The
DSM-5 and the Family Systems approach to understanding psychopathology are
based on models that differ in their theoretical underpinnings in that one is based on the medical model of
pathologising the presenting concern and thus attempting to intervene in order
to ‘fix’ the client; and the other is based on a recovery model where the
client is seen as possessing qualities (e.g. self-actualisation) that,
alongside the therapist and their family, can serve to combat presenting
concerns through the use of dialogue, the ability to differentiate oneself from
a dependence on one’s surroundings, and perspective taking. This essay attempts
to give an overview of these separate approaches to understanding and forming
interventions for psychological concerns, and suggests that a more holistic
systemic approach might serve the client more adequately than the pathologising
alternative.
DSM-5:
Overview and Critiques
The
Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its
fifth edition (DSM-5), was published by the American Psychiatric Association
(APA) in May of 2013 with a number of significant revisions from the previous
edition (e.g. new categorisation in substance-use disorders, addition of adult
ADHD, and the riddance of the penta-axial system; George, 2013). The DSM-5
serves to provide a “common language” to be used by researchers and clinicians
from a number of different orientations in the diagnosis of mental disorders
(APA, 2013). The DSM-5 serves to provide the clinician and researcher a
resource that aids assessment and diagnosis of mental disorders through an
understanding of the client’s clinical history, and the social, biological, and
psychological factors that may have contributed to the client’s presenting
problems (APA, 2013). A clinician must also use his or her clinical expertise
to recognise any combination of predisposing, precipitating, perpetuating, and
protective factors that may be signaled in the psychopathology of the client.
Although
the DSM has changed quite significantly in its structure and content throughout
the years and is periodically being revised in order to include the most
up-to-date information on mental disorders, it has been subject to scrutiny by
a variety of mental health professionals. For example, Frances (2013a) notes
that there are ten fundamentally harmful changes within the fifth edition of
the DSM, which were: the pathologising of so called “temper tantrums” into a
disorder termed Disruptive Mood Dysregulation Disorder; the removal of the grief
exclusion in Major Depressive Disorder thereby potentially heralding the grief
process after the death of a loved one a mental illness (though this shall be
discussed in more depth later on in this essay); the misdiagnosis of the
everyday forgetting of old age into Minor Neurocognitive Disorder; the
inclusion of Adult Attention Deficit Disorder; the diagnostic features of Binge
Eating Disorder being such that if one eats excessively in one sitting (12
times in three months) they could be diagnosed with the latter; the change in
the diagnostic features of Autism Spectrum Disorder (although this one is
contested as to whether these changes may be beneficial or detrimental to
services for the person suffering from the disorder); the pathologising of
first time substance users; the discussions around the potential inclusion of
internet and sex addiction in later revisions; the change in definition of the
diagnostic features of Generalized Anxiety Disorder which could potentially
pathologise the “worries of everyday life”; and finally, the potential for the
“misdiagnosis of PTSD in forensic settings.” (Frances, 2013a)
For
Berk (2013) however, although the significant changes to the diagnostic system
are indeed important to consider in light of the apparent lack of support of
biomarker research, the prime concern must be directed towards the use of the DSM-5. Berk asserts that
clinicians rarely exercise rigidity when distinguishing between diagnostic
categories, but rather use them “as best-fit, pattern-recognition adjectives”
(Berk, 2013, p. 2). Another concern regards the use of the DSM-5 by regulators,
the legal system, and insurers. Berk notes that these mediums apply little
scrutiny when assessing the diagnostic categories (categories which have been
cited as having numerous limitations such as “excessive comorbidity”, overuse
of not otherwise specified categories, among other problems; Jones, 2011, p.
485), but take them at face value and therefore set structures in place that
clinicians must oblige by even though they may be intrinsically incorrect.
