychology professors, led by Gerald Haeffel at the University of Notre Dame, called HiTOP overly simplistic, untested, and even potentially harmful. There’s “no substantive justification whatsoever” for it, they wrote, and it’s “not ready to use in real-world clinical settings.” Simply put, “the choice to use a simple structure approach is based on convenience and tradition.” It’s akin, they said, “to pouring water into an ice tray, freezing it, and then claiming the ice cubes are the empirical structure of ice.”
It’s a bit of a shame, really. Although this place is pleasant to look at, and seemed to hold great promise, our journey doesn’t end here.
The Research Domain Criteria Project
Well, whatever new arena we’ve stumbled into, it’s certainly quiet. Maybe a little too quiet, don’t you think? In fact, we should probably keep our voices down. If we are where I think we are, there’s someone here who’s hard at work and won’t want to be distracted. It’s almost sterile here, with these ivory walls and high ceilings, and chilly, too. Grab two of those lab coats on the rack over there, would you? And now, without further ado, welcome to the Research Domain Criteria project, or RDoC, for short.
See that half-finished marble statue? The one that looks like a brain, with all its wrinkles and grooves? That’s the
RDoC initiative. It’s a work in progress, and fairly new. It was released in 2010 by the National Institutes of Mental Health (NIMH) and seen by many as a direct challenge to the DSM after NIMH announced in 2013 it would no longer fund research proposals that used the DSM. Unlike the DSM, which critics say formulate diagnoses based only on symptoms, RDoC examines biology, particularly genetics and brain circuitry, and pulls heavily from molecular, cellular, and systems neuroscience. NIMH claims it’s a more integrative, scientific approach to diagnosing, and that, in conjunction with clinical studies, it can construct objective, measurable traits for understanding mental disorders.
Who’s that man on the ladder, meticulously chiseling? Ah, that’s neuroscientist and psychiatrist Thomas Insel. He was the director of NIMH from 2002 to 2015, quite outspoken in his critique of the DSM and highly influential in RDoC’s creation. Symptom-based diagnosis, he says, has been outdated for the last half-century and suffers from a “lack of validity.” That’s where he believes RDoC comes in, with its heavy research base, multidisciplinary approach, expert scientists, and objective laboratory measures.
I see someone else has caught your attention. That’s Stefan Hofmann. He’s a clinical psychology professor at the University of Boston and co-creator of Process-Based Therapy (PBT), which rethinks the disease model of diagnosis. Like Insel, he’s not a fan of the DSM, though he was an advisor on DSM-IV’s anxiety-disorder section. He likes to visit this place to check in.
“In PBT, we’re not treating a diagnosis: we’re treating an individual,” he says. “Process-based approaches are client focused, not symptom focused. We ask, ‘Where do you want to go in your life? What’s holding you back? What kind of relationships do you want?’ That’s not captured by the DSM. Eventually, I think, all therapy models will be based around what clients want. That’s not to say diagnostic labels don’t have a place: they give people a name for their suffering. The problem is they aren’t the right labels, and they’re overly reductionistic. The idea that a client comes into your office and you pull a book off your shelf and give a diagnosis and treat them based on a protocol is nonsense. We don’t need more books and manuals. We need to step back and rethink clinical science, to combine these strategies in a way that fits the individual.”
Hofmann speculates that diagnosing in the future will use individual data in a clinically useful way, including via smartphones or wearables that track sleep problems, or activity problems, or how often people text. Or perhaps it will utilize language-processing software, he says. “I think we’ll reuse certain classification terms we’re all familiar with,” he adds, “but in a more meaningful way that’s linked to clinical practice and much more tied to the individual.”
What does he think of RDoC?
“Insel was clearly not happy with the DSM,” Hofmann says. “He basically declared war against it. I was on phone calls with him where he said to DSM proponents, ‘Go to a drug company or another agency, I don’t want to validate your silly diagnostic categories anymore.’ It was a dark period, but he shook the field like nobody else did. Still, RDoC is biologically reductionistic. Insel thought there were particular genes and cells and circuitries related to these domains, but we now know there’s not a single gene that accounts for any diagnostic category.”
I’m sure many clinicians would still prefer using RDoC over the DSM, but as Insel will tell you, he never intended for it to replace the DSM. Instead, he wants it to inform future research. Plus, it doesn’t refocus our attention on social and environmental factors. As you can see from the chisels and rough marble slabs, it’s also still a work in progress.
I know, you’re tired of running into dead ends. But don’t despair, there’s one more place to visit. See that tiny purple thread on the ground? Pick it up. Let’s follow it and see where it leads.
