THE POWER OF DSM-IV; DIAGNOSING FOR DOLLARS?, By Mary Sykes Wylie, Ph.D.

By: Mary Sykes Wylie, Ph.D.

 

Family Therapy Networker. May/Jun 1995.Vol. 19 (3), pg. 22
Posted by permission. Copyright by Networker Magazine

DURING THE GLORY YEARS OF THE LATE 1960s AND EARLY 1970s, when reimbursement for insured outpatient psychotherapy was automatic, unchallenged and comprehensive, it’s fair to say that diagnosis was of only fleeting concern to most therapists. Finding the right coded diagnosis in the Diagnostic and Statistical Manual of Mental Disorders-II (DSM), at that time a meager bookette of 134 pages, published in 1968 by the American Psychiatric Association (APA), was a mildly annoying formality required for insurance reimbursement, the key that opened the vault.

Probably every therapist in private practice had a favorite diagnosis; “I diagnosed almost everybody with ‘adjustment reaction’ because I didn’t want to hurt them,” says Dana Ackley, a clinical psychologist in Roanoke, Virginia. “I could hardly ever remember what I diagnosed for my clients it didn’t really matter but I could tell you chapter and verse about the details of their lives.”

Formal diagnosis, specifically the entire DSM enterprise, was regarded as a practice from the Pleistocene era of inappropriate medicalization, fossilized in a manual that nobody took very seriously. Even after the publication of the vastly expanded, explicitly medical DSM-III in 1980, and the revised edition (DSM-III-K) that appeared 7 years later (together adding 110 categories to DSM-//), diagnosis remained a marginal matter of economic expedience to many therapists. One client remembers how the question of diagnosis was handled when she asked her therapist for help filling out an insurance form in 1987. “My therapist wrote a code number on the form,” she recalls. “I asked her what she had written, and she said the code for ‘Dysthymia,’ which she called a kind of low-grade depression. I remember making a face because I didn’t really think of myself as depressed, and didn’t like the idea of that diagnosis being permanently entered in some file on me somewhere.” The therapist assured the client that the diagnosis “didn’t really mean anything she didn’t think I was really depressed, either but it was one that got reimbursed. Still, I was worried, so she laughed, tossed me a pocket-sized version of DSM-III and said, ‘Okay, you pick one.’ I leafed through it, came across ‘anxiety disorder, not otherwise specified,’ and said I liked that one. I did feel kind of anxious a lot, and besides, the code number 300.0 was easy to remember.”

Such were the subtle, recondite considerations that often went into determining a diagnosis. Therapists may have felt obliged to adopt the medical model for the few seconds it took to scribble down a coded rationale for treatment on an insurance form, but once that little mosquito had been swatted, it could be forgotten, they could quit playing doctor and the real business (or art) of therapy could proceed. Although the official diagnosis was never entirely confidential clients had to sign a release-of-information form even then the appearance of a nebulous, nonspecific condition and code number on a piece of paper buried somewhere in the pre-cybernetic file cabinet of an insurance company didn’t detract from what was felt to be the essentials of therapy: the art of compassionate listening, freedom from outside control and inviolable privacy.

Now, that mosquito has become a swarm of killer bees. Formal diagnosis, once no more than a formal, medical laisser passer to the nonmedical world of therapy, is, in the era of health care cost containment and economies of scale the newly ascendant, meticulously defined and vigilantly enforced law of the land. And the 887-page DSM-IV, published a year ago, is the closest thing to a statute book the mental health field has yet to muster, the authoritative guide for defining “medical necessity,” without which there would be no third-party reimbursement for any health care for anybody for any reason.

In the era of managed care, therapists who don’t come equipped with a caseload of independently wealthy clients now find themselves taking official DSM diagnoses seriously if they want to get reimbursed. “When you first join a managed care panel, case managers interrogate you very closely, at least until they get to know you better, to find out how you come up with diagnoses,” says Charles Browning, co-author with his wife, Beverly, of How to Partner With Managed Care. “They want to know exactly what DSM criteria you are using to decide on ‘Dysthymia’ and not ‘Major Depressive Disorder,’ for example, why ‘Generalized Anxiety’ and not ‘Panic Disorder.'” In short, therapists are expected, as never before, to pass a DSM litmus test for diagnostic legitimacy, to show cause to a stranger sitting in a large corporate office checking off notches on a symptomatic yardstick, exactly why, by what measure and in what way their clients need treatment at all.

DSM was not written with managed care economics in mind, as its makers are probably weary of insisting. “The question comes up a lot to what extent was the book informed by reimbursement considerations?” says Michael First, DSM-IV text and criteria editor. “The answer is, not at all. It is inherently impossible to gear DSM to reimbursement, to figure out what the insurance industry will do; they will use it however they see fit, and we cannot second guess them.” And yet, what must be one of the strangest de facto institutional marriages of our time has occurred between a diagnostic enterprise widely revered as a major triumph of modern psychiatry and a new reimbursement system widely feared as the potential nemesis of humane mental health care. In the convoluted and turbulent history of mental health care policy and economics over the past decade or so, DSM intended, if anything, to broaden and extend the province of treatment has become a mechanism for narrowing and contracting it, the official justification for denying “medical necessity.” As one therapist said, “If DSM didn’t exist, managed care would have had to invent it.”

