For your Final Project, you will write a 8- to 10-page theory paper that articulates your theoretical orientation toward working with couples and families.Your paper must include the following elements that evolve from your personal theoretical orientation:The basic view of human nature as seen through your theoretical lensKey factors that account for changes in behaviorAn explanation of how intervention strategies are designed within this theoretical orientationAn explanation of how your theory conceptualizes mental healthKey factors that contribute to healthy family/couple relationshipsA description of the skills necessary within this theoretical orientation to meet the agreed upon goals and outcomes for couples and familiesThe nature of the practitioner-client relationship and its relative importanceAn explanation of the evidence to support your theoretical orientation as an appropriate intervention for couples and families in need.Information on scholarly writing may be found in the Publication Manual of the American Psychological Association(7th ed.), and at the Walden Writing Center website.VOLUME 52 NUMBER 2
JUNE 2013
Editorial: DSM-V and Family Therapy
JAY L. LEBOW*
Fam Proc 52:155–160, 2013
T
he media has been replete recently with reactions to the release of DSM-V, the diagnostic guide to mental disorders of the American Psychiatric Association (American
Psychiatric Association, 2013). Reaction has been intense as advocates claim advances in
the scientific basis of classification, while critics castigate the extension of what they
regard as an artifice that has little to do with the realities of experiencing and coping with
human problems.
Those of us committed to a family and systemic perspective are placed in an exquisitely
difficult position in relation to this document. On one hand, it carries forward the troubling trend to extend the medical model to virtually all human behaviors, so much so that
no less than Alan Frances (2013), the eminent psychiatrist principally responsible for
DSM-IV (not a document steeped in systemic or psychological theory), has written:
Diagnosis and the use of psychotropic drugs have both gotten out of hand; 20% of the adult population qualifies for a mental disorder, and 20% take medicine. The boundary of psychiatry keeps
expanding; the realm of normal is shrinking… People who don’t need diagnosis and treatment
will get it, while people in desperate need will be frozen out; and drug companies will laugh all
the way to the bank.
This is quite a comment from a proponent of psychiatric diagnosis. Those of us of a certain age can remember a time when the family system perspective represented a radical
alternative to the application of the metaphor of brain disorders in the DSM. Prescient in
their wisdom, founders of the field of family therapy and Family Process, such as Jay
Haley, Salvatore Minuchin, and Gregory Bateson, were adamant critics of the medical
model of mental health (Beels, 2011; Imber-Black, 2011a,b). Their treatises about these
matters were not of the both and/or discourse that has become so common in our field;
instead emphasizing the dangers of where this line of reasoning might lead.
Fifty years of Family Process finds a much more ambivalent attitude about psychiatric
diagnosis among family therapists and family scholars. Evidence has accrued that some
*
Editor, Family Process.
Correspondence concerning this article should be addressed to Jay Lebow, Ph.D., Family Institute at
Northwestern, 618 Library Place, Evanston, IL 60201. E-mail: j-lebow@northwestern.edu.
155
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doi: 10.1111/famp.12035
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FAMILY PROCESS
disorders, such as schizophrenia and bipolar disorder, truly represent diseases of the
brain. Although these syndromes are affected by life experience and family context, these
disorders clearly are primarily diseases of brain that have devastating effects on mental
functioning (Hooley, 2007; Miklowitz & Cichetti, 2010). Technological developments, such
as fMRIs and ways of assessing genetic markers and neurotransmitters, leave no doubt
about the importance of brain function and appropriate diagnosis in these difficulties.
These developments have led to the emergence of powerful combinations of medications
and individual and family intervention for these disorders that now number among the
most effective evidence-based treatments (Lucksted, McFarlane, Downing, & Dixon, 2012;
Suro & Weisman de Mamani, 2012). These advances certainly obviate the pronouncements in these pages 50 years ago that schizophrenia was simply the product of a problem
of communication or double bind that could be fully resolved by presenting the correct
family prescription.
However, such syndromes with a clear primary basis in brain function firmly anchored
in evidence have been augmented over the 50 years of Family Process to produce the present DSM-V, a volume of hundreds of pages with hundreds of diagnoses combining multiple
behaviors into syndromes with a subtext that these difficulties have a primary basis in the
individual (and often in the individual brain despite minimal evidence). In conjunction
with this ever expanding world of individual diagnosis, proponents of medications have
come to make claims for their effects across a very broad range of human difficulties and
processes. This applies both to usage directly in relation to the syndromes labeled by the
DSM and to off-label uses that consumers actively seek out such as Cialis and Viagra for
better sex, Concerta for better concentration, and SSRIs for coping with overly stressful
jobs and family lives.
In addition, those committed to a belief in the notion that human problems are primarily brain disorders are more in charge of the control of the flow of monies in mental health
than at that time 50 years ago. As Hoyt and Gurman recently highlighted (Hoyt & Gurman, 2012), therapists and clients are put in a moral dilemma by a reimbursement system
that more readily approves claims for individual diagnoses than relational difficulties.
The incentives for an individual medical model view of human functioning have increased
dramatically; to say a problem is a family problem is often to say the clients will pay for
their own care. Trends in research parallel those in clinical practice; it has become virtually impossible to receive funding from many government agencies in the United States
and elsewhere without reference to an individual diagnosis in one person as the core focus
of the research. Researchers today are often more successful in obtaining funding for studies that examine brain functioning during psychotherapy than for developing and studying more effective therapies.