The Power Threat Meaning Framework
Here we are at the Power Threat Meaning Framework, or PTMF. Hold on to that thread! You’re right, it stretches far ahead of us, and ultimately connects to that giant tapestry hanging from the trees in the distance. Beautiful, isn’t it? Notice the five circles stitched into the center. Those represent PTMF’s five messages: emotional distress and troubling behavior are understandable in context, there’s no separate group of people who are mentally ill, meaning-making is an empowering alternative to existing diagnostic models, different cultural experiences and expressions of distress should be respected, and all distress stems from social inequality and injustice.
The PTMF is unlike any other model we’ve seen so far. Interestingly, it doesn’t consider itself a diagnostic system. In fact, it flat-out rejects the notion of diagnoses altogether. When professor Mary Boyle and clinical psychologist Lucy Johnstone created it in 2018, as part of the United Kingdom’s Division of Clinical Psychology, they argued that the psychotherapy field improperly attributes mental illness to individuals, not to oppressive power structures in our society like poverty, inequality, abuse, discrimination, and violence. They say our reflexive symptoms and behaviors—like anxiety, depression, and trauma—are natural, protective responses to problems created by these existing power structures.
Johnstone said it well: “One of the ways in which less powerful people are badly treated is they aren’t given sound, alternative ways of thinking about their experience. They’re told, ‘You have bipolar disorder’ or ‘You have a personality disorder.’ And if they try to object, they quickly find where the power lies.”
Here’s where the PTMF really gets radical: even though it’s not a diagnostic system in the traditional sense, Boyle and Johnstone admit that it’s an unapologetic attempt to overhaul the medical model. In other words, it’s not just an adjunct, like so many of the other approaches we’ve seen.
Here’s how it works: as part of understanding an individual’s suffering, it poses five questions: what happened to you (essentially, how is power operating in your life), how did it affect you, how did you make sense of what happened, what did you do to survive, and what strengths and access to power do you have? Let’s say your boss was verbally abusive; the boss represents the power structure. Say the verbal abuse affected your sense of emotional safety; that’s what happened to you. Maybe it made you feel worthless; that’s how you were affected. Let’s say you believed the abuse was your fault; that’s how you made sense of what happened. And let’s say you developed a coping mechanism, like binge drinking; that’s what you did to survive. An investigation of your strengths might uncover hidden skills or social supports.
The PTMF framework offers another aspect to the work: helping the client craft a new, healing self-narrative. Essentially, it asks, “What’s your story?” It’s a profound shift from a diagnostic approach to a narrative-based one. And although, unsurprisingly, it’s stirred up some controversy, it appears to be especially popular among social workers, who generally take a holistic, systems approach to diagnosis and treatment.
How nice! It seems we’re not alone. Looks like some students are here for a field trip. Budding therapists, no doubt! And look who’s leading them—it’s therapist and Antioch University psychology professor Martha Straus. It looks like a big, passionate group. I don’t think they’ll mind if we sidle up and try to hear some of what she’s saying.
“A lot of people in private practice are ducking, bobbing, and weaving around diagnosing. We’re saying for many different reasons, social and political, that we don’t want to diagnose. It’s not just the hassle of filling out insurance forms. It’s that we’re being asked to participate in a white, male power system that’s becoming increasingly hard to stomach.
“Moving away from the DSM would mean a paradigm shift. How does that happen? The old paradigm has to be chewed up. Is that going to happen? I like to think so. The trend is toward more relational therapy, power-sharing, collaborating with our clients, and thinking about things like empowerment, privilege, and identity. When an adolescent or young adult comes into therapy having self-diagnosed, I meet them where they are. I might have different ideas and ask questions, but they’re challenging me, in a positive way, to think outside the boxes in which I was taught to operate.”
That’s good news, but it seems it’s up to therapists like you—brave dreamers of a different diagnostic future—to push forward with a new paradigm. Which one will you choose? Personally, it feels like we’ve got a bit of a Goldilocks problem on our hands. Where one framework is lacking, another excels—but then seems to be lacking in another department.
Maybe our mistake is thinking there’s a single best framework at all. Perhaps each of these frameworks needs the other, and an approach that meets the needs of the future—one that’s easy to understand, data-driven, client-centered, and relational—borrows elements from many frameworks. We might not have found that integrated, magical model quite yet, but I’m not giving up hope.
Therapists may disagree on things, but something they often have in common is the reason they do this work: to hold the light for their clients, to act as wise guides on the path toward healing. I believe that eventually, all of us, no matter what we’re seeking, will get to where we need to be. To quote Rumi: “If light is in your heart, you will find your way home.”
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