DSM-5, Consumers, and Mental Ill-Health
Given
Frances’ (2013a) prior precautionary statement about the potential
pathologising of bereaved persons, it is adequate to outline a case in point
where the new diagnostic features were used regarding a client (Mr. Quinn)
after he was bereaved of his son to suicide. Although Mr. Quinn’s psychiatrist
originally informed him that his reactions (i.e. insomnia, grief, social
withdrawal, and increased alcohol use) to his son’s suicide were “normal grief
reaction[s]”, it was upon later assessment that the psychiatrist observed Mr.
Quinn’s symptoms worsening in intensity in terms of “the development of
cognitive [e.g. his negative and destructive thoughts regarding what he could
have done to prevent the death of his son] and neurovegetative [his
dissociation from society as a whole] symptoms” (Barnhill, 2013). Given the
increasing severity of Mr. Quinn’s condition, along with other factors such as
his personal and family history, he was diagnosed with Major Depressive
Disorder six weeks after the death of his son.
This
diagnosis has the potential to aid in his mental health treatment given the
assessment information of prior major depressive episodes a few decades
earlier, and the improvement thereof by the use of antidepressant medication
coupled with specific psychotherapy. His psychiatrist may draw on his
psychiatric history (along with the recent diagnosis) in order to formulate a
treatment that will aid in Mr. Quinn’s recovery.
A Shortcoming of DSM-5: Grief and
Depression
Friedman
(2012) notes that “[c]linicians and researchers have long known that… grief
typically runs its course within 2 to 6 months and requires no treatment” (p.
1855). The DSM-IV-TR (the previous edition and revision of the DSM prior to
DSM-5; APA, 2000) echoed these clinical assertions through its grief exclusion
criteria to Major Depressive Disorder. The DSM-5 however has removed this
exclusion given recent research that has suggested, “bereavement is a legitimate
etiological contributor to major depression” (Fox, & Jones, 2013). Others
have argued however that rather than medicalising grief the medical profession
must act in such a way to normalise it (Friedman, 2012). The debate against the
relevance of the exclusion criteria within the DSM is multi-faceted and
complex, and also not the focal point of this essay, thereby it shall not be
discussed further, but only to provide an example of a proposed limitation of
the DSM-5 in terms of consumer diagnosis and treatment.
The
DSM-5 does carry with it various in-house debates regarding the relevance of a
number of its categorical diagnostic mental illnesses, and within the mental
health field there is little universal consensus as to which symptom clusters
belong to which syndrome (and therefore which categorical mental disorder) on
the mental illness spectrum. Notwithstanding the latter, the consumer has been
shown to benefit when their problem has been diagnosed (through the use of the
DSM) and treatment possibilities offered by the mental health care professional
(Fox, & Jones, 2013). Regarding consumers however, Frances (2013b) notes
that,
Psychiatric
diagnosis can be a turning point in your life, leading to great good if
accurate, great harm if not. Take at least as much care in buying a diagnosis
as when you buy a house or car. Become fully informed consumers, knowledgeable
enough to challenge doctors who make quick or questionable diagnostic calls…
Make sure the diagnosis fits before you buy it.
The Family Systems Model: Overview
As
observed above, the DSM-5 approach to mental health can be identified as
operating via a medical model framework that focuses primarily on psychiatric
symptomatology. Other models have been proposed that focus on the strengths of
the consumer rather than attempting to pathologise presenting concerns. The
Recovery model is one such model that falls under consumer-centred care and
advocates a client-centred journey where “one’s attitudes, values, feelings,
skills, and/or roles” are changed in order to impact the person’s life through
empowerment and the realisation that they are self-actualising agents
(Commonwealth of Australia, 2009, p. 31; as cited in Hungerford, Clancy,
Hodgson, Jones, Harrison, & Hart, 2012).
A
central theme in Bowen’s Family Systems theory is the differentiation of self.
This is the ability to employ reflective thinking into ones own interpersonal
reactions and to be flexible enough to act wisely, even when faced with
environmental stressors (Nichols, 2010). The Family Systems approach (Bowen
being the originator of this approach, though other family systems approaches
have developed out of his one) focuses not on pathologising the client, but
understanding him or her in the context of the interrelated systems that are
evident in the client’s world.
