Well, I do admit, people seeking help for emotional disorders are certainly ill-at-ease, dis-eased. But that is not what we mean.

We are talking about the Official Disease Model, the DSM 5. In Scientific American, Peter Kinderman makes a case for abandoning the whole DSM 5 model.

You will want to read his argument for yourself:

http://bit.ly/11kTPLg

I offer you a few concepts of my viewpoint.

 

Traditionally, diagnosis and treatment are linked. The proper diagnosis tells the physician what treatment to pursue.

Is that true in the psychotherapy profession?

Of course not. Regardless of the diagnosis, all treatment is essentially the same. We engage in supportive, heart-to-heart talks with a troubled person. That is, while the “evidence based treatment” argument says that we should follow different treatments for different conditions, in reality, the evidence that such targeting makes any difference if quite weak. There may be some exceptions, but frankly, most therapists are helping people struggle with dilemmas and emotional pain, not so much with particular diagnoses.

You see, again with a few exceptions, treatment programs that compare different approaches, such as cognitive therapy versus psychoanalytic therapy, the outcomes are equal.

That is called “The Dodo Bird verdict.” It comes from Lewis Carroll, in Alice in Wonderland.” The animals get wet and run in different directions for different amounts of time, so as to dry off. Then they decide they have run a race, and want to know who won.

The Dodo Bird replies, “Everyone has won, and all must have prizes.”

Saul Rosenzweig first raised this idea in 1938. Since that time, most of the evidence supports the Dodo Bird verdict.

http://en.wikipedia.org/wiki/Dodo_bird_verdict

CBT practitioners claim that for anxiety, it is the preferred treatment, but again, a recent long-term analysis showed that, compared with insight-oriented therapy, the outcomes were the same. Admittedly, the short-term advantage goes to CBT, but we aren’t so interested in that as we are in long-term prognosis. (Also, see this writeup.)

Now, you ask, “Where is Johnson going with all the blah-blah-blah?”

Simple: If there is little or no difference between different treatment strategies, if they tend to all get roughly the same outcome, then what good is diagnosis?

Now for a technical point: Kinderman points out that reliability of the DSM 5 is very poor, almost non-existent. That is very important.

Reliability is the measure to track the same factor accurately. If five diagnosticians all arrive at the same diagnosis for the same patient, then diagnosis is reliable

It may or may not be valid. Validity is whether the measure actually tracks what it is supposed to track. Now for technical reasons, the validity cannot be greater than the square of the reliability. Perhaps the reliability is .80, which is a good, high number. The validity cannot exceed .64, or in other words, the measure cannot explain more than 64% of the variability. There would be 36% of the variability that is unexplained.

If the reliability of the DSM is low, then there is virtually no validity. There simply cannot be any validity. (A good deal of why the DSM 5 is unreliable is that there are too many diagnoses, and many of them are new.)

Some diagnoses like obsessive compulsive disorder have a relatively clear and direct path between diagnosis and treatment. That is also the argument about anxiety generally. There I am not as sure. Yes, exposure and relabeling does help. But does that justify all of the separate anxiety diagnoses? 

Schizophrenia, like Bipolar, seems to be something we can reliably diagnose. There is a recent study showing that CBT without medication is a helpful treatment for schizophrenia.

Similarly, depression can be diagnosed as a specific condition that needs such general approaches as raising activity, raising mastery and pleasure experiences, and developing a hopeful image of the future.

Embracing diagnosis is necessary for the people who believe there are specific treatment, but embracing the Dodo Bird verdict is useful for clinicians who believe that the general factors are mostly operant in psychotherapy. A trusting relationship, emotional support and release, finding new ways of seeing the problem are examples of the general factors.

Which do you think is right? These are value driven positions, and we know that humans will always cherry pick evidence to support their point of view.

I prefer to believe in the Dodo Bird, considering him as a wonderful source of wisdom. Others prefer to believe in specific treatments, so they must throw out the Dodo Bird’s evidence.

Those people are in a crisis currently. The DSM 5 has created that crisis. No reliability equals no validity. So there cannot be any specific treatments without reliable diagnoses.

Why are we engaging in applying diagnosis with no validity? We may as well say that our patients are possessed of demons.

Your opinions? Has DMS 5 gone too far? Are the diagnostic categories meaningful? Discuss! Please leave your opinions below. I will read them and post a follow-up.