In this environment, there have been some advances. A considerable literature has
accumulated about evidence-based methods for helping those with individual psychiatric
diagnoses (Nathan & Gorman, 2007). In this context, family therapists have developed
very effective methods for combining psychopharmacology, individual therapy, and family
therapy in systemic approaches to treat such disorders as schizophrenia and bipolar
disorder. Useful disorder-specific and family-assisted treatments have emerged for a wide
range of problems (Baucom, Whisman, & Paprocki, 2012).
Although never a priority of federal funding, very valuable work has also been done to
establish a coherent and useful categorization of relational difficulties and their impact
(Miklowitz et al., 2006; Wamboldt et al., 2010). Such relational problems as couple distress, child abuse, or couple violence number among the most distressing and salient of
difficulties producing many negative effects including missed work, lowered school performance, and individual difficulties (Heyman et al., 2006). The creation of reliable and valid
categories for relational problems has many benefits in advancing our understanding of
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these difficulties and developing algorithms for treatment decision making. For example,
the evidence indicates that individual depression in the context of couple distress is best
addressed through couple therapy (Beach & Whisman, 2012). However, the dilemma the
proponents of relational diagnosis are faced with is that the best opportunity for dissemination for relational diagnosis arises in its being incorporated into the individually and
biologically centered DSM; thereby adding to one of the worst of problems in the DSM-V:
its tendency to expand the medical model to all human problems.
Today, we must ask, as Haley did, whether the costs of such incorporation outweigh
the benefits. Alternative ways of organizing the world look to be potentially more useful.
For example, research and clinical articles that have recently appeared in Family Process
point to the value of considering problems in the context of culture (Baumann, Domenech
Rodrı́guez, & Parra-Cardona, 2011; Parra Cardona et al., 2012; Santisteban, Coatsworth,
Briones, Kurtines, & Szapocznik, 2012), stressors (Baumann et al., 2011; Marchetti-Mercer,
2012; Weine, 2011), family structure (Favez et al., 2012; Zeiders, Roosa, & Tein, 2011),
family environment (Santos, Crespo, Silva, & Canavarro, 2012), family strengths (Valdez,
Abegglen, & Hauser, 2012), emotional experiencing (Boss & Carnes, 2012; Weingarten,
2012, 2013), families’ needs for information (Solomon & Chung, 2012), larger systems
(Cruz-Santiago & Ramı́rez Garcı́a, 2011), the treatment system (Ungar, Liebenberg,
Landry, & Ikeda, 2012), and case-specific formulations as to what is occurring (Breunlin,
Pinsof, & Russell, 2011; Pinsof, Breunlin, Russell, & Lebow, 2011). Organizing the world
around individual symptoms represents at best a nonsystemic view of the world which is only
one of many ways of possible nosology (Sexton et al., 2011) and of organizing intervention.
Big pharmacology and biological psychiatry announce with the DSM-V that we are
entering an era in which the dominant view of human problems is that they are syndromes that indicate underlying brain disorders. For the community of family therapists
and family researchers, the costs of joining with such a system outweigh the potential for
gains. Family therapy should never be thought of an “adjunctive” treatment to medication
unless the medication can also be thought of as “adjunctive” to the family therapy. However, such language in which family intervention is seen as “adjunctive” is becoming typical in many practice settings. Medication clearly is valuable in schizophrenia, bipolar
disorder, and other syndromes, but what is the treatment and what is adjunctive is in the
eye of the observer (and I might add often the product of marketing). In those disorders
with a clear underlying biological basis, family therapy cannot do much without medication to influence the functioning of the clients, but nor can the medication do much if the
family does not work to make the environment conducive to recovery and in assuring the
adherence to the medication regimen (Hooley, 2007).
Biological viewpoints are very useful in certain difficulties, leading to helpful pharmacological treatments, and can be interesting and informative in others, pointing to brain
activity that is nice to know about, but which is only minimally relevant to treatment
(such as when the therapist can point to research that demonstrates that the amygdala
becomes overly active under certain circumstances, and thus the information is used in
promoting understanding (Fishbane, 2007). However, such biological views should be
accompanied by the following warning label:
There is no evidence that most human behaviors are the product of errant biology. That this medication may under some conditions lessen the effects of problematic states of being does not mean
that it should be taken as a substitute for dealing with systemic and individual processes that
underlie the physical symptoms. Treating a problem that requires change on some other level by
merely changing your physical being may lead to what ultimately are undesirable effects.
One alternative is to return to the roots of family therapy and explore the systemic
properties of different client life situations. Another is to focus on problems rather than
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FAMILY PROCESS
disorders unless there is convincing evidence that a “disorder” is truly a disorder. Coalitions of family-oriented psychiatrists and psychologists have made considerable efforts to
bring family systems views to classification and the DSM committees. Lyman Wynne and
colleagues made a substantial effort to incorporate relational diagnosis into DSM-IV that
led to an axis that assessed relational functioning (Wynne, 1987). However, this accomplishment ultimately was a pyrrhic victory as relational assessment became marginalized
compared with the omnipresent axes 1 and 2 of DSM-IV. Over the last decade, a group
that included Marianne Wamboldt, Steven Beach, Nadine Kaslow, Richard Heyman,
David Reiss, and several other prominent family therapists and researchers have worked
to strengthen the evidence base for relational diagnosis and influence the DSM process
(Beach, Wamboldt, Kaslow, Heyman, & Reiss, 2006b; Beach et al., 2006a; Miklowitz &
Clarkin, 2003). They have produced admirable documents, but again had little impact on
DSM-V.