WEIGHING IN AT FIVE POUNDS, and including 340 different psychiatric conditions, DSM-IV is a very big, very influential book, even though almost nobody except mental health providers and liability lawyers has ever heard of it. DSM-IV exudes scientific prestige; the opening pages and final appendices bristle with more than 1,000 names of contributing authorities participants in the DSM Task Force, 13 work groups, 20 adviser groups, focused field trials, general reliability field trial and the data reanalysis project, not to mention the 40 or so national mental and health care organizations asked to “designate liaisons” to the Task Force. And, if success is measured in dollars, as it so often is in America, DSM-IV promises to be a very respectable cash cow. In the first 10 months of publication, about 458,000 copies were sold to the tune of roughly $18 million. At least $3 million more had come from sales of titles from the “DSM Library,” as the American Psychiatric Association refers to the 10 or 12 “essential companions” guides, commentaries, background sources (including a $125 sourcebook, the first of five volumes documenting the research efforts), reference books and computer software that accompany the piece de resistance itself.

Written largely from a medical perspective, in the style and language of a medical textbook and published by an organization of physicians, DSM has become the official lingua franca for the entire culture and economy of a mental health establishment made up primarily of nonphysicians: clinical social workers, psychologists and counselors, who vastly outnumber psychiatrists. The approximately 40,000 members of the American Psychiatric Association is roughly equivalent to the clinical practitioners in the National Association of Social Workers and not substantially more than the 33,000 clinical members of the American Psychological Association. Nor do these figures account for psychologists, social workers and other accredited therapists or counselors who are not members of the two latter national organizations. According to some estimates, there are more than a half-million therapists practicing in America. Yet, in spite of several attempts to create alternative diagnostic systems, DSM remains a juggernaut, the most exhaustive and widely used system for identifying, classifying and describing mental and emotional disorders in the world.

But DSM is also a deeply controversial best-seller. Therapists, longtime benign scofflaws on the matter of diagnosis, are more than willing to tick off what they believe are DSM’s inadequacies and anomalies. “It’s a joke to think that psychiatric syndromes coincidental symptom pictures are the same as physical illnesses,” says Leston Havens, psychiatry professor at Harvard Medical School. “Psychiatry is where medicine was 100 years ago; the three-part foundation necessary for medical science diseased tissues you can identify, dependable chemical tests, reasonably accurate prognoses are still not available.” According to some critics, DSM reduces people to the sum of their symptoms, undermining their innate capacities for self-healing. “DSM’s whole emphasis is on pathology, deficits, limitations, problems,” says Charles Browning, “which doesn’t help us find the strengths, competencies, abilities and potential within people.”

Many critics are disturbed by what they see in DSM as an excessively biological view of emotional and mental disorders that feeds a bloated psychopharmaceutical industry and reinforces the overuse of medications. “If you use medically diagnostic categories, you don’t think in terms of whole people but only in terms of disease, and what other purely medical treatment exists for mental disorders except medications,” says Herb Kutchins, social work professor at California State University in Sacramento and co-author with Stuart Kirk of The Selling of DSM.

While DSM-IV throws a few politically correct bones to the multiculturalists, it remains essentially a “honky, middle-class document,” says Virginia psychologist and forensic specialist Fred M. Kerman, which “grossly underweights environmental, class and cultural factors.” In an attempt to be more culturally sensitive, DSM-IVs producers included sections throughout the book on variations in disorders related to culture, age and gender, as well as a glossary of “culture-bound syndromes” found in largely non-Western folk traditions that confound standard diagnostic categories. But “while they’ve made a stab at addressing environmental issues, [the DSM authors] have ignored their own backyard,” says Kerman. “There is not one mention of inner-city black culture, Appalachian culture, no recognition of the role homelessness, poverty and violence play in psychopathology.”

Even its producers do not consider it the “Bible” it is often sardonically called. “Basically, it’s a useful guide to communication between mental health specialists, but it should not be taken for more than that,” says Harold Alan Pincus, DSM-IV vice-chairperson.

“People make too big a deal out of DSM and spend too much time studying it,” says Michael First, “DSMIV text and criteria editor. “DSM is a labelling system that is inherently superficial, and it is a convenient fiction to suppose that patients’ problems can be broken down into discrete categories. We don’t understand the etiology of mental illness, and lab findings are practically never found that are diagnostically useful.”

How did a mere “labeling system,” a rather dry, technical, highly schematic system of diagnostic nomenclature, come to be the world’s most important de facto textbook of abnormal psychology? How did a manual of frequently hypothetical and unproven categories gain such political, cultural and financial sway over a motley, heterogeneous crew of mental health providers, many of whom still claim it doesn’t help them much? And why is it a medical book, anyway?

