AMERICAN FAMILY THERAPY ACADEMY POLICY STATEMENT
DSM-5: TOWARD A RELATIONAL AND CONTEXTUAL APPROACH TO DIAGNOSIS
The American Family Therapy Academy (AFTA) is concerned with the intersection of the biological, psychological, relational and socio-cultural dimensions of individual and family health and well being. It is from this frame of reference that AFTA has serious reservations about the process and content of the ongoing revision of the Diagnostic and Statistical Manual (DSM-5).
AFTA has joined over fifty organizations and thousands of practitioners and researchers worldwide, in writing to the DSM Task Force and the American Psychiatric Association to express these concerns. The response from the American Psychiatric Association has been minimal, at best. None of the organizations or individuals have been invited to participate in the decision making process.
We find that the current revision of the DSM continues a long history of ignoring research and excluding vital contributions of non-psychiatric mental health disciplines resulting in invalid diagnostic categories and treatment protocols. The DSM is dominant in determining mental health diagnosis and treatment and is more harmful than helpful in delineating best practices. AFTA calls upon the American Psychiatric Association to engage in a more inclusive and research -supported process.
AFTA has three primary concerns:
1. We recognize that people think as they have been trained and thus the American Psychiatric Association, being the sole creator and developer of the DSM-5, almost exclusively considers medical causation and medical treatment. The DSM employs a biomedical model suggesting that people and their problems can be explained in terms of an underlying deviation from normal function such as a pathogen, injury, genetic or developmental abnormality; in other words, a description of symptoms and causation. This narrow focus omits the entirety of human experience as little or no consideration is given to the role that family and socio-cultural contexts have on wellbeing. This frame of reference ignores years of research and provides no mechanism for those using the DSM to incorporate the familial, psychological and social factors affecting child development and adult functioning. It delegitimizes the focus on relationship, life stage, community, and access to power and resources. It is no accident that there has been a decline in funding for services to help families with normal problems in living as the DSM has become increasingly dominant in mental health diagnosis.
Input has been limited from other mental health professionals who subscribe to a biopsychosocial model, which is based in part, on the vast research on the social determinants of health. This research shows that social factors play a major role in the development of serious health problems. The findings of the ‘Adverse Childhood Experiences’ study conducted by the CDC suggest that certain traumatic and/or stressful childhood experiences are major risk factors for the leading causes of illness and death in adults.
The extensive body of high quality evidence-based research examining the social, psychological, familial, and environmental factors in understanding mental health issues must be considered on a par with the biomedical, biochemical and physiological research that has been predominant in developing the DSM-5. Such a comprehensive and realistic approach is essential to the understanding and alleviation of human suffering.
2. This strong emphasis on a biomedical model results in medication becoming the treatment of choice to the detriment of other psychological and systemic approaches. Research has shown that therapy can be equally as effective or more effective than pharmacology. It does not cause the side effects often associated with medication.
Some psychiatrists who contributed to the DSM offered the disclaimer that "they do not mean this to be a bible." However, the DSM's control of treatment derives from insurance companies that only pay for treatment following "DSM medical guidelines," ultimately defining treatment and diagnosis in every public and private setting. This has led to the marginalization and subordination of other effective approaches such as family therapy.
Thus, the DSM has become a supporter and partner of the pharmaceutical industry which stands to profit from the emphasis on medication as treatment. The financial connections between psychiatry and pharmaceutical companies, which often fund research studies, raise questions about the bias toward medication.
3. We strongly criticize the current system of deciding diagnostic categories primarily by "medical consensus." The reports are that the studies done by the DSM task force had very weak results, and these studies have not yet been released. Therefore the current DSM reflects the opinions of its writers and without scientific studies to support these opinions. The "medical consensus" in formulating the DSM has not included much actual research on human problems (psychosis, ADD, anxiety, depression, trauma, etc.) or on child development, leading to a number of destructive changes.
a. The normal process of grief has been pathologized and reduced to a diagnostic category.
b. Children's behavioral problems have been further pathologized without consideration of the relevance to child development of such contextual factors as stress, family and social systems.
c. The addition of medical diagnoses for sexually violent predator acts opens the door for those who commit these crimes to avoid prosecution and/or incarceration.
The American Psychiatric Association should:
1. Convene or facilitate a meeting of all of the professional organizations involved in research and providing treatment for people experiencing emotional, psychological and/or family distress.
2. Support the creation of a work group, from that meeting of researchers and practitioners, to develop a meaningful, comprehensive, research-based diagnostic manual.
3. Support the inclusion of "life situation" in diagnosis as well as the inclusion of the "missing contexts" of culture, class and experience.
4. Support the incorporation of "destructive unjust social factors" in diagnosis. These include poverty, hunger, homelessness, violence, racism and other forms of oppression.
5. Ensure that the DSM legitimizes clients' concerns, stressors and distress arising from coupling, parenting, aging, family relationships, developmental issues and life stage issues beyond those that are symptom-based.
We wish to thank the many national and international scientists and clinicians who shared their research and work with us; particularly David Elkins, Ph.D., who with his colleagues, is planning an international summit in 2013 with representatives from all therapist groups. The agenda will be to discuss the feasibility of developing an alternative system to the DSM for the conceptualization of emotional distress.