Ironically, over this period, many very useful treatments for specific problems have
been created. These therapies have no need for the medical model as part of their substructure even though typically these treatments have been formulated in relation to
DSM syndromes (Baucom et al., 2012) because funding for treatment development and
research demanded that framework. In most cases, it would be just as easy and more useful to target such treatments to specific problem areas or to combinations of family
dynamics, cultural context, individual personality, and particular difficulties, rather than
to disorders.
Classification systems aren’t useless; they can have considerable value in helping
enable understanding and shape treatment. A classification system that actually paid
attention to what mattered rather than endlessly comorbid disorders would potentially be
much more helpful. Wouldn’t it be better if there were a list of problems designated as suggesting the need for mental health resources and that problem list didn’t need to be yoked
to the DSM-V? Relational diagnosis, freed of the medical model of classification, would be
very helpful in orienting therapists to bodies of work about specific problems and evidence-based methods for their treatment. For example, criteria for assessing intimate
partner violence, distressed relationships, and parent child violence have already been
created (Heyman & Slep, 2006) and could help provide useful guideposts for practice that
incorporates family, couple, individual, and larger system factors. The important question
is ultimately pragmatic: What will it take to affect the world we live in, in which pharmacological companies influence all human problems to be seen as primarily biological and
individual disorders. Relational diagnosis is today marginalized and often consigned to
peripheral sections of the DSM that do not trigger reimbursement for services for these
problems. The paradox is that problems either need to be seen within this arcane flawed
system or therapy typically occurs without reimbursement. Furthermore, when therapies
do not focus on the “right” problems, treatments such as systemic therapies may not qualify for approved lists of treatments and, thereby, come to be excluded from care delivery
systems (Von Sydow, Beher, Schweitzer, & Retzlaff, 2010).
Perhaps with the strong negative response to the DSM-V and its willingness to
eschew evidence and pathologize normal behaviors such as grief, the tide may be
beginning to turn. Those of us in family therapy and family science need to reread Haley and colleagues, not so much for the technical correctness of their positions, but for
clues about how to meaningfully challenge its pernicious subtext about the nature of
problems and appropriate treatment, and more generally about people and social systems.
Complementing this editorial is another viewpoint on the same subject which follows by
Marianne Wamboldt, President of the Family Process Institute and one of the prime
movers of efforts to influence DSM-V toward greater inclusion of relational diagnosis.
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LEBOW
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Australian and New Zealand Journal of Family Therapy 2013, 34, 90–103
doi: 10.1002/anzf.1009
DSM-5 and Evidence-Based Family
Therapy?
Tom Strong1 and Robbie Busch2
1 University of Calgary, Calgary
2 University of Notre Dame Australia, Perth
The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) extends a profession and practice-defining direction for family therapy. Warranting and expediting this medicalised direction has
been a scientific and administrative coupling of diagnosed symptomatic conditions with evidence-based treatments
for addressing those conditions. For systemically or poststructurally oriented family therapists tensions can follow
from this direction which we elaborate upon in this article. Specifically, we examine the premises behind this
medicalised direction for family therapy, juxtaposing these premises with systemic and post-structural premises of
practice. We relate these juxtapositions to tensions family therapists may need to reconcile in their work with
families. We close with an overview of this special issue’s contributions that pertain to the DSM-5 and family
therapy.
Keywords: diagnosis, evidence-based practice, family therapy, post-structural therapy
Key Points
1 The continuing symptomological and individualistic focus of DSM-5 creates tensions for family therapists
who practice from systemic and post-structuralist orientations.
2 A discursive approach enables us to understand how DSM-5 discourse both enables and constrains our
understanding of human concerns.
3 DSM-5 does not address relational aspects of practice and creates “linguistic poverty” in limiting understandings of family concerns.
4 Evidence-based practice tied to a medicalised diagnostic classification framework is a seductively algorithmic
practice, which reproduces normative, standardised conversations in mapping client concerns to DSM-5based diagnoses.
5 DSM-5-based algorithms of evidence-based practice ignore the importance of context and the ever-changing conversations of human concerns and multiple practices are required to reflect, articulate and work with
family concerns effectively.
So what is it about the biopolitics of life itself…that provides the spaces within which
bioethical authority seems to be required and simultaneously circumscribes the issues to
which such ethical concerns appear relevant? (Rose, 2007, p. 31)
Welcomed or not, the American Psychiatric Association’s (2013) Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will influence the conversations therapists have with families. In writing about diagnostic language as it
relates to relationships, Tom Andersen (1996) long ago wrote that “language is not
innocent”. The diagnoses of DSM-5 cannot be regarded as neutral scientific discoveries, nor can the expected diagnostic practices accompanying the DSM-5’s use be
Address for correspondence: Tom Strong, Faculty of Education, University of Calgary, 2500 University
Way, Calgary, Alberta, Canada, T2N 1N4. strongt@ucalgary.ca
90
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DSM-5 and Evidence-Based Family Therapy?
considered benign. Considerable rancor preceded the December 2012 vote by American Psychiatric Association members to accept the contents of the DSM-5, which
now details the new lingua franca of mental health practice. Family therapists uneasy
about the DSM-5 might take solace in knowing that the Chairs of DSM-IV and
DSM-III aligned themselves against what they saw as an excessive medicalising direction in DSM-5. Regardless, the DSM-5 is upon us and in this special issue we and
our contributors consider its influence on family therapy.