IN FACT, DSM-IV IS THE CONSOLIDATION of what is widely regarded to be the psychiatric “revolution” of 1980, when the American Psychiatric Association abandoned the fusty and familiar DSM-II as comfortable and unremarkable as an old tweed jacket for the new DSM-III, a vastly transformed and enlarged new classification system, presumably based on the latest developments in biological psychiatry and psychometric research. According to the mythology that soon encrusted the new manual, DSM-III saved psychiatry from professional oblivion, wresting it away from psychoanalysis, re-medicalizing it and establishing its preeminence throughout the mental health field. “DSM-III represents a fateful point in the history of the American psychiatric profession… a significant reaffirmation on the part of the American psychiatry of its medical identity and its commitment to scientific medicine,” said Gerald Klerman, one of America’s most prominent psychiatrists, in 1982. “The victory of DSM has already been acknowledged by our colleagues and our adversaries in psychology, in the other mental health professions and in other countries.” There was good reason for such jubilation. By the mid-1970s, when work began in earnest on DSM-III, psychiatry as a profession was in low repute, suffering a full-scale “crisis of legitimacy,” writes psychiatrist Anthony L. LaBruzza, co-author with Jose M. Mendez-Villarrubia of Using DSM-IV. Except for prescribing psychotropic medications (then relatively few in number, with mostly atrocious side-effects), psychiatrists actually did the same kind of mix of psychodynamic and cognitive therapies as psychologists and social workers. Even more damaging to a field purporting to have its base in medical science, there was almost no agreement among any practitioners of any persuasion about what actually constituted a “mental disorder.” Many psychiatrists made their diagnoses by “gut intuition,” or an “uncanny feeling,” semi-mystical guesses that were responsible for such interesting anomalies as the diagnosis of 40 percent of American mental inpatients with schizophrenia, for example, compared with 24 percent in Britain (where psychiatrists favored “manic-depression,” instead). Indeed, in the absence of any widely shared criteria for identifying and defining mental disorders, the arbitrary diagnosis of “schizophrenia” became a national scandal in 1973, with the appearance of the famous David Rosenham study, “Being Sane in Insane Places,” in Science, the most prestigious scientific journal in America. In that study, 19 psychology graduate students voluntarily had themselves admitted to psychiatric units, each one complaining of hearing a voice saying, “Thud.” Though behaving normally on the wards, they were all diagnosed with schizophrenia, their ordinary, unremarkable activity regarded as “symptomatic” of their condition, i.e., a nurse wrote on the chart of one student, who was openly taking notes (as they all did), “patient engages in writing behavior.” When students politely and respectfully asked pre-formulated questions of doctors, for example, “Doctor, when do you think I will get grounds privileges?” the doctor would generally look them in the eye and say with hearty obliviousness something like, “Good morning to you, too, John!” Besides revealing the virtual invisibility of mental patients and the offhand contempt with which they were treated, the study also demonstrated the absolute void of systematic, reliable and valid diagnoses.

Political struggles presumably irrelevant to the “science” of diagnostic classification significantly influenced the making of DSM. Homosexuality, which had been considered a mental disorder in 1968 when DSM-II was published, was voted out of the book in 1973, after extensive lobbying by gay rights organizations (and a battle with psychoanalytic holdouts who wanted it to stay in). On the other hand, the vague, almost undefinable 19th-century chestnut, “Neurasthenic Neurosis (Neurasthenia)” stayed in. The neuroses were a major diagnostic category, though there was virtually no commonly accepted definition of what they were. Among the personality disorders was something called “Inadequate Personality,” whose symptoms could be almost anything any individual therapist might find (or find lacking) in a patient, and for which the treatment of choice was probably 10 years of nondirected analysis. Not surprisingly, reasonable people wondered how valid any mental diagnosis was, or how helpful was a profession that couldn’t remotely define or agree about the nature of the disorders it was supposedly treating.

Money, or declining amounts of it, almost proved the final coup de grace to psychiatry. By the mid-1970s, public research funding to NIMH decreased alarmingly (five percent a year between 1965 and 1972), representing the loss of confidence in the scientific viability of the field. How could a mental disorder be studied without agreement on its definition, its symptoms? Insurance money was also drying up partly because third-party payers, both public agencies and private insurers, had no idea what they were paying for. There was no clarity or uniformity about diagnosis, no common standards for defining disorders, no established methodology for determining diagnostic criteria.

DSM-III was intended to solve these problems, give psychiatry some scientific respectability and, in the process, restore its flagging status and fortunes. Led by Robert Spitzer (who had helped win the fight to drop homosexuality from DSM-II) , a group of energetic psychiatrists, biologically oriented and dedicated to psychometrics, including standardized tests, structured interviews and rating scales originally developed by psychologists, developed categories of disorders based on operational criteria. In short, these were measurable, behavioral signs and symptoms, which, grouped together, presumably constituted discrete mental syndromes.

“Research diagnostic criteria” hardly sounds like the stuff of heart-pounding reading, but Spitzer’s 1975 paper on this topic created a sensation in a field parched for something that looked like real science; it was cited an amazing 600 times in the professional literature. Spitzer’s work, in turn, was based on diagnostic standards established for 14 psychiatric syndromes by J.P Feighner (the so-called “Feighner Criteria”) in a paper cited 4,000 times far more often than any other psychiatric paper of its era.

DSM-III seemed to herald a tectonic shift in power among mental health professionals. “There is not a textbook of psychology or psychiatry that does not use DSM-III as the organizing principle for its table of contents and for classification of psychopathology,” Fred Klerman exalted. He was right. Karla Moras, a psychotherapy researcher and a DSM-1V work-group adviser on anxiety disorders, was a graduate student in 1980 and remembers that her professors “responded to DSM-III as if it were now the new ruling worldview. It looked something like a coup d’etat, with a very powerful impact, often negative, on non-psychiatric researchers who did not think in terms of a medical model.”

By 1985, Moras points out, the National Institutes of Mental Health had reorganized and restructured its research branches to reflect DSM-III categories. “It had a profound effect on treatment researchers, who couldn’t get funded unless they identified their patients in terms of DSM diagnoses. People who wanted to do psychosocial research study families, for example didn’t even know which branch to call, how to get advice on applying for grants.” Any categories not found in DSM-III, any theories that couldn’t be applied to treatment of the classified disorders, were, so to speak, “disappeared” from the world of federally funded clinical research.

