The DSM and the professional counseling identity: bridging the gap.

Many of the values, assumptions, and philosophies inherent in the DSM diagnostic system conflict with those of the mental health counseling profession. This article describes these conflicts; provides clinical practice suggestions for addressing these issues when using the DSM system; and offers strategies for bridging the divide between mental health counseling's professional identity, and the DSM system of conceptualization.

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The influence of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR; American Psychiatric Association, 2000) assessment system on the mental health field has been profound. In fact, it is difficult to overstate the magnitude of the DSM's presence in the mental health profession (Eriksen & Kress, 2005; Hinkle, 1999; Seligman, Walker, & Rosenhan, 2001; throughout this article "DSM" will be used to refer to the system of diagnosis described in the various editions of the Diagnostic and Statistical Manual). The DSM's multiaxial assessment system has become the primary language of communication regarding client problems, offering a way of reducing complex client-related information into a manageable form (Seligman et al., 2001). Also, the DSM, by categorizing people's psychological problems, aims to assist researchers and theorists in comparing various treatment approaches to particular problems. Further, researchers may investigate underlying causal mechanisms and processes of particular diagnoses, which in turn may allow for prevention and improved control over the outcomes of psychiatric disorders (American Psychiatric Association [APA], 2000; Hinkle, 1999; Maniacci, 2002; Mead, Hohenshil, & Singh, 1997). In addition, the DSM provides information about the course, prevalence, cultural, gender, and familial issues related to each diagnosis--information that may be helpful to counselors who are struggling to fully understand their clients' experiences. This understanding, in turn, may enable effective referral and/or planning of counseling, psychotherapy, and other psychiatric treatment strategies (Duffy, Gillig, Tureen, & Ybarra, 2002; Mead et al., 1997; Waldo, Brotherton, & Horswill, 1993). DSM diagnoses may also help mental health counselors to identify those clients whose problems extend beyond the clinician's areas of competence (Eriksen & Kress, 2005).

The DSM may also benefit clients in more personal and direct ways. For example, sometimes clients benefit from an ostensibly concrete explanation of their behavior, and experiences. Labeling clients' behaviors and experiences may offer them freedom from self-blame and the ability to invest their energy more productively in resolving or managing their problems (Eriksen & Kress, 2005; Houts, 2002; Shergill, Barker, & Greenberg, 1998). Houts (2002) states that receiving a diagnosis may be "personally comforting" to some people as it provides a "kind of 'explanation' for behaviors or feelings that are upsetting" (p. 48). Diagnostic labels may also focus families of those diagnosed on an identified external enemy or cause, and away from blaming one another or themselves (White, 2002). Furthermore, believing that a client bears a clinical diagnosis may even positively change counselors' feelings towards a client, enabling them to be less critical and more supportive (Eriksen & Kress, 2005).

Mental health counselors may be particularly aware of the financial and occupational benefits of using the DSM because third-party reimbursement for services requires the ascription of a diagnosis (Eriksen & Kress, 2005). For instance, various governmental agencies use the DSM categories for census purposes, for specifying target populations whose treatment may be funded by grants, and for determining who is eligible for specially funded programs like Medicaid, Social Security Disability Income, benefit programs for veterans, and Medicare (Kutchins & Kirk, 1997; Regier, First, & Marshall, 2002). Almost all settings in which mental health counselors work currently require a DSM diagnoses for reimbursement of services (Mead et al., 1997). Consequently, without knowledge of diagnosis, counselors may lose reimbursement, may lose credibility and status in their professional fields, may not be able to fulfill their employment requirements, and may lose credentialing opportunities (Sperry, 2002a; Russell, 1986; Waldo et al., 1993). Because of its economic power, influence, and popularity, it has been said that the DSM "is the key to millions of dollars in insurance coverage for psychotherapy, hospitalization, and medications" (Kutchins & Kirk, 1997, p. 12). Essentially, entry into almost any service in the mental health care delivery system requires the ascription of a DSM diagnosis.