In this issue’s introductory article, we will consider DSM-5 and family therapy
under the umbrella term “evidence-based” practice. The diagnostic categories furnished by the DSM-5 acquire added medicalised (i.e., diagnose and treat) logic when
conjoined with evidence-based interventions (Conrad, 2007). Normally focused on
contextualised family members’ understandings and interactions, such a decontextualised orientation to practice can seem incongruous to family therapists. So, we will
consider DSM-5 in this light, highlighting tensions therapists may have to reconcile
in their work with families because of what we anticipate will follow from publication
of the DSM-5. As post-structuralist practitioners, we question the notion that there
are neatly predetermined, underlying, singular and fixed structures of meaning that
we can use to build universal, conventional and normative systems of practice (e.g.,
the DSM) without regard to reflexivity or context (Young, 1981). We instead regard
meanings for experience as arising in and from how people use language to articulate
and communicate experience in acceptably familiar ways (Lock & Strong, 2010).
A post-structuralist stance thus enables critical reflection on “acceptable meaning”,
a reflection that we and other contributors to this special issue are inviting about the
DSM-5 and family therapy. We also bring a systemic practice view regarding the
importance of patterned language use for how it contextualises and regulates understandings and social interactions. It is in this sense that families can be seen to construct realities particular to them (Reiss, 1981), while professions and institutions can
be seen to construct and maintain realities particular to their uses of language (e.g.,
Danziger, 1997). In this article, we raise questions about DSM’s science and the clinical applications that follow from its use. We will also close with an overview of our
contributors and their contributions to this special issue.
When I (Tom) first proposed a special issue of the Australian and New Zealand
Journal of Family Therapy to its editor, Glenn Larner, over dinner at a conference we
were attending, I still felt some of the fire that had prompted me to rant about the
American Psychiatric Association’s (1994) DSM-IV in Family Process 20 years earlier
(Strong, 1993). As a psychologist trained in systemic approaches to therapy, who had
taken up narrative therapy’s linguistic and post-structuralist turn, I was working in
the public mental health system in British Columbia. Increasingly at that time, the
scope of conversations I was to have with clients was expected to narrow to a focus
on symptoms. The problem-solving and contextual/systemic aspects of how client concerns could be discussed seemed subordinated to irrelevant Axis 5 details for any, then
impending, DSM-IV disorder I could diagnose and treat. With the subsequent professional uptake of the DSM-IV came a ratio-technical view that algorithms of practice
could come from melding DSM diagnoses to evidence-based treatment, which
enabled an audit culture mentality to develop within mental health administration
and govern conversations therapists have with clients (House, 2005). DSM diagnoses
offer more than a professional or administrative language, however; for Lionel Trilling
they have become part of the “slang” of popular culture (cited in Illouz, 2008, p. 10).
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If we don’t diagnose clients, they will do it for themselves, or each other, it increasingly seems. DSM-5 promises to extend such professional, administrative and cultural
developments.
Family therapists tend to have conversations that do not narrow on the symptoms
of individual members alone. Family therapy began, in part, out of a recognition that
the symptom-bearing patient might be caught up in unrecognised and problematic
family members’ patterns of thought, emotion, and interaction. On DSM-5 terms, an
angry child might merit a diagnosis of the new “temper dysregulation disorder”
whereas a systemically oriented therapist might identify a problematic pattern that
engages child and parent in particular ways. The therapeutic direction typically
following either way of articulating the concern can be quite different, particularly if
one subscribes to the view that diagnosis prescribes only certain forms of treatment.
Such ways of coupling assessment and intervention are foundational to not only
evidence-based practice but to growing expectations for “treatment fidelity” (Drake,
Goldman, Leff, Lehman, Dixon, Meuser & Torrey, 2001; Tucker & Blythe, 2008).
That clients’ therapeutic concerns might be articulated and addressed in more than
one discourse of practice can seem challenging, if not sloppily unprofessional. Being
informed or influenced by the DSM-5 is not the same as having one’s practice
determined by the DSM-5, however.
Our Discursive Reflections on the DSM-5
We approach the DSM-5 and family therapy in a discursive way (e.g., Busch, 2012;
Lock & Strong, 2012), with an eye to what is potentially constrained or enabled by any
discourse. By discursive, we relate our early mentioned post-structuralist views to how
language is used in micro-dynamic (i.e., face-to-face dialogue) and macro-dynamic
(institutional, professional, cultural) communications. Wary of dominant discourses or
those that claim exclusory truth status, we see discursively minded practitioners facing
inescapable tensions in their conversational work with families and family members.
Most importantly, however, we see an important ethic of practice in the notion
that therapists address “linguistic poverty” (Vico, 2001) wherever it arises, helping
clients to stay discursively resourceful so as to elude discursive capture (Massumi, 2011).
Discursive capture, in our sense, refers to getting stuck in particular ways of thinking,
acting, or communicating within the constraints of any discourse, such as the DSM-5 or
family therapy’s models.