With DSM-III, it became increasingly apparent that overt political pressure from outside the psychiatric world could make the difference between exclusion and inclusion of diagnoses. Post-Traumatic Stress Disorder, for example, would probably not have made it into DSM-III if Vietnam veterans and their supporters hadn’t massively lobbied on its behalf; before DSM-III, many PTSD sufferers were routinely diagnosed as having character disorders. Late Luteal Phase Disphoric Disorder (LLPDD), later renamed Pre-Menstrual Disphoric

Disorder (PMDD), was stuck in the limbo of the DSM-III Appendix (which was created especially to house it, and where it still languishes in DSM-IV), deadlocked by gender politics. Supporters of PMDD, including Judith Gold, a Canadian psychiatrist who chaired the DSM-IVwork group on it, maintain there is good research evidence that a severe depressive disorder is related in some small number of women to the onset of the menstrual cycle. Opponents argue that the potential, social and legal misuse of such a diagnosis the ultimate “raging hormone” female defamation to discriminate against or punish women far outweighed the admittedly equivocal evidence for inclusion. According to Michael First, the issue produced a classic political stalemate: “We thought that if we got an equal number of PMDD researchers and an equal number of opponents all women to look at the literature on its merits, we would get a consensus. We were naive. People read the literature according to what they already believed; the PMDD researchers thought there was more than enough evidence for it, the others thought the research was based on value judgments. So we put it back in the appendix, to wait for more data.”

Some argue that the prevalence of certain diagnoses reflects the changing tides of political, economic and social trends at least as much as the discovery of new diagnostic populations that objectively meet improved criteria. Paul Genova, a psychiatrist in Maine and columnist for the Psychiatric Times, suggests that managed care has already affected diagnostic categories; changing the name of Multiple Personality Disorder to Dissociative Identity Disorder, he suggests, represents a symbolic shift away from a diagnosis identified with the need for long-term, intensive and expensive therapy to call forth scores of personalities a modality for more likely to be reimbursed in 1980 than in 1994. “I also predict that Attention-Deficit/Hyperactivity Disorder will become the fad diagnosis of the late ’90s,” says Geneva. “ADHD is a very well-defined condition, which lends itself to a short-term, biological treatment that managed care prefers in an era of scarce resources. Certainly, this is a real condition and people have it, but the huge expansion in the population afflicted by it reflects, I think, a cultural and economic phenomenon beyond the objective reality of the diagnosis.”

THE PROFOUNDLY CONSERVATIVE revolution begun by DSM-III and confirmed by DSM-IV, restored to legitimacy the ancien regime of psychiatry. But it remained a hollow revolution for thousands of clinicians who half-heartedly saluted the new banner by submitting their official diagnoses to insurance companies, while carrying on clinical practice exactly as before, dispensing therapy as they saw fit, without much regard for the scientific niceties of DSM. As one wag put it, trying to organize therapists was like trying to herd cats; it would take something more than a fat rule book to bring to order this mob of isolationist felines.

That “something” was the managed care industry, which needed a rationalized system for deciding what to reimburse as much as the psychiatrists had needed a justification for their own existence. How else, except via DSM, were they going to make decisions about “medical necessity”? How else to determine treatment guidelines, except through the criteria they found there? Like nature, organized commerce and established science abhor a vacuum; standards, definitions, formulae, guidelines, systems, procedural codes are the structures that sustain them. A psychiatric researcher cannot study an undefined illness without name or attributes, nor can a managed care administrator determine a treatment protocol for it, nor an accountant determine the projected cost of curing it. All needed DSM to organize and rationalize what they did. Even if average therapists didn’t care much about the professional and scientific legitimacy of psychiatrists, they cared intensely about being paid, and if being paid were tied strictly to diagnoses and treatment guidelines geared to DSM, they also would learn to care intensely about DSM or accept a life of involuntary volunteer work.

Some argue that there is little direct connection between the economics of mental health care and the process of making DSM. “Decisions about how health dollars will be spent are influenced by forces beyond the diagnostic system,” says Allen Frances, DSM-1V chair. “DSM is only one factor in the way managed care chooses to determine medical necessity and make decisions about eligibility for reimbursement.” Yes, but a very significant factor. Without DSM, mental disturbance and emotional unhappiness wouldn’t have been defined as medical disorders in the first place, and therefore wouldn’t be reimbursed at all. But once DSM had wedged open the door of “medical necessity,” managed care administrators found they could play fast and loose with its categories, choosing which disorders were more or less truly “medical,” which did or did not deserve the reimbursable status of illness. Adjustment disorders, for example, are regularly denied apparently regarded as nothing more than passing quotidian responses to life’s predictable stresses. Personality disorders (Axis II diagnoses) are notoriously not reimbursable for the opposite reason; managed care considers them to be inherent and unchanging characterological structures for which the concept of medical necessity is irrelevant. It is common opinion, however, that the real reason for denial is that they take too long to treat, which is, therapists almost universally suspect, the guiding principle behind virtually every claim rejection.

Indeed, the diagnoses usually accepted are those with symptoms that take the least time to ameliorate, which most quickly respond to standardized treatment models generally, a combination of brief, solution-focused or behavioral cognitive therapy and/or medications. Current good shots for reimbursement include depressive, anxiety and learning disorders, but not post-traumatic stress or dissociative disorders.

It is hard to exaggerate the minuteness with which some managed care companies monitor therapists it is “managed” care indeed particularly those treating something other than one of the preferred diagnoses. One therapist, for example, after having submitted claims for a man whom he had primarily diagnosed with Dysthymia (complicated by the news that he had just been told he had cancer) and secondarily with Avoidant Personality Disorder, was asked for treatment records for each session, along with behavioral goals and whether they had been met. What was the therapist actually doing to help the client show more initiative in his personal and work relationships, the case reviewer wanted to know? What homework assignments was the therapist giving? How, specifically, was the client showing what the therapist called an increased capacity for intimacy with his wife was he having more conversations with her in which he showed his feelings?