However, limitations of DSM diagnosis and potential harm to clients that may emerge from such limitations call on mental health counselors to use the DSM carefully and to consider ethical challenges related to its use. The limitations that have been cited include the following:

* The DSM diagnostic system fails to predict treatment outcomes or to promote understanding of underlying pathology (Sarbin, 1997)

* DSM diagnostic categories can lead people to accept a self-fulfilling prophecy that their situation is hopeless and that they are sick (Rosenhan, 1973)

* DSM diagnoses can narrow a counselor's focus by encouraging the counselor to only look for behaviors that fit within a medical-model understanding of the person's situation (Ivey & Ivey, 1998; Malik & Beutler, 2002; White, 2002)

* The act of diagnosing may preclude a focus on the client's narrative construction of his or her experience (Goncalves, Macahdo, Korman, & Angus, 2002)

* DSM diagnosis fails to include a full understanding of contextual factors that may more aptly illuminate both etiology and helpful treatment (Maracek, 1993; Shields, 1995)

* The application of diagnostic labels has historically stigmatized and hurt those who are different from the mainstream. This practice continues today (Caplan, 1995)

* Problems exist in the science of the DSM diagnostic process (Jensen & Hoagwood, 1997; Houts, 2002; Malik & Beutler, 2002; Szasz, 1974)

* DSM diagnosis implies the imposition of a certain set of values on clients and the counseling process (Woolfolk, 2001)

* Diagnostic categories can minimize peoples' individual uniqueness (Denton, 1989)

* The diagnostic process takes the focus away from clients' reality and understanding of their problems by directing clients away from an internal and subjective way of understanding their experiences, instead putting the focus on external conceptions about them (Sarbin, 1997)

Counselors, in particular, must ask how to rectify the contradictions in values between the DSM and counseling's developmental and contextual identity (Eriksen & Kress, 2005; Lewis, Lewis, D'Andrea, & Daniels, 2003; McAuliffe & Eriksen, 1999). The purpose of this article is to outline some of these contradictions and propose approaches and practice suggestions for ethical diagnosis and assessment.

THE DSM SYSTEM AND PROFESSIONAL COUNSELING: CONFLICTING VALUES, ASSUMPTIONS, AND PHILOSOPHIES

Diagnosing, like counseling, is a political act; that is, it is one that involves power in relationships and is performed in value-laden political and contextual environments (Brown, 1990; Houts, 2002). Ethical practice requires that mental health counselors become aware of their values, attitudes, beliefs, and behaviors and how these may influence their work so as to avoid imposing their values on clients (ACA, 2005, Standard A.4.b; AMHCA, 2000, 1.D.2.). Although mental health counselors typically receive training in understanding values related to such issues as faith, abortion, homosexuality, and family constellation, they less seldom consider the values inherent in the diagnostic processes that they use (Eriksen & Kress, 2005). In the following sections, the values, assumptions, and philosophies inherent in the counseling profession and the DSM system of diagnosis will be compared and contrasted.

Values Inherent in Professional Counseling

Growth and development. The ACA and AMHCA ethical codes indicate that counselors are to encourage the growth and development of their clients (ACA, 2005; Preamble and Section A, Introduction; AMHCA, 2000, 1.A.1.). A developmental focus depicts people as dynamic, rather than static, organisms and points to people's natural inclinations toward growth and health (Sperry, 2002b). Developmental perspectives offer hope because client problems or positions are not permanent; instead, change and growth are continuous and always possible. Therefore, inherent in the developmental perspective is the understanding that people have the capacity to move forward, to change, to adapt, to heal, and to attain optimal mental health or wellness (Fitzsimons & Fuller, 2002). One might argue that from the developmental perspective, one actually focuses on change and on trying to understand the processes of adaptation over time in an ever-changing context (Ivey & Ivey, 2001).

As part of their developmental focus, mental health counselors aim for wellness, rather than merely the absence of infirmity (Myers, Sweeney, & Witmer, 2001). In pursuing such a goal, they commandeer whatever resources, assets, or characteristics that clients might possess; counselors also try to help clients to develop others (Fitzsimons & Fuller, 2002; Saleebey, 2001; White, 2002; Worell, 2001). For instance, mental health counselors might identify the "unique strengths that an individual has and amplify those strengths" (Seligman et al., 2001, p. 692). Counselors might further focus on increasing positive subjective experiences and positive individual traits. They might intervene early with prevention programs that teach cognitive and coping skills in order to decrease the risk of depression, anxiety, and violence. They may also celebrate such client virtues as "responsibility, nurturance, altruism, civility, moderation, tolerance, and work ethic" (Seligman et al., 2001, p. 692).