Corey
(2013) notes that according to the family systems perspective problematic
behaviour in a client may,
(1)
serve a function or purpose for the family; (2) be unintentionally maintained
by family processes; (3) be a function of the family’s inability to operate
productively…; or (4) be a symptom of dysfunctional patterns handed down across
generations. (p. 397)
Clients
cannot be understood on their own terms, but rather, according to the
functional purpose they serve in the family unit (Kolbert, Crothers, &
Field, 2013).
When
operating with a person using a Family Systems perspective, one understands
that when a client is less differentiated they tend to have trouble
differentiating between intellectual and emotional functions, thus tending to
be more rationally oriented and displaying an external locus of control (e.g.
holding other people accountable for their ability to be happy; Kolbert, et.
al., 2013). On the other hand, more differentiated persons tend to have a coherent
sense of self, and display “clearly defined beliefs, convictions, and life
principles” (Bowen, 1978, p. 365). These senses of selves are, of course,
complex concepts that are intrinsically linked to their pragmatic purpose
within the context of the family system.
A
therapist’s focus on the family unit is shaped by the comprehension of other
factors that influence the makeup of the family. These include any relevant
psychiatric concerns within the family (e.g. children’s learning disorders),
neurophysiological factors (e.g. the neurobiology of a child or adult with
hyperactivity or impulse issues), and cultural factors (e.g. the role religion
might play in the everyday life of the family; Spronck, & Compernolle,
1997).
Since
there is such an emphasis placed on the family unit in the development of a
family member’s symptoms, the real problem is not on the symptom bearer, but on
the family (Burton, Westen, & Kowalski, 2009). One very important point
however, as identified in Burton et. al., is that the systemic approach is not
compatible with any other perspectives of psychopathology given that it
operatives on a level of analysis that requires emphasis to be placed on the
family for one of its members’ symptomatology. The family unit, at bottom, is
responsible for the symptoms evident in a specific family member.
The Family Systems Approach, Consumers,
and Mental Ill-Health
Take
the case example of 15-year-old Jennifer who although was a high achiever at
her secondary college and often commended for her academic and artistic
achievements was also frequently described by her teachers as appearing “down”
and determined by the school counsellor as being depressed (Kolbert, et. al.,
2012). Upon investigation and participation in counselling sessions at a community
health care centre, it was found that Jennifer’s parents were adamant that they
were not interested in attending family counselling with their daughter.
For
the counsellor, it was imperative that Jennifer’s family dynamics would be
explored in order to understand the nature of her depressed mood. It was found
that Jennifer’s parents were not interested in “renegotiating their
relationship with Jennifer as they both benefitted from the family patterns of
communication and problem solving” (Jennifer’s mother benefitted from getting
help with cooking, cleaning, shopping, taking care of her other children, and
complaining about her relational problems with her husband, whereas Jennifer’s
father benefitted out of her helping her mother and taking the burden from his
shoulders; Kolbert et. al., 2012, p. 93).
Jennifer
seemed overwhelmed given these ‘arrangements’ and this contributed to her
depressed mood. However, once she understood the predicament of her situation
given her mothers craving for the ‘perfect family’ seeing that she was raised
in foster care, her father’s discontent given her mothers over-emotionality,
and a more differentiated view of herself as a member of her family, she was
able to understand that her own discontent with her parents and her
perspectives and emotions thereof were indeed relevant. What was important
however, was how she communicated those feelings, and how she chose to
“honestly discuss the burden of occupying her current role within the family”
(Kolbert et. al., 2012, p. 93).
For
Jennifer her depressive symptoms were instigated given her family dynamics.
Once she understood her own differentiated self, and the multiple perspectives
at work in her current predicament she was better equipped to manage her
emotions and work towards a greater level of satisfaction in life.