How many more conversations than when he had begun? Was the couple having sexual relations any more often? Was there an increase in the number of positive contacts with co-workers since his first session?

Where managed care goes, the profession itself seems bent on following. An ominous trend to many therapists is the appearance of official mental health treatment guidelines, geared to DSM diagnostic categories, currently being developed by both the federal government and the American Psychological Association. The government’s Agency for Health Care Policy and Research has in print a Clinical Practice Guideline on depression (another one is planned on anxiety), which strongly emphasizes medications and specifically advises limiting therapy to 20 sessions or fewer, “since efficacy research on longer forms of therapy is not available and since strong evidence for the efficacy of medication with clinical management is available.” Also in limited circulation is something called the Template for the Development of Guidelines for Psychotherapy Practice, written by a group of research psychologists for the American Psychological Association, about APA plans to develop a comprehensive treatment manual, based on objective, quantifiable research. According to an in-house APA memo, the Template’s supporters hope it will have an impact on therapeutic methods and treatment equal to that of DSM-IV on diagnosis. While proponents suggest that the planned APA treatment guidelines, besides making therapists more rigorous and accountable, might do for psychologists what DSM did for psychiatrists, critics regard it with foreboding, for much the same reasons.

According to Fred Wertz, Fordham University psychology professor and president of APA’s division on humanist psychologists, the template would encourage the “medicalization” of psychology and curtail the field’s unique identity as a humane and philosophical, as well as scientific, discipline. “In order to make therapy data useful for research purposes, a treatment manual could dictate what a clinician should do session to session; any practice that is deemed too ‘loose’ could be considered malpractice,” says Wertz. “But with the wholesale adoption of a quantifiable, objective methodology intended mainly to eradicate symptoms, we could lose a genuinely valid and illuminating way of getting at human experience, of understanding how people’s symptoms are inextricably bound up with who they are, their relationships, the larger structures of their existence, the meaning they give to their experience. We could lose the ‘I-thou’ quality that is essential to the therapeutic encounter.”

THERAPISTS ARE FOREVER TRYING to fit their diagnosis to the procrustean bed of official DSM terminology and managed care’s interpretation of it. In the world of managed care, where “medical necessity” is a sometime thing, regardless of DSM, corporate accountants are turning a game invented by therapists manipulating the system into a double, triple bind that plays therapists, clients and payers against one another in an ethically tortuous and pragmatically complicated game of reimbursement cat-and-mouse. One very driven and compulsively active man came in to see psychiatrist Paul Genova complaining of a “late mid-life crisis.” In fact, says Genova, the man’s repressed anger, compulsive activity, inability to slow down and difficulty with relationships were contributing to a chronic state of severe high blood pressure, but between DSM’s prototypical categories and the rules of managed care, there was no “official” diagnosis that really fit. “If I wanted to be precise, and get a lot of argument from the insurance people, I could say he had a personality disorder, but what sort of personality disorder? DSM doesn’t give you personality types [as opposed to disorders], and his type is actually considered adaptive in our culture, regardless of whether it’s healthy or not. I can say he is having a major depressive episode, even though he isn’t, in order to get him reimbursement, and I don’t feel unethical shoe-horning him into that acceptable diagnostic category, because he does have a potentially life-threatening illness, which needs treatment.”

Family therapists traditionally have it harder than most because, as every one of them knows, according to the DSM medical worldview, mental and emotional disorders, like the flu or a coronary occlusion, can afflict individuals, but not relationships. Which means that just about every life difficulty in their repertoire, including all family and couple relationship difficulties, are relegated to the V-codes a kind of grab bag of diagnostic leftovers at the back of DSM which fail to meet the gold standard that defines an “illness” for which treatment is medically necessary. Though beefed up considerably since the last DSM, the V-codes, which now include child and spouse abuse and/or neglect, difficulties with academic or occupational life, personal identity, religious or spiritual issues and “phase of life problems,” are, with rare exceptions, still the kiss of death to any hopes for reimbursement. “Let’s say a husband and wife come into therapy for treatment of marital difficulties. If I treat them as a couple for their presenting problem, and then submit a claim to the managed care company with a V-code diagnosis, it’ll be turned down flat,” says Tony Jurich, who teaches family therapy at the School of Family Studies and Human Services at Kansas State University.

So, at every professional convention, in every university department where family therapy is taught, at every agency staff meeting, and in countless daily classrooms and consultations and supervision sessions, says Jurich, something like the following conversation occurs: “Can one or both of them meet the criteria for a sexual dysfunction?” asks a colleague, “maybe Male Erectile Disorder (302.72) or Female Orgasmic Disorder (302.73) does their plan cover those?”

“Didn’t the wife say she remembered an abuse incident when she was a child?” another asks hopefully. “Couldn’t you maybe use Post-Traumatic Stress Disorder with delayed onset (309.81)?” “Well, if they’re fighting and not having good sex, surely one or both of them are depressed about it,” says another. “Does one of them meet the criteria for Dysthymic Disorder (300.04) or Major Depressive Disorder, Recurrent (Code 296.3x).”