Our discursive approach contrasts with the notion sometimes ascribed to DSM
thinking, that there is a single correct way to name experience. Discursive therapists
(e.g., narrative, solution-focused, collaborative) often invite clients to reflect upon and
converse beyond the linguistic poverty of any singular discourse. Representing a
person’s experience of bereavement in psychiatric discourse alone can foreclose on
other ways of making sense of profound loss, for example. The human concerns that
one finds articulated in the DSM-5 represent a particular kind of history-making
for mental health professionals, with new understandings for old concerns, and
newly identified concerns. Reflecting upon past representations of such concerns
(e.g., Foucault, 2006; Grob, 1991), developments leading to the DSM-5 appear to
show a triumphant march of psychiatric science. A symptom-based discourse emerged
enabling practitioners to move beyond imprecise and disrespectful terms like moron
or neurotic. Concurrent with these developments, and perhaps because of the empha-
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sis on symptoms in patients, the diagnostic focus became increasingly biological, to
the point where normal but unwanted or unpleasant aspects of being human were
medicalised (e.g., Furedi, 2004; Rapley, Moncrieff & Dillon, 2011). Correspondingly,
intervention shifted in this biological (read: pharmaceutical) direction, and not without considerable controversy (Angell, 2011; Whittaker, 2010). For family therapists,
questions can arise about our relevance in this new therapeutic landscape.
However, psychotherapy has been the site of some nasty professional turf wars
between psychiatric and other professionals, with the heart of the controversies being
over whether the concerns clients present should be treated as medical in nature
(Grob, 1991). Psychologists felt they had much to lose if they failed to demonstrate
that their ways of practice could make beneficial differences in clients’ lives (Beutler,
1998; Galvin & Fernando, 2008; Task Force on Promotion & Dissemination of
Psychological Procedures, 1995). The sudden introduction of managed care in the
1990s in the United States produced an impetus for psychologists to market themselves through evidence-based interventions (Beutler, 1998). Both Australia and New
Zealand seem to be following this direction, although perhaps slightly less fervently
(e.g., Galvin & Fernando, 2008; Montgomery, 2003). However, the Australian
Psychological Society (Australian Psychological Society, 2010) produced a literature
review of evidence-based therapies, matching them to ICD-10 mental disorders,
using evidence criteria from the National Health and Medical Research Council and
the evidence-based practice in psychology policy from the American Psychological
Association. The aim of the review (in its third edition) is for the APS to assess the
evidence base for therapy, as it argues, “Government sponsored health programs
quite reasonably require the use of treatment interventions that are considered to
be evidence-based as a means of discerning the allocation of funding” (Australian
Psychological Society, 2010). So, borrowing from medicine’s initiatives to establish
an evidence base of effective treatments, psychologists eventually imported the science
used by medical researchers (e.g., randomised clinical trials in laboratory circumstances; manualised interventions) to prove the effectiveness of their clinical efforts
(Busch, 2012; Levant, 2005).
Family therapists, in claiming their relevance as mental health practitioners, faced
what Nichols and Schwartz (2008) have referred to as an “undeclared war” over their
assertions that many family members might be best (or also) treated within the context of the family. They, too, eventually took up the evidence-based direction (e.g.,
Crane & Hafen, 2002; Pinsof & Wynne, 1995; Stratton, 2005), though not without
concerns expressed about what constituted evidence, or how the effectiveness of their
work should be best evaluated (e.g., Larner, 2004).
Evidence-based Directions in Family Therapy
For post-structuralist therapists, this evidence-based direction, tethered to a medicalised diagnostic classification system, epitomises Foucauldian concerns about “governmentality” (Rose, 1990). One modern scientific ideal is that the phenomena in any
sphere of concern are correctly nameable, explainable, and made responsive to
humans to control them. To those sharing this ratio-technical view, therapy’s landscape can seem like an untamed frontier urgently requiring scientific management. It
is this kind of scientific management (or “governing”) that requires diagnoses for a
grid of intelligibility useful in identifying and micro-managing concerns, by practitioª 2013 Australian Association of Family Therapy
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ners as well as the lay public (Hook, 2007; Illouz, 2008). To post-structuralists, the
DSM-5 and its administrative coupling to evidence-based practice presents an idealised form of discursive capture (Massumi, 2011; Walsh & Gillett, 2011).
An extreme version of such capture can arise when diagnostic and treatment
protocols or manuals algorithmically prescribe or delineate each conversational move
or judgment in therapy. The upshot is a particular science to legitimise particular
(and curtail perceived unnecessary) articulations of concerns presented to family
therapists. For therapists informed by Deleuzian (e.g., Skott-Myhre, 2008; Winslade,
2009) and hermeneutic (Cushman, 1995; Hacking, 1998) notions of practice, clients’
concerns are best addressed with evolving, multiple understandings and forms
of intervention which fit clients’ circumstances and preferences. Thus, one tension
accompanying the DSM-5’s publication, for systemic or post-structural family
therapists, is how to reconcile their ways of naming and responding to client concerns
with the governmentality of the DSM-5 and evidence-based practice (EBP).
An Evidence-based Revolution; But What Kind?
…we can define a scientific fact as a thought-stylized conceptual relation which can be
investigated from the point of view of history and from that of psychology, both individual and collective, but which cannot be substantively reconstructed in toto simply
from these points of view. (Fleck, 1979, p. 83)
In a recent editorial podcast for the Journal of Family Therapy, Mark Rivett
(2013) spoke of a revolution for family therapy that he associated with evidence-based
practice. Evidence-based practice has come to mean many things but we agree with
its general premises: practitioners should be able to justify what they do according to
evidence informing their actions and they should also heed what clients have to say
about the helpfulness of their work together. So, for example, Rivett cites the important research of Crane and colleagues that convincingly makes the case for family
therapy as an economically efficacious way of responding to client concerns (e.g.,
Crane, 2008; Morgan, Crane, Moore & Eggett, 2013).