Contextual focus. The ACA (2005) and AMHCA (2000) ethical codes also repeatedly mandate that mental health counselors provide culturally sensitive and competent services. Multicultural competence includes recognizing that families and broader societal influences are important to understanding and treating those who pursue counseling or psychotherapy. For instance, counselors who operate from a family perspective tend to locate problems within families, and also include other contextual influences in their conceptualizations of clients (Christian, 2002; Gladding, 2002). Culturally sensitive counselors do not separate clients' difficulties from their sociocultural group experiences. For example, they might consider dysfunction to reside in the transactions among the individual and environmental factors (Bhugra & Bhui, 1999; Caplan, 1995; Cermele, Daniels, & Anderson, 2001; Chrisler & Caplan, 2002; Duffy, Gillig, Tureen, & Ybarra; 2002; Sadler, 2002).

Multiculturally competent counselors are further aware that those with less power in society experience a greater quantity of life's difficulties, and therefore, have their biological predispositions activated more frequently than those from the dominant race, ethnicity, age, sexual orientation, or gender (Belle & Doucet, 2003; Rigazio-DiGilio, Ivey, & Locke, 1997). Such counselors also realize that those from non-dominant cultural groups garner fewer of society's resources, and thus, acquire treatment later in the problem cycle, which may in turn allow problems to more frequently develop into full-blown diagnoses. In addition, because those with less power are less likely to seek help, they may come to the attention of mental health providers only when the problems have reached a greater intensity.

Values Inherent in the DSM System

The DSM system aims to be atheoretical and value free; yet some believe that it does not succeed in these endeavors (Denton, 1989, 1990; Mead et al., 1997; Mezzich, 1999a, b; Sarbin, 1997; Sporakowski, 1995; Stravynski & O'Connor, 1995). Making judgments about what is normal behavior versus abnormal behavior implies value decisions (Denton, 1989). The medical model notions of symptoms, illness, and cure implied in the DSM assume underlying neurological or biochemical causes for client problems (Denton, 1989; Double, 2002; Laungani, 2002; Sarbin, 1997; Stravynski & O'Connor, 1995). Therefore, the medical model assumes that mental disorders are in a person, regardless of what is happening in the family or in wider social contexts (Denton, 1990; Double, 2002; Laungani, 2002).

The medical model has been criticized for other reasons as well. For instance, it has been criticized for being reductionistic, in that it tries to reduce complex information about people into a few words; mechanistic, in that it assumes that one can explain the wholeness of a person by describing the person's parts (symptoms); static, in that it fails to see individuals' lives as dynamic or people as engaged in a developmental and ever-changing process of living; and linear, in that it relies on an objectivist science as an explanation of experience--that is, it assumes that a few factors that precede the problems historically can be assumed to lead directly to the problem (Double, 2002; Laungani, 2002; Sporakowski, 1995).

Those using the DSM, might then, tend to focus primarily on whether illness exists (Jensen & Hoagwood, 1997; Saleebey, 2001; White, 2002), and acknowledge only the mentally ill part of a person without affirming the rest of the person (Rosenhan, 1973). Further, once diagnosed, research indicates that it may be difficult for some clients to "develop" into "normal" or "sane" people again (Hayward & Bright, 1997; Jussim, Palumbo, Chatman, Madon, & Smith, 2000; McLaughlin, 2002; Rosenhan, 1973). Also, ongoing reimbursement for services often requires continuing a diagnosis which warrants payment for services. Therefore a holistic or wellness oriented focus does not seem economically viable, at this time, for most mental health professionals (Lammers & Geist, 1997).

Recent versions have, however, improved the DSM's contextual focus somewhat, now requiting practitioners to indicate life stressors and medical conditions that may have a bearing on the development or maintenance of clients' disorders or on their treatment. Therefore, the DSM has acknowledged (i.e., in Axis IV) an understanding that life stressors may be a factor in symptomatology or may result from symptomatology (Denton, 1990). Also, the Global Assessment of Relationship Functioning, currently an appendix to the DSM, can be used by practitioners if they choose (Mottarella, Philpot, & Fritzsche, 2001; Ross & Doherty, 2001).