Perhaps the therapist decides that one or both spouses are unhappy enough to pass the test for Major Depressive Disorder, but hesitates to apply it, anyway. Assuming the wife is a newly graduated lawyer, or perhaps an ambitious, mid-level civil servant, she worries about her possible diagnosis and full details of her treatment floating in a vast cybernetic delta of interconnecting data banks between merging and dissolving managed care companies and insurance firms. Who might see it and what might it mean for her future job prospects? If the company she works for is big enough to organize its own managed health care system, the news of her condition might filter up directly to her employers. Or, what if either spouse wants to buy life insurance? Might the “stigma” of depression keep them from being accepted?

The couple has good cause to worry. Many diagnoses can still shadow a client’s life like hounds from hell, and much more efficiently in the cyberspace age than ever before. “I always struggle with a diagnosis of depression, and discuss it very carefully with my clients; most insurance companies dump it into a national data bank, and according to our research, when the client tries to get life insurance, they have to be cleared from major depression [and assumed suicide risk] for five years,” says Jordan Oshlag, co-director of a solution-focussed therapy center in Natick, Massachusetts. Oshlag says the fax, in particular, a very common mode of transmitting treatment reports back to an insurance company, “scares the daylights out of me.” Every now and then, he says, he gets faxes accidentally from a pizza parlor is the pizza parlor perhaps getting faxes about his clients?

Therapists are increasingly caught in a three-way crunch between diagnostic accuracy (often complicated by ambiguous symptoms), confidentiality, and the power wielded by the insurer, usually around “problem” diagnoses that are stigmatized not only depression, but bipolar disorder, substance abuse and panic disorders. Bud Protinsky, director of the marriage and family therapy program at Virginia Tech in Roanoke, describes a client with mixed symptoms that suggested both Adjustment Disorder and Panic Disorder with Agoraphobia. “When I tried Adjustment Disorder, the company called me and went over the DSM criteria list, one by one, then denied the claim because it didn’t fit well enough.” The young man needed help, so Protinsky submitted the Panic Disorder diagnosis, treated him successfully and was reimbursed. A year later, however, when the client, ostensibly cured, applied for life insurance, he was turned down as a bad risk because of his Panic Disorder. If the client’s place of business changed health plans, he might also be denied mental health coverage because of a “pre-existing condition.” So the same old bind, finding a diagnosis that is at least passingly accurate, reimbursable and doesn’t compromise the client’s reputation, still exists, but now it looks more like a noose; no matter how the therapist squirms, it just gets tighter.

But the real death knell to a diagnosis of Major Depressive Disorder in Jurich’s hypothetical couple is the probability that their health plan will deny authorization for more than a few sessions of treatment unless the “identified patient” begins an immediate course of antidepressant medication, to be monitored by the plan’s psychiatrist, or even the primary-care physician. “There is no question that insurance companies are looking for the cheapest solution, and that meds are cheaper to fund than therapy,” says Michael First. They are cheapest of all when prescribed without therapy by a primary-care doctor; according to a recent article in the Journal of the American Medical Association, one major depressive episode treated by a primary-care physician with medications but no therapy, costs $1,070, compared with $4,200 for treatment with medications and therapy by a psychiatrist. Therapy alone without medications, provided by a non-M.D. mental health clinician, costs $2,500 per depressive episode, $3,500 if the therapist is a psychiatrist. All the factors of cost are wasted on the hypothetical couple Jurich describes who are adamantly opposed to medications they are not “sick,” they say, and they don’t want any “strange chemicals” floating around in their brains.

The therapist who manages to diagnose one or the other of the couple as an “identified patient,” in order to be reimbursed, still has many ethical and practical hurdles to leap in order to treat them for the marital difficulties that brought them into therapy. Therapists who do indicate on the insurance form a secondary diagnosis from the V-codes of Partner Relational Problem wonder, says Jurich, if “they might not be sending a red flag that invites an audit from managed care people who suspect that the primary diagnosis is really a pretext for the marital problem,” which, of course, it is. In any case, the clinician must somehow do marital therapy with the couple while making the treatment records match the individual diagnosis, which is either ethically and technically impossible, or involves some very creative writing skills.

Therapists handle the dilemma in different ways. For decades, family and couples’ therapists have made individual diagnosis of the “identified patient,” then gone on to do marital or family therapy anyway, without revealing it to the insurer. Many still follow this route, but they cross their fingers very tightly these days, and hope they are not asked to submit a detailed treatment plan; not only is the practice technically unethical and inaccurate, it may be illegal. Certainly, the managed care company that discovers evidence of the practice can drop them for “fraud.” Other therapists get around the dilemma by seeing the “identified patient” alone for at least part of every conjoint session, to maintain some semblance of congruence between diagnosis and treatment.

A more honest and possibly promising, but time-consuming, practice is to attempt to educate the managed care company about the value of systems therapy by providing, along with an individual DSM diagnosis, a comprehensive report detailing the impact of family, work and school factors on the individual presumably under treatment. The clinician can then suggest how systems work might be shorter, more efficient and cost-effective than individual therapy. Don-David Lusterman, a Long Island family therapist, uses the reporting system of the managed care company to present the entire systemic picture in which the individual diagnosis is embedded, including the results of the Global Assessment of Relational Functioning (GARF) Scale, now included in a DSM-IV appendix, and how he intends to address these problems. Partly by dint of truly heroic educational work with managed care long and painstaking written reports on clients and their families, research findings on the value of systems therapy and extensive personal contacts with case reviewers he is now rarely denied reimbursement for doing family therapy by companies that initially refused to cover it. To one case reviewer who continued to insist that the company did not reimburse for family therapy, he said he could see the three people in the family together for the price of one session, or, he could see each one separately at triple the cost for which the company would be liable, which did they prefer? The company, not surprisingly, chose the former.