Our concerns are instead focused on a view described in the evidence-based literature
of medicine and therapy that speaks of “algorithms” (e.g., Rush, 2001). An algorithmic
view of practice is based on the quintessentially modern view that problems can be
diagnosed and treated according to a science that disregards context and is antithetical
to methodological pluralism (Cooper & McLeod, 2010). Algorithms of this sort map
concerns to a diagnostic procedure; and from the diagnosis to “corresponding” intervention manuals – standardised conversations to diagnose and treat client concerns. The
enemy from this view of practice is “variation in care” (e.g., Tannenbaum, 2013); yet
the algorithmic approach tempts therapists and clients with a compelling sense of
certainty about how to address suffering and disharmony (cf., Amundson, Stewart, &
Valentine, 1993). Rivett’s revolution brings him to advocate for CBT, largely because
that is the primary intervention for which our field has evidence.
One of our concerns has been with how much of the evidence-based revolution
has been underpinned by the diagnostic language of the DSM-IV, which in effect
medicalises individuals’ symptoms in what many family therapists would see as relational concerns (see Denton & Bell, 2013; Kaslow, 1996). For family therapists, this
needn’t be an either/or (symptoms or dysfunctional relating) issue, of course. However, much current evidence-based research in family therapy relates to symptom relief
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based on DSM diagnoses. Despite some exceptions, our field begs for more evidenceyielding research to show family therapy’s effectiveness, such as by formulating and then
researching clients’ concerns and therapeutic outcomes, in ways reflective of our different therapeutic approaches. Many family therapy approaches are based on relational
or post-structuralist formulations of clients’ concerns, premises, and practices that differ from those which inform evidence-based treatment for DSM diagnosed conditions. At minimum family therapists using such approaches can be informed by client
feedback on their experiences in therapy (Gabbay & Le May, 2012; Green & Latchford, 2012). Changes to symptom discourse is but one of the discourses we and clients turn to, to know if therapy helps.
Local Practice, Dynamic Nominalism, Preferences, and EBP
The meaning of experience is perhaps the most crucial site of political struggle over
meaning since it involves personal, psychic, and emotional investments on the part of
the person. It plays an important role in determining the individual’s role as social
agent. (Weedon, 1987, p. 79)
The scientific view of language and experience grounding most evidence-based practice is that unwanted experience needs to be articulated and addressed in standardised
ways, to create what pragmatist philosopher, Richard Rorty (1989), called an “ur-language” or “final vocabulary”. The view that experiences (like concerns that families
present to therapists) could ultimately be named in their totality, and with certainty,
concerned Rorty. Language is a humanly constructed resource for adapting to changing
and challenging circumstances, not a means to name and address circumstance with
finality. The downside of such an “ur-language” is that while it may seem to enable
familiarity and predictability, too often language (the already said and known) comes
up short in addressing unanticipated circumstances. Toward the end of his life, Rorty
came to be known as a “dynamic nominalist”, someone who favoured creative language
use to enable people to aptly respond to challenging circumstances, and to each other.
Among a growing number of philosophers of science (e.g., Hacking, 1983) a
dynamic and more human view of language, for scientific research and its subsequent
applications, has been emerging. Humans, for their particular purposes, agree to name
experiences in particular ways enabling such developments as temperature or the
world clock (Chang, 2007; Galison, 2004). This is a different view than the view that
the correct meaning for experience awaits discovery – as if experiences like “oppositional defiant disorder” could name themselves, or that our methods of diagnosis
enabled us to recognise them “as they were” so to speak. Contentious arguments eventually resolved how time and temperature would be measured globally, and any readers following the process leading to the DSM-5 would know that a slew of debates
accompanied its political adoption by members of the American Psychiatric Association.
These points relate to a post-structuralist view on concerns and how they are
articulated (Butler, 1997; Weedon, 1987). In the words, of quantum physicist and
feminist, Karen Barad (2007), “Matter and meaning are not separate elements” (p. 3).
How scientists represent experience and intervene to influence experience, based on
their representations, is at the heart of contemporary science (Hacking, 1983). The
challenges begin when different articulations of experience compete for legitimation
(cf., Habermas, 1975). In considering human concerns, are therapists and clients best
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served by biochemical, genetic, anthropological, or spiritual discourses; or might it be
the case that each discourse offers potentially useful articulations and resources? To
return to Rorty (1989), what matters in such cases are effective discourses because
human language is incapable of representing experience correctly. Some of the anxieties that contributors Chambers, MacDonald and Mikes-Liu (2013) point to over
DSM-5, for post-structuralist therapists, relate to how the DSM-5 could conceivably
become therapy’s only legitimate language with respect to payment or professional
ethics.
Across the therapeutic spectrum one finds many ways to recognise and articulate
client concerns. This kind of pluralism is welcomed by many therapists (e.g., Cooper
& McLeod, 2010), but runs counter to efforts to standardise the diagnostic language
used by therapists. Efforts to contextualise client symptom presentations are typically
subordinated to Axis 5, despite efforts by Denton and others to advocate for relational
circumstances as part of the diagnostic process (see Denton & Bell, 2013; Kaslow,
1996). Algorithms of practice, like those described earlier, are easier to operationalise
for a single diagnostic language, particularly when evidence-based interventions are
coupled with the diagnoses. Such algorithms enable therapy-rationing schemes, offer
means to monitor scientifically legitimated practice, warrant the bases upon which
correct training and supervision is seen to be offered, and telegraph to the public clinically approved ways to manage oneself and others (House, 2005). Underpinning such
algorithms is the symptom language of the DSM-5. A Foucaultian nightmare version
of practice management is offered up on this theme by Nobbs (2013).
