The Dangers of Pledging Blind Allegiance

Examining Our Faith in the DSM

Gary Greenberg

Greenberg_spot-smA client comes to see you. Let‘s call him Fred. He tells you he has a dream job, one in which he’s mostly left alone to do what he loves. But there’s a hitch: in order to get paid (which he does, and well), he has to stand in front of a video camera once every hour, raise his left hand, stand on his right foot, and say, “I declare obeisance to the Great Gazoo.” He tells you that he knows the Great Gazoo doesn’t exist. He tells you that he, and all his coworkers, think the ritual is stupid and undignified, and he worries that some day the digital video archive of his hypocrisy will come back to haunt him. He also tells you that he’s appalled at himself, at the ease with which he engages in a pointless exercise purely for the sake of money but then drives awareness of his bad faith out of his mind. "Isn’t this how the worst acts are committed—when people still their consciences to get on with the business of daily living?" he asks himself (and you).

At first, the complaint seems rich, intriguing, even piquant. All the tortured ambivalences of a postmodern life seem captured in his hourly degradation at work. It provides fodder for conversation about his expectation that the world will conform to his needs, his disappointment at finding out that it won’t, the difficulties imposed by his quest for integrity. It gives rise to meaningful talk about the fear of poverty, the cruelties of capitalism, the needless difficulty of our economic lives. You discuss alternatives with him: finding a different job, refusing to participate in the ritual, organizing a protest with his coworkers. Sometimes he leaves your office determined never again to declare allegiance to the Great Gazoo, only to come back a week later, sheepish and forlorn, with a story about how he just couldn’t follow through. You and Fred agree on a new goal: to stop worrying and learn to love the Great Gazoo.

You’re feeling pretty good about this outcome as he leaves your office and you sit down to make your session notes. To sign the note, however, you have to provide a diagnosis. You’ll probably use the same one you entered when you first saw Fred: 309.28 (adjustment disorder with mixed emotional features), or perhaps 300.02 (generalized anxiety disorder), or any of the other of the handful of diagnoses whose codes you’ve memorized. You probably think this is an innocuous enough diagnosis, not likely to impede his access to health or life insurance or to become an issue should he decide to run for elected office or seek a security clearance.

And it is, except for one thing, or more accurately, three things. First, you know that the only reason you’re entering that diagnosis is that Fred’s insurer isn’t going to pay you to sit around with Fred and figure out the meaning of his life, at least not if that’s what you say you’re doing. It’ll pay for therapy only if he has a medical disorder, which is why you shelled out a hundred bucks for your copy of the Diagnostic and Statistical Manual (DSM) in the first place.

Second, you know that there’s no such thing as adjustment disorder or generalized anxiety disorder or any of the other 200 or so diagnoses in the DSM—at least not in the same way that there’s such a thing as strep throat or diabetes. Although it’s debatable whether the DSM provides an accurate anthropology of suffering, a working catalog of our common miseries, its status as scientific medicine isn’t in doubt.

Third, you know that your diagnosis isn’t helping you figure out how to treat Fred. It’s not really for his benefit (other than that it helps him pay for it), and ultimately, it’s not even for your benefit, but for the benefit of a mental healthcare delivery system that increasingly demands a kind of accountability that has little to do with mental health.

If you’ve ever felt guilty about this, you might take comfort in the fact that after a couple of years spent talking to virtually every prominent psychiatric nosologist in the country about this question, I can report that finding someone who will say that the DSM is of clinical value, let alone that it’s an accurate compendium of mental disorders, is like walking around Athens with a lamp lit in the daylight looking for an honest man. I once asked a former president of the American Psychiatric Association how he used the DSM in his practice. “I recently had a patient I had to diagnose in order to bill,” he told me, “so I turned to the DSM and came up with obsessive compulsive disorder,” he said.

“Did this change the way you treated her?” I asked.

“No,” he replied.

“So what was its value, would you say?”

“I got paid.”

For everyone, from lunchbucket therapists like me to the nation’s psychiatrist-in-chief, making a DSM diagnosis is the ritual you have to perform to get the system to work. It may not be quite as silly as Fred’s ritual at work, at least not on the surface, but we therapists have responded to it just as Fred did. Like Fred, we’ve engaged in all sorts of evasions and subterfuges to avoid the glaring and simple truth: the DSM is our Great Gazoo. Invoke it, and the cash rolls in.

Read Gary's full article, "The Cult of DSM: Pledging Allegiance to the Great Gazoo," in the March/April issue of Psychotherapy Networker magazine.

Topic: Business of Therapy

Tags: Diagnostic and Statistical Manual | DSM | dsm-5 | Gary Greenberg | mental disorders

Comments - (existing users please login first)
Your email address will not be published. Required fields are marked *


Tuesday, May 27, 2014 3:16:49 PM | posted by mrsportpsych
Biofeedback Federation of Europe to Host Webinar for Health Professionals on Neurotherapy by Canadian Psychologist Dr. Paul G. Swingle
Dr. Paul G. Swingle will kick off his 2014 webinar series with a free webinar on "Adding Neurotherapy to Your Practice". In the first of a series of four webinars, he will discuss the basics of neurofeedback and the benefits of using this method with clients.

Tuesday, May 27, 2014 9:00:31 AM | posted by Psychotherapy Networker » Challenging the Cult of DSM
[...] hypocrisy, and lack of scientific validity at the heart of the diagnostic system, what his recent article in the Networker described as “The Cult of DSM.” As he put it, “Finding someone who thinks the DSM is of [...]

Wednesday, March 12, 2014 1:43:28 PM | posted by Virginia Anderson
I quit my private practice for these very reasons. My mental health was not worth the insurance battle. It seems bizarre to think of charging folks for spiritual wellness but the church doesn't have a clue how to help people deal with grief and loss and I'm not talking about death. Half of physicians income is from preventative medicine yet therapists have to swear someone is some degree of crazy in order to get help they need to live a much more productive and peaceful life!

Tuesday, March 11, 2014 9:48:33 PM | posted by Linda Bilunka
The new thing on the block for me was an insurance company demanding copies if session notes that verified that I was treating " their" client for 309.28. They said it was not serious enough of course I complied after several efforts to resist them and upped the ante; 300.00.
If I were a Catholic, I would go to confession. L.

Tuesday, March 11, 2014 4:49:54 PM | posted by nasimm2
what an interesting way to look at the most painful and disturbing part of our work as psycho- therapists. I found it most refreshing, thanks for sharing this honest thought. regards

Tuesday, March 11, 2014 3:26:46 PM | posted by judith gibson
How refreshing. Someone tells the truth about the DSM in public. It's been many years since I've heard anybody say such things openly. I usually believe my colleagues believe what they're saying when they talk about the diagnostic flim-flam (my word) being useful for planning and executing treatment. If only.....Maybe when I can be OK without the income I'll be able to forget the DSM. Thanks to Gary Greenberg and PN.

Tuesday, March 11, 2014 3:26:05 PM | posted by Jeanne Merkel
Thank you! Finally someone tells the truth - with an outrageous sense of humor. I never became a psychotherapist because I didn't believe in pathologizing our essential humanity - and here is a well-respected therapist taking on the Diagnostic and Statistical Manual of the establishment. Maybe it's time for me to enter the playing field - outside the box!