However, as Parker, Georgaca, Harper, McLaughlin, and Stowell-Smith (1995) indicate, taxonomies (classification systems) are by nature descriptive, static, and unidimensional. They provide relatively little context for understanding how psychopathology emerges within the broader surround. The DSM's focus on signs and symptoms of disorders omits many portions of clinical reality, such as the contextual and interactional realities that we have just described (Bilsbury & Richman, 2002; Hawley, 2000). Such a focus also draws attention away from clients' subjective attributions about their life experiences and symptoms. Currently observable behaviors are the focus, and meaning and peoples' motivation are not addressed (Fireman, 2002). Finally, the DSM system does not suggest or require contextual input into the diagnostic process itself. The practitioner is still the person who "does" the diagnosing to the client (Caplan, 1995; Ivey, Jankowski, & Scheel, 1999; Kutchins & Kirk, 1997).

The DSM's static, illness-oriented approach to understanding problems in living, therefore, poses a challenge to ethical practice for members of a profession that espouses developmental and contextual perspectives for understanding problems and change, perspectives that ascribe many client problems to normal developmental struggles and transitions and to societal, cultural, and family dysfunctions (Caplan, 1995; Duffy et al., 2002; Eriksen & Kress, 2005; Kutchins & Kirk, 1997; Sperry, 2002b). The medical model's problem focus, the placement of the problem within the individual, and the failure to include more recursive causality is inconsistent with the counseling profession's identity and values.

BRIDGING THE GAP: PRACTICE SUGGESTIONS FOR MENTAL HEALTH COUNSELORS

A number of potential resolutions may be available to developmentally and contextually focused counselors in pursuit of ethical diagnosis that is consistent with their professional values.

From Static Labeling to Development

A constructivist approach to the ascription of diagnosis may be helpful in resolving some of the aforementioned questions and issues. That is, if a developmentally focused counselor offers a permanent, provisional, or temporary diagnosis, the counselor may also add a phasic or stage developmental story or other stories during assessment (Eriksen & Kress, 2005). For instance, the mental health counselor may attribute the college student's depression to the normal developmental (phasic) difficulties of feeling isolated and lonely while trying to establish intimate relationships (Erikson, 1963) or to the challenges of being in transition between imperial and interpersonal ways of knowing (Kegan, 1982, 1994). The mental health counselor may further engage in dialogue among these stories in the attempt to discover what might be most useful to this client at this particular time and place. The practitioner might then tentatively try one of the possibilities considered, using her or his clinical observation skills to determine the usefulness of the problem definition and resulting intervention. Thus, constructivist theory allows mental health counselors to emphasize the client's unique set of personal constructs and the client's own multiple identities, as opposed to situating clients only within an externally validated set of diagnostic constructs (Tomm, 1989).

Externalization of clients' diagnoses has also been proposed by narrative therapists as a means of using DSM diagnoses with clients in an empowering fashion (White, 2001, 2002). Counselors may encourage clients to externalize their problem by naming the problem (e.g., "The Angry Man," "The Sweet Young Thing"; White & Epston, 1990) and talking about it as though it were someone else's problem, or as though it were an entity "out there" beyond the client (for examples, see Fristad, Gavazzi, & Soldano, 1999). Externalizing encourages clients to objectify and at times to personify as oppressive the problems that they experience. Because a problem becomes a separate entity from the person or relationship, problems that have previously been considered to be inherent in DSM diagnosis, as well as other relatively fixed qualities that may be attributed to persons and relationships, are rendered less fixed and less restricting (White & Epston, 1990).

Contextual Options

Contextually oriented counselors approach the conflict between their undergirding systemic worldview and an individualistic diagnostic system with varying degrees of flexibility. For instance, purists may claim that individual and systemic approaches and theories are incompatible (e.g., Haley, 1987). They may consider most "disorders" to be expectable responses to abuse, stress, loss, and trauma, that is, to abnormal environmental events (e.g., Kutchins & Kirk, 1997). Therefore, although these events are painful and people want relief from distress, the people themselves are not disordered or out of touch with reality. Such therapists might consider it unethical to ascribe a DSM diagnosis, and may thus refuse to participate in a reimbursement system that requires such diagnoses. Clearly, there are financial ramifications in such a choice. Further, coordination of services with other providers who do utilize DSM diagnoses may be hampered.