A Shortcoming of the Family Systems Model
One
strong criticism towards the family systems perspective (especially in its
application to adolescents) is its non-efficacy in clients from collectivist
cultures. Kolbert et al. (2012) notes that given the salience of ‘the self’ in
Bowen’s family systems theory there seems to be an incongruence with the
emphasis on shared familial and communal values, practices, and beliefs in
collectivist cultures. Corey (2013) also notes that a possible shortcoming of
Bowen’s theory is its seeming disregard for diverse families outside the
Western-based model of the nuclear family. To Corey, many family therapists do
not seem to take into account the large variations in family structure,
communication and processes, especially in diverse populations.
Towards a Comparison
Corey
(2013) draws a comparison between systemic and individual approaches to
elucidate a therapist’s process in assessing a client, Anna, for her depressive
symptoms over a two-year period. Focusing on the medical model the individual
therapist would attempt a diagnosis of Major Depressive Disorder using the
DSM-5, select a therapeutic technique (probably cognitive behaviour therapy) to
address Anna’s detrimental and irrational thoughts that lead to her depression,
focus on predisposing, precipitating, perpetuating, and protective factors that
play into her diagnosis, and assess her individual perspective and experiences
with the intervention chosen by the therapist for the proposed benefit of Anna
(Corey, 2013).
On
the other hand, the systemic therapist would attempt to understand the family
system, and possibly incorporate the use of a genogram. The therapist may
invite Anna’s parents and siblings into therapy in order to understand the
dynamics of their inter-familial relationships and how they may be affecting
Anna’s mood. The therapist might then look for “transgenerational meanings,
rules, cultural and gender perspectives within the system, and even the community
and larger systems affecting the family (Corey, 2013). The therapist may then
attempt to intervene in such a way that breaks down the anxiety caused by a
specific relationship within the family unit (e.g. Anna’s father might abuse
alcohol and this could contribute to Anna’s depressed mood; if the therapist is
able to work with the family so that the father decides to stop drinking, there
could be better results within the entire family unit). For Corey (2013) even
though Anna’s depression could have organic, hormonal, experiential, or
behavioural components (as the medical model would quickly identify), the
systemic therapist would rightly pursue an understanding as to how the family
unit might influence Anna’s symptoms.
Towards a Holistic Systemic Approach to
Psychopathology
Although
caution should be placed towards uncritically accepting the systemic approach
to psychopathology (in this case, the Family Systems approach) given some
potential shortcomings (e.g. the proposed difficulty in application to diverse
populations, and its stringent premise that psychopathology is an outcome of
family dynamics), it can be argued that there is more potential for
understanding and alleviating negative psychological symptoms given a more
holistic approach to addressing clients’ presenting concerns. As Spronck and
Compernolle (1997) note, when one thinks systemically they are more able to
take into account cultural, familial, and societal information and how this may
have contributed to the presenting client, along with information about the
individual, their ability for differentiation, and their own psychophysiology.
Where a child is dyslexic, for example, a systems therapist may attempt to
understand any psychophysiological factors that affect their ability to perform
well in class. They may also take into account the way his dyslexia is handled
in the classroom as well as at home. And they may also look into the way the
child handles his dyslexia personally (Spronck, & Compernolle, 1997). Via
attempting a more holistic understanding of the presenting person and family
the therapist is better suited to focus on relevant interventions.
In Summary
Although
the newest edition of the DSM asserted that it rested on the latest research on
psychiatric illness there has been much controversy leading to and following
its publication in May, 2013. Frances’ (2013a) critiques the negligible
efficacy of some of the alterations to a number of psychiatric disorders and
states that an informed consumer and professional perspective apply to one’s
assessment of the new DSM. Alternatively, the systemic approach to
understanding psychopathology was portrayed as a more holistic way of
understanding the presenting person in therapy. Although not without its
limitations, the systemic approach does (arguably) provide room to expand and
work with an individual on their own terms (and within a systemic paradigm
where multiple factors outside the control of the individual are taken into
account in light of the client’s presenting concerns) rather than the medical
approach of pathologising the client and working on a way to ‘fix’ him or her.
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