Part of a post-structuralist approach to practice, evident in such approaches as
narrative therapy (Simblett, 2013), proceeds from understandings of client concerns that
do not fit within a pathologising, decontextualised, or algorithmic approach to naming
and addressing client concerns. Instead, problem names, and even the kinds of conversations post-structuralist therapists discuss with their clients, are more fluid and contextualised than those required for algorithmic adherence to diagnostic interview schedules
and manualised intervention protocols. Missing from a post-structuralist view of practice
is a common diagnostic language for client concerns and evidence-based interventions
addressing those diagnosed concerns. To those preferring an algorithmic approach, poststructuralist practice sounds like professional anarchy or unethical practice.
The flipside of EBP (what therapists should already know) is practice-based
evidence (PBE) derived from clients to make therapy relevant and effective for them
(Green & Latchford, 2012). The most conclusive evidence we have about therapy is
that interventions, while important, matter less than the quality of the therapeutic
relationships in which they are used (Hubble, Duncan & Miller, 1999). Therapist
responsiveness to how clients respond to any intervention is critical (Stiles, 2009). For
us, collaborative and ‘local’ dimensions of post-structuralist practice come together
around how therapists and clients name problems in ways that enable contextualised
decisions about how to address clients’ concerns. Practice-based evidence from clients’
views of the helpfulness of therapy, and feedback from clients that can optimise that
helpfulness, also makes therapy evidence-informed – without tethering practice to
conversational scripts and names embedded in an algorithmic matrix.
In the mental health system of Norway, for example, clients use outcome rating
scales to evaluate and inform practice (Duncan, Miller & Sparks, 2004; Owen,
Duncan, Anker & Sparks, 2012; Sundet, 2012). Further, the names given to client
concerns using the outcome rating scale are collaboratively developed with family
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therapists; client satisfaction with the process is what matters. A different kind of evidence-base can emerge; one informed by client satisfaction with process and outcomes
and the quality of therapeutic relationships without being prescriptive. Among some
health-care providers a new kind of evidence-informed (both EBP and PBE) practice
is emerging in response to some of the algorithmic or script-like excesses of EBP; in
what Gabbay and Le May (2012) refer to as “clinical mindlines” of practice.
It is important to remember that DSM-I began first as a language for researchers
and only later was appropriated by clinicians, administrators, courts, and the public
(Grob, 1991). However, further evolutions of this language have brought us to the
DSM-5, and along the way not only has a particular dominant view of therapy
emerged from these evolutions, but a way the media-savvy public regards, monitors
and “treats” themselves and each other has followed (Illouz, 2008). This is the concern
of Epstein, Wiesner and Duda (2013) who invite us to ponder where the DSM journey
is taking not just family therapists, but families and their members. That funded help
to families is offered only on the basis of diagnosed DSM conditions in many parts of
the world is a by-product of this journey, and one of the ethical dilemmas many therapists must address in trying to be helpful (e.g., Moses, 2000).
This Special Issue
In the articles which follow, our contributors offer different experiences and opinions
on the DSMV. Nobbs (2013) article shares ethical dilemmas of diagnosis that she
faces in her practice. Writing from the position of an Australian systemic family therapist working in the Netherlands, and informed by a narrative perspective, Nobbs
argues that family therapy practice is constrained and medicalised within a multilayered health classification system. This system merges national citizen registration with
DSM diagnoses as well as outcome monitoring of psychotherapy by Dutch insurance
companies, which privilege DSM diagnoses for reimbursement. This multilayered
system of classification creates, what Rom Harr e (1983) would argue as, a file self – a
decontextualised record that constitutes the identity of one person. Illustrating the
challenges of working within the constraints of DSM diagnosis, Nobbs argues that
one can feel compelled to (mis)fit diagnoses to family issues. This is because the
Dutch health system legitimises and funds DSM diagnosed individuals, which is challenging for systemic therapists working from a narrative perspective and wishing to
avoid individualistic pathologisation. She raises important issues around the potential
for DSM-focused diagnoses to become a globally pervasive and unquestioned cultural
norm that might negatively discriminate and potentially harm clients.
Simblett’s (2013) article also looks at the ethical dilemma of working from a different philosophical perspective to the pervasive DSM values that inform the economic foundation of mental health care. However, he argues that very little is written
about how to assist practitioners who work in such dilemmas. Simblett reflexively
examines his position as a post-structuralist and narrative-informed psychiatrist who
works with families under the dominance of the DSM, identifying new discursive
spaces to negotiate between two seemingly diametrically opposed discourses: narrative
and the DSM. Simblett uses the Foucaultian notion that if uncertainty builds as a
form of resistance within a system of knowledge and therefore power, the dominant
discourse that pervades that system is weakened. He uses a dance metaphor to reflect
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on the fluid positions or “dance styles” that he chooses to take up as a narrativeinformed practitioner, dancing with the DSM as his partner.