Less extreme strategies do exist for contextually oriented counselors. They may find themselves conceptualizing clients from a systems perspective, yet using a medical, individualistic perspective solely for the purposes of reimbursement (Denton, 1989; Sperry, 2002b). These mental health counselors may have some difficulty explaining to clients the need for a diagnostic "label" when the clinical focus is on the family or system as a whole. Such counselors may also find it difficult to write or explain treatment plans to more medically oriented managed care companies.

Other mental health counselors consider it important to acknowledge and integrate understandings of various systems levels and types of interactions (Nelson, 2002). For instance, they conceptualize their clients as physical bodies, acknowledging the impact of cell and physical systems; psychological entities, acknowledging the roles of individual characteristics and patterns of behavior; family members, acknowledging the contributions of family history and patterns of interaction; community members, acknowledging the impact of school, faith, social class, faith, etc.; and members of a global community, acknowledging the power of wars and natural disasters. Therefore, the DSM merely addresses one of the systems they are concerned with.

Some counselors integrate the multiple perspectives of the client, the practitioner, the patient, and the family into the diagnostic process. Including a wider range of perspectives may decrease the experience of diagnosis being done by one person to another. In addition, regularly soliciting these multiple perspectives may also overcome the tendency toward diagnostic permanence (Dietz, 2000; McAuliffe & Eriksen, 1999; Mezzich, 2002; Tomm, 1989).

Contextual mental health counselors may also define DSM symptomatology as very functional attempts on a person's part to adapt to or cope with a dysfunctional context (Ivey & Ivey, 1998, 1999). Acknowledging the dysfunctional context--for example, traumas such as rape, incest, abuse, and battering--in the diagnostic discussion creates a very different diagnostic picture than considering symptoms without the context (e.g., post-traumatic stress disorder versus major depression). It may also result in a different practitioner-client relationship, one in which a mental health counselor acknowledges and recognizes the value of the symptoms, appreciates all that the client is doing to manage, and encourages the client to use the symptoms until other, less damaging or more helpful coping strategies become apparent or useful (Eriksen & Kress, 2005; Jensen & Hoagwood, 1997).

Adding an Axis VI to the DSM's current multiaxial system, an axis that can be reflective of practitioners' theoretical perspectives, has also been proposed. Such an addition might make the DSM more useful to practitioners and might motivate use by practitioners whose implicit paradigm currently contradicts that of the DSM (Denton; 1990; Kaslow, 1993). For instance, an Axis VI for family evaluation might include a narrative case formulation from a family systems' perspective, a family typology, a global assessment of family health, or a rating of families on various dimensions such as enmeshment or power (Denton, 1990). Such Axis VI attention to each family member would provide critical information to more individually oriented mental health professionals and might challenge family counselors to add the DSM's "individual system" focus to their considerations of the family (Sporakowski, 1995).

Ethics-Based Solutions

Typical ethical practices may enhance counselor practice with respect to the conflicts between DSM and counseling values. For instance, mental health counselors should adhere to principles of informed consent and standards of professional practice. They could also adopt an egalitarian, tentative, and constructivist approach to diagnosis and assessment (Eriksen & Kress, 2005). That is, practitioners might do the following: (a) talk openly about their counseling and diagnostic procedures as part of the informed consent process, thereby giving clients a chance to examine the values inherent in such procedures (Gambrill, 2003; Nelson & Neufeldt, 1996); (b) accept that there are many ways of making meaning and that none are sufficient explanations of human behavior, and that the medical model is one way of making meaning (for insurance purposes, for research, and for certain aspects of practice), albeit one that needs the addition of other explanations to be useful in counseling (Brown, 2002; Ivey & Ivey, 1999; Sperry, 2002a; Tomm, 1989); (c) adopt a dialogical, egalitarian, and tentative approach with clients, checking out clients' perceptions about the developing counseling process, posing ideas gently, and encouraging clients to participate fully in the choice making process, not only about counseling goals and behaviors to be changed, but about the counseling process and diagnostic processes themselves (Bilsbury & Richman, 2002; Fitzsimons & Fuller, 2002). Diagnoses might then be considered case-and-situation specific, as though there are many potential descriptions and explanations for the presenting difficulties. These diagnoses would evolve as new information became available over time, rather than remaining static, objective truths (Tomm, 1989). Although not all mental health counselors will find such approaches congruent with their theoretical choices or personality styles, such strategies may provide ways to reduce the potentially damaging effects of counselors imposing DSM values onto clients.