Lusterman, along with a number of other family systems thinkers, are all active in an even-more-comprehensive movement to have relational diagnoses officially recognized by both the mental health establishment and the reimbursement industry, and they have made some limited progress. Besides the GARF Scale, the creation largely of family therapy pioneer Lyman Wynne, which makes its first DSM appearance in the new volume, family therapists are also working on alternative relational diagnostic systems that could work either in tandem with DSM or stand alone. Under the direction of Herta Guttman, a Montreal psychiatrist, the Committee on the Family of the Group for the Advancement of Psychiatry, has formulated a model called the “Classification and Diagnosis of Relational Disorders” (CORD), written in the manner of DSM, but geared to relational problems in families and couples. Florence Kaslow, director of the Florida Couples and Family Institute in West Palm Beach, who was the first chairperson of the Coalition of Family Diagnosis, an umbrella group of medical, psychological and social work organizations, is currently editing a Handbook of Relational Diagnosis and Dysfunctional Relational Patterns, which will recast standard DSM diagnoses in relational terms and discuss the systemic impact of individual disorders on families.

The difficulties of the undertaking, however, reflect the Catch-22 of trying to buck any established system. For the last two decades, aided and abetted by DSM-III, III-R and now IV, research into mental and emotional disorders has been heavily invested in an individual biological model. Much of that research is funded by the pharmaceutical companies developing and testing their own psychotropic medications, which are, in turn, geared to DSM diagnoses. (In fact, the Food and Drug Administration requires a specific medical diagnosis in order to conduct trials of new medications.) Not only are the criteria for family diagnosis likely to be inherently more complex and variable than those for individuals, and less likely to prove appropriate targets for medications (a clinician can hardly just prescribe a “trial” of Prozac for every symptomatic person in a multi-problem family), there is less available money to do the research in the first place. So far, much of the work on embryonic relational classification systems has been done by volunteer labor; most of the Coalition’s designated members have had to personally pony up the $200 yearly membership dues.

So, when Michael First suggests that relational diagnoses weren’t included in DSM-IV because of a “paucity of research,” family therapists are inclined to agree. And yet, many syndromes and conditions included in DSM-III and III-R likewise exhibited an admitted “paucity of research,” but were included anyway, on the assumption that their very inclusion would stimulate new research. Certain of these conditions have been carried over to DSM-IV, still without much good data, “grandfathered in,” says First. “It’s hard to get rid of some categories because they have their constituencies many [in DSM-III and III-R] wouldn’t get in, now, because we have higher standards.” Unfortunately, because family diagnoses were not founding members of the DSM club, when it accepted just about anybody, they are having a very hard time getting in now, when it is big and powerful and a magnet for research funds.

WITH THE EXCEPTION OF A FEW unreconstructed DSM-haters, most therapists are probably willing to make their peace with the system, admitting (often grudgingly) that they have found it helpful in organizing their perceptions of clients with ambiguous or perplexing symptoms. Few therapists, for example, think that the addition and refinement of Post-Traumatic Stress Disorder and the dissociative disorders have not contributed enormously to understanding whole worlds of suffering that were virtually invisible before. Most can also readily admit that DSM has been critical to the development and effective use of medications. Confusing the diagnoses of Schizophrenic Disorder, Bipolar Disorder and Major Depressive Disorder (all three of which may initially exhibit depressive symptoms) can result in the wrong medication with disastrous results, actually making the disorder worse. Further, even therapists who say that DSM has been generally unhelpful to their practice can find significant, highly therapeutic, exceptions. Norma Akamatsu, a therapist in Northampton, Massachusetts, remembers seeing a family in which the parents seemed to regard their difficult, impulsive and anger-prone son as intrinsically morally flawed; they described him as defiant, irresponsible, dishonest, unremorseful for his misbehavior. “Then I started reading up on Attention-Deficit/ Hyperactivity Disorder, and I felt saved.” The boy was evaluated by a psychologist who supported an ADHD diagnosis, which “threw open to question these parents’ moralistic judgment of their son. I could tell them that the boy’s avoidance of homework, his inconsistency, which they took for deceit, his impulsive outbursts were not the signs of ‘bad character,’ but of a problem that could be remedied. It gave the parents a chance to re-envision their son in a more humane, less judgmental way.”

Other therapists point out that good diagnosis is necessary to treatment outcome studies that are part-and-parcel of health care reform. “Somebody who excludes diagnosis in their treatment plan is merely using old methods shown to be ineffective,” says Leonard Goldstein, clinical professor of psychiatry at Georgetown University and president of Integrated Behavioral Care. Goldstein argues in effect that responsible health care delivery of any kind depends on data-based clinical outcome studies, which, in turn require dependable, clinically reliable diagnoses. “DSM was a great leap forward for behavioral health care because it created a nomenclature based on observable phenomena that people could agree upon,” says Goldstein. And the treatment guidelines based upon DSM criteria short-term therapy and medications for depression, for example are proving their merit in outcome studies, regardless of what opponents think. To the insistence that diagnosis must precede treatment ergo, the necessity of DSM one rejoinder is that these days the economics of treatment and a creeping bottom-line psychology are actually driving the engine of diagnosis. “If your job, your livelihood, your Christmas bonus and the corporate structure of the firm where you work all revolve around the beauty of the short-term treatment model, it is not easy to be open and objective about diagnosis, and you tend to ignore data that don’t confirm your own biases,” says Skip Robinson, a California consultant on health care issues, who teaches psychology at Sonoma State University. If the treatment “cookbook” limits itself to only a few, quick, microwaveable recipes, a lot of dishes that take more time and care won’t get made.