This clever metaphor is used to examine the ethical complexity of being a narrative
psychiatrist. Sometimes he feels ethically bound to tango closely with DSM discourse
(e.g., when medication would be helpful or when a diagnosis is needed for evidencebased treatment funding). On the other hand, a more distant jive, enabling space for
narrative discourse, loosens the tight hold DSM discourse has on constructing the
truth, identity and realities of persons within families and enables a more contextual
understanding. Simblett argues that these different dance strategies (tango, jive, hijacking, backleading, and declining – along with its risks) have enabled creative workarounds for manoeuvring between and within two dissimilar epistemological stances.
Chambers, MacDonald and Mikes-Liu (2013) also highlight the complexity of
having to work within multiple paradigms, but focus their argument on the need to
foster a constructive dialogue about DSM issues in relation to family therapy without
emotional reactivity. Their concern is that opponent and proponent arguments on
the issues and controversies of the DSM are emotionally charged and reactionist.
They draw from Bowen family systems theory to understand how processes of emotional reactivity (e.g., anxiety as an emotional and relational threat) can be unhelpful
to professional and practitioner-client interactions. Chambers, MacDonald and
Mikes-Liu argue that when perspectives are expressed through heightened emotional
reactivity, they create an anxious focus or a selective judgement of others, which
impedes constructive dialogue. Although they provide suggestions to manage emotional
reactivity (e.g., maintaining an openness to diverse paradigms and being aware of our
cultural and personal biases), they also concede that solutions are complex and
dilemmas exist (e.g., each time a practitioner privileges particular paradigms that
make sense of family problems and family therapy, he/she diminishes the importance
of others).
An awareness of paradigmatic changes in the DSM enables us to contextually
understand how the DSM emerged and where it could be heading in relation to family therapy. Denton and Bell (2013) address this issue by outlining a concise historical
overview of paradigm shifts that have constituted the DSM since its inception and
examine implications of the latest shifts on family therapists. They argue that the
DSM-I was the most systemic of all versions because it conceptualised mental disorder as mainly reactive to the environment; it was a product of the dual influence of
environmental stressors and biological susceptibility. The DSM increasingly became
less systemic through psychoanalytic and descriptive paradigm shifts where mental disorder was viewed as something existing within an individual, and where family issues
were marginally addressed through Axis V codes. Denton and Bell note a recent
paradigm shift in diagnostic classification from neuroscience research where the
National Institute of Mental Health have been developing new methods of classifying
mental disorders from observations of behaviour and neurobiology. This new possible
shift, called the Research Domain Criteria (RDoC) project, conceptualises mental
disorder as a brain dysfunction that also takes into account relational processes and
systems of functioning. This new view of mental disorder, Denton and Bell argue,
may provide a welcome space for some family therapists because it deviates somewhat
from the current DSMs’ reductionist and individualist notions of mental disorder.
Epstein, Wiesner and Duda’s (2013) take a different approach to examining the
constraints of the DSM by arguing that there are certain aspects of the language of
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the DSM that are recursive, which limits the construction of self-identity. They are
concerned by a global uniformity and decontextualisation of possible identities
through the current therapeutic state, and argue that diagnosis is a MacGuffin – an
object (from director, Alfred Hitchcock) that is irrelevant but yet essential to a plot.
It is a recurring central object but there is no meaning behind it. The mere recurrence
of the object enables an assumption that it is important or fundamental. Epstein,
Wiesner and Duda argue that because diagnosis is a MacGuffin, it anaesthetises us
from questioning the assumptions that contribute to its existence, which then serve to
negate any contextual examination of family issues. They suggest a post-therapeutic
state could be a way forward, one that privileges a plurality of meaning and culture
that therefore is not constrained through the discursive dominance of diagnostic
vocabularies and psychiatric categorisations.
Discussion
All our mental categories without exception have been evolved because of their fruitfulness for life, and owe their being to historic circumstances, just as much as do the
nouns and verbs and adjectives in which our languages clothe them. (William James,
1987, p. 551)
The DSM-5 would not be worth a special issue of the Australian and New Zealand Journal of Family Therapy were it not for some of the concerns that we and our
contributors are raising. Undeniably, the diagnoses enabled by previous DSMs have,
in many circumstances, been helpful (Grunebaum & Chasin, 1978); our concern
in this article has been over its dominance as a discourse of practice. How family
therapists come to terms with the DSM-5 – or if they even need to – relates to our
view of practice that is part systemic and part post-structuralist. On the systemic side,
we have concerns for what an individualised basis for practice offered by the DSM-5
translates to for a relational conception of practice. On the post-structuralist side, our
concerns relate in part to what Vico (2001)/1744 raised centuries ago about “linguistic
poverty”; circumstances where existing language was proving inadequate to addressing
human challenges. For Vico, such circumstances required what he termed “poetic
wisdom”, and we believe that this relates to the quote above from pragmatic philosopher
and early psychologist, William James.
A dominating language of human concerns tethering the conversations and interventions of families and family therapists has animated our efforts in this contribution
to this special issue on the DSM-5 and family therapy. In reading other articles of
this issue we invite readers to reflect on how their conversations with families have
been possibly shaped in ways by previous DSM editions, and how they will practice,
given the global influence (Watters, 2010) of this way of understanding and responding to human concerns.
Acknowledgements
The writing of this article was supported by funding from the Social Sciences and
Humanities Research Council of Canada. With thanks to the Taos Institute, the
University of Calgary, and the Social Sciences and Humanities Research Council of
Canada
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