Mental health counselors may also recognize that the DSM diagnostic process is only one part of a comprehensive assessment that may be expanded to include developmental and contextual factors. For example, Sadler and Hulgus (1994) and others (e.g., Nelson, 2002) state that for assessment to contribute effectively to client care, it must include a careful description and operationalization of all relevant phenomena--individual symptoms, functional abilities, family interactions, contextual factors, and longitudinal-historical information--each of which may have developmental components. Ethical counselors might further attend to context by following Castillo's (1997) guidelines for culturally sensitive diagnosis: (a) assess the client's cultural identity; (b) identify sources of cultural information relevant to the client; (c) assess the cultural meaning of a client's problem and symptoms; (d) consider the impacts and effects of family, work, and community on the complaint, including stigma and discrimination that may be associated with mental illness in the client's culture; (e) assess personal biases; and (f) plan treatment collaboratively. These guidelines propose a more comprehensive assessment than merely assigning a diagnostic name and number.

Beginning with Training

Counselor educators and supervisors need to assist students and supervisees to develop critical thinking skills that improve their awareness of ethical dilemmas associated with DSM usage and that help them think through the ramifications of the various choices. For instance, together educators or supervisors and students or supervisees may explore how to manage the values associated with the DSM that contradict the developmental, contextual, or wellness orientation of mental health counseling. The counseling profession's focus on normal human growth and development (Myers, Sweeney, & Witmer, 2001; Sperry, 2002b) might be philosophically compared with the DSM's medical model philosophy, and discrepancies identified. Couples and family counseling's systemic focus (Gladding, 2002) might be compared with the DSM's individualistic focus. Person-centered and humanistic therapists' focus on growth potential and choice (Boy, 1989) might be compared with the DSM's more static and deterministic values. Students and supervisees can then use the discussions about conflicts and differences to launch efforts at reconciling the differences or resolving ethical dilemmas that arise from demands to work concurrently from different philosophical orientations.

CONCLUSIONS

Despite the best efforts of counseling leaders to establish and promote a counseling identity that is unique and distinct from other mental health professions, market demands often dictate elements of practice. Although some counseling specialties (e.g., school and college counseling) seem more fully able to affirm a clear and distinct professional identity, others (e.g., family, mental health, and community counselors) find themselves in environments that demand affinity with behaviors that are incongruent with the established developmental and contextual identity. They find themselves in competition with mental health professionals whose professional identity does not call into question medical model ways of operating. These counselors' very survival financially and professionally depends upon behaviors that may be inconsistent with developmental and contextual worldviews.

In response, some mental health counselors may take a non-questioning stance and operate as the market dictates solely because the market demands it and because they see themselves as having few other choices. However, a non-questioning stance of the DSM as it relates to mental health counseling and its philosophies may create ethical and professional quandaries. We prefer to challenge the hegemony of market demands, asking students and professionals to question previously held assumptions. Although no easy answers exist to the conceptual dilemmas addressed in this article, an ongoing dialogue about these issues aims the profession down a path toward resolution. Hopefully through dialogue, mental health counselors will collectively and individually learn to operate within their own profession's identity, to rest more easily and congruently within that identity, holding the hands of both their profession and the market's prescribed ways for helping clients.

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Karen Eriksen, Ph.D., is affiliated with California State University, Fullerton. Victoria E. Kress, Ph.D., is associate professor in the Department of Counseling at Youngstown State University in Youngstown, Ohio. Correspondence concerning this article should be addressed to Karen Eriksen at [e-mail]. A more exhaustive discussion of the issues in this article may be found in Eriksen & Kress (2005), Beyond the DSM Story. Thousand Oaks, CA: Sage.