The DSM is USELESS for Therapy

I personally feel that in the realm of therapy, giving people a diagnosis tends to make their lives worse, and I hate it because really we mainly use it to give insurance a reason to cover their care, and that’s not a good enough reason to give someone a life altering label. Let’s talk more about why the DSM really doesn’t have a place in the world of Therapy.

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Ever since I started studying psychotherapy, I’ve always been curious about this whole process of diagnosis, and why we use the DSM, the Diagnostic Statistical Manual. Because the truth is that actually wasn’t created for psychotherapists, it was created for psychiatry. But I want to talk about diagnosis. There’s two issues I have.

Number one is how do you know when it’s accurate? It is a completely subjective experience and those decisions are really big. They impact the medicines people will take, the lives people will get to lead. They make a really, really big difference, make a really, really big impact on people’s lives.

And number two, the act of diagnosis itself can make people’s lives worse. It makes them focus on a problem.

And I’ve been talking about being non diagnostic as a field for so long. That’s one of the things that attracted me to Solution Focused Brief Therapy, is it’s non diagnostic. We don’t need a diagnosis in order to do our work.

You guys, we have to understand that diagnosis is really about billing. That’s it.

If it wasn’t for billing, we wouldn’t really have to do this. But insurance companies require diagnosis in order to pay the clients. It actually has nothing to do with the work that we actually do. That’s just the truth.

And I saw a study recently. Somebody brought this to my attention and it blew my mind. And it’s called the Rosenhan Experiment. Now, if you’re not familiar with this, let me go ahead and explain it to you. Rosenhan was a professor at Stanford University and he wanted to experiment on whether or not psychiatrists could accurately diagnose for the purpose of residential treatment. So he, along with some of his peers and students, eight total, himself and some peers and students, decided to go to a local psychiatric hospital and get themselves admitted.

And what he did was he told everybody that while you’re in the assessment, the initial assessment, to report that you are hearing voices, but once you’re in the hospital, behave perfectly normal. Now, the people in the experiment were not in any way diagnosed with anything. They had no psychological history of problems of any kind whatsoever. They simply went into the initial assessment and said, I’m hearing voices. They were admitted and once they were admitted, they were to behave perfectly normal, like their perfectly normal selves.

That was the experiment.

Now, what happened is all eight of these people ended up with diagnosis like schizophrenia, bipolar disorder. All eight of them ended up getting prescriptions for medication and being held in this facility. So at the end of the experiment, Rosenhan, went back to the hospital and explained it.

He said, I had eight people, all perfectly normal, with no clinical issues whatsoever, come into your hospital. They reported hearing voices, but they entered in your hospital and they all left with diagnoses, they all left with medications. They all left all these crazy things. And the hospital was incredibly embarrassed. The hospital said, you know what? We think we could do a much better job. Can you repeat the experiment? And Rosenhan said, absolutely. And the hospital said, send us eight more students, eight more experimentees, eight more volunteers, and we will find them.

So Rosenhan agrees. He said, okay, I will do that. A few weeks goes by, the hospital administrator calls Rosenhan and says, we found them. We have been looking very closely and we think we have found all eight of these subjects. Then Rosenhan said, I haven’t seen anyone. So the hospital was embarrassed again.

And what does that say about our field and diagnosis? And what it says is it’s a completely nebulous thing, and we’re basing so many huge decisions based upon how people fall into these categories of diagnosis. And the simple truth is, I’ve seen this cause tremendous harm in people’s lives.

I have a friend who’s a part of the Kanyenke’haka Nation up in Ontario. You know them through the English name, the Mohawk tribe, but their actual tribal name is Kanyenke’haka, and his name is Joe. I went on the reservation in Ontario to do a training, and Joe and I have become pretty good friends. And Joe was explaining to me how much he loves Solution Focused Brief Therapy for his people. And I said, “Joe, why is that?” And he said, “In our culture, we speak to our ancestors. That’s part of what we do. We speak to our ancestors when we’re experiencing trouble. When we need consult, we consult with our ancestors.”

So they brought in a psychologist or psychotherapist, somebody in the helping professions years ago, and that person ended up diagnosing lots of people in this community with schizophrenia because they associate that with visual and auditory hallucinations. And Joe was like, “That’s just our culture. And in Solution Focused Brief Therapy, we don’t feel judged by you. We don’t get these diagnosis. We don’t have these problems or these issues.”

And that is really touching to me because, think about how many communities around the world are doing things, that in their culture, in their community, doing things that are good for them, that we are labeling as a psychological trauma or problem, and causing issues in that person’s life.

So when I saw this experiment, I was like, look, I’ll let you guys decide whether or not diagnosis is important to you and your work. That’s fine, whatever. But I also want you to understand that more important than that is actually non-judgment, because diagnosis in its nature is judgment. More important than that is if you do point out someone’s flaws and criticism, which is what diagnosis does, you inherently make their life and their life situations worse.

But if you talk to people about hope and change, then they get better.

The last thing I’ll share with you on this topic is, my good buddy Chris Iveson, who I think is one of the best Solution Focused Brief Therapists who ever lived. He has a video, a series of videos actually, of him working with a client who had been diagnosed with Alzheimer’s, disease and was having very difficult times, having lucid thought, memory issues, everything.

And by the end of the third session, Chris has three of these sessions recorded. And by the end of the third session, this client is significantly, noticeably more lucid and more clear of thought and better communication. And I remember showing the video, Chris and I were teaching together and showing the video, and someone in the audience asked, “How did you know that Solution Focused Brief Therapy worked with people with Alzheimer’s?” And Chris said, “I just forgot that he had Alzheimer’s. I just talked to the person.”

Now, did that person’s Alzheimer’s get cured? No, but he was noticeably. You guys are familiar with Alzheimer’s. The people go in and out of lucid thought, and as it gets worse, they have less and less experiences of, like, feeling like they’re being present. And through this conversation with Chris, that actually was reversing the person having more and more moments of being present and less and less moments of being confused.

And Chris’s response was, “I just forgot that he had Alzheimer’s. Just talk to him like a person.”

And for me, that’s a very powerful lesson on why we should focus on people, and not problems. And when we try to focus on problems, we’re actually not good at it, as highlighted by the Rosenhan experiment.