Perhaps there has always been something of a mismatch between the categorical imperatives of formal diagnosis and the eclectic miseries of human suffering. Family therapists have long repudiated the idea that mental and emotional disturbance could somehow be contained inside the skin of a single “diagnosed” individual. More recently, narrative therapists have rejected diagnosis because it locks people into dispiriting pathological identities and robs them of their human capacity to create and re-create other, better stories about themselves.

To the constant refrain that DSM labels and stigmatizes people, its producers protest that it classifies illnesses, not people; it “avoids the use of such expressions as ‘a schizophrenic’ or ‘an alcoholic’ and instead uses the more accurate, but admittedly more cumbersome, ‘an individual with Schizophrenia’ or ‘an individual with Alcohol Dependence,'” reads the DSM-IV Introduction. Few appear to believe this disclaimer. Removing the descriptive nouns from the classification has not undercut DSM’s social and cultural influence as a de facto labeling system, and the seductive power of its language to draw therapists into its world-view is magnified now as never before. In a time of enormous economic and social anxiety, DSM lends itself exactly to the kind of reification, the false assumption that its categories are concrete realities, which transmogrifies a useful diagnostic and research aid into a cultural monster. DSM is a system of symbols that rationalizes the power of the psychiatric profession and provides the philosophical grounding, so to speak, for the medical technology that develops around it, argues Howard F. Stein, a medical and psychoanalytic anthropologist teaching in the department of family medicine at the University of Oklahoma Health Sciences Center. To the pharmaceutical companies, for instance, DSM really is the Bible; without these coded “diseases,” there can be no drug trials. And, without the mediations, with their vast impact on mental health care, DSM might lose its significance as a legitimate biological-medical tool and sink like a stone into obscurity.

MEANWHILE, HOWEVER, UNDER the combined influence of DSM and managed care, therapists begin to police themselves, watching the way they practice, thinking of diagnosis and treatment in ways that might once have appalled them. “It’s hard not to think in the terms of DSM when I have to use it every day for managed care,” says one clinician. “The language seeps into my brain, into the way I look at clients, even when I know better.”

More than the insidious mental imperialism of DSM, the rage for rationalized, standardized diagnostic and treatment guidelines, particularly short-term models, “rips apart the fabric of the healing process,” says Robinson. The current impasse creates a “perversion of the science of diagnosis,” and demands a kind of diagnostic “shuck and jive,” which badly compromises the therapist’s ability to do a good diagnosis at all. Caught between their own vocational imperatives to fully assess their clients’ problems (which could include, but don’t necessarily require, a DSM diagnosis), to treat them with as much skill, patience and time as needed and the demands of managed care that they punch out a quickie diagnosis, then limit and curtail treatment, therapists “fall into a kind of hypnotic state, an illusion that they can do both, which is an impossibility,” says Robinson. “I am observing a drastic increase in therapist suffering as they try to maintain an internal sense of consonance between the desire to practice a healing art in the best way they know how, and the deep fear that they may not survive as practitioners if they do.”

The distress, almost despair, at the loss of the “healing relationship,” the conflict between professional ethics and financial exigency, the sense of growing estrangement from a vocation they have loved are notes commonly sounded by therapists in almost any conversation about therapy and managed care. “We have lost the noble concept of the patient, a suffering individual coming to see a professional, expecting empathic understanding,” says Anthony LaBruzza. “A lot of what goes on in healing is an art. Medications can help, but without the context of the healing relationship, people won’t get better.”

What gives therapy its special quality as a “healing” relationship, however, and what makes it more humane art than medical technology is the therapist’s ability to help clients draw from the chaotic, messy circumstances of their lives a sense of meaning, some understanding or vision of themselves that transcends even the most exacting, refined and objectively derived diagnostic criteria. “It isn’t rocket science to know in two minutes that a client complaining of sleep disturbance, difficulty concentrating, appetite decrease, crying spells and sad feelings is depressed,” says Iowa family therapist Lois Braverman. “But what is the story? What is this person’s story, this couple’s story, this family’s story? How do they understand what is happening to them, and how to solve it? People don’t usually come in complaining of symptoms; the symptoms aren’t the presenting problems, the problems are the presenting problems. The bad marriage, the son on drugs, the job he just lost; the sister who isn’t talking to her, the cancer diagnosis.” Even if everything seems “perfect,” says Braverman the great marriage, the beautiful house, the wonderful kids, but this mysterious feeling of unhappiness there is still a story waiting to be told. “Even if they need to take medications,” says Braverman, “they still need to make sense of what is happening to them.”

There can be no healing profession besides therapy in which this creation of meaning the myths, beliefs, explanations, justifications, hypotheses by which we try to understand ourselves is so central of the very definition of the work. This is not to deny the irreducible reality of neurobiology. “Everybody has a biology, which therapists don’t always realize,” says Paul Geneva. But every human biological system comes with something we still, quaintly and unscientifically, refer to as the mind. The human drive to explain ourselves, to heal ourselves through our stories, will not be legislated away by more meticulous cost-accounting procedures developed at the higher levels of corporate finance, any more than it will vanish in the test tube of another new selective serotonin re-uptake inhibitor. However standardized, rationalized, organized and professionalized therapy becomes, in the end, clients will still want someone they can talk to.

Mary Sykes Wylie, Ph.D., is senior editor of The Family Therapy Networker.
Copyright Psychotherapy Networker, Inc. May/Jun 1995
Reproduced with permission of the copyright owner. Further reproduction or distribution is prohibited without permission.