Despite the criticisms of the latest guidelines for what constitute mental illnesses, practitioners continue to rely on them to justify their diagnoses to patients and in courtrooms.
The release of the American Psychiatric Association’s (APA) fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) last year was accompanied by heavy scrutiny and condemnation by critics in the psychiatric and psychological community.
Both the Australian and British Psychology Societies, and even divisions of the APA, have voiced concerns over the new guidelines.
These concerns relate to the DSM-5’s revision of the definition of mental disorder, its lowering of diagnostic thresholds and strong emphasis it puts on biological or medical causes of mental illnesses.
Yet despite these well-known and publicised concerns, practitioners continue to rely on the manual in their everyday work.
Dr Mitch Byrne, Senior Lecturer of Clinical Psychology at the University of Wollongong, said the issue is crucial as professionals need a common diagnostic framework to justify whether a patient qualifies for access to healthcare or support services or when giving evidence in court.
“What they generally tend to use it for, besides communication between professionals, is to justify a particular approach to an individual,” Dr Byrne stated.
“That justification often has legal ramifications and the difficulties of the DSM and for anybody challenging it is that, when you’re in a court of law or if something goes wrong, you want to have faith that the decisions you made and the basis of the diagnosis that you derived were justifiable and that you won’t be prosecuted for making poor decisions.
“A psychiatrist will make a diagnosis on the basis that this is going to influence the extent to which a person has access to a hospital admission, or to a benefit, or to restricted medication – and those decisions are important for the psychiatrist and also important for the patient.”
Dr Byrne, who is also a forensic psychologist, said he refers to DSM diagnoses when giving evidence in court even though he disagrees with their reliability, because it is the guidelines that are officially used as the standard diagnostic process in Australia.
“If courts are relying on one agreed set of facts and that agreed set of facts is the DSM, which is unreliable, then the courts may make unreliable decisions,” he said.
“But when I go to court, I will refer to DSM diagnoses as well because that’s a way in which you communicate with the court what it is you’re facing and seeing.
“And I will continue to use the DSM as long as the DSM remains the primary form of diagnostic technique that we use. So I perpetuate the problem, because the courts won’t listen to people who speak outside what is the norm in the profession.”
One of the problems with relying on the DSM is that what gets chosen to be included as a mental disorder can be influenced by ulterior motives.
“It’s of course influenced by the politics that are behind it, in terms of what the diagnoses might mean for people’s access to healthcare and access to support services,” he explained.
“There’s micro-political processes in terms of people’s egos and research areas and promoting those.”
“And there’s macro-political issues in terms of things like Government funding for various disorders and Government funding for various areas of research – then that’s really important and I don’t think we can bypass that.
“So there’s a lot that goes into the diagnostic system other than just giving a person a diagnosis.”
But it’s the legal ramifications of making diagnoses that Dr Byrne highlighted as particularly important when it comes to needing guidelines to justify them.
“The legal ramifications are enormous because the courts make decisions at all sorts of levels including things like people’s compensation as a result of accidents, if they make decisions with regards to incarceration, the lengths of sentences can depend on people’s diagnoses.
“The courts make decisions as to whether children are kept or taken away from their parents on the basis of a diagnosis that a parent might be given.
“These things are really important in people’s lives and the courts are naïve in these matters, and that’s why people like myself are called into court to give evidence.”
Dr Byrne suggested Australian psychiatrists should move away from the American diagnostic model to the European model, which offers a more holistic approach.
“A better diagnostic system is what’s called the ICD, the “International Classification of Diseases”, which is used to classify all health problems – including mental health problems.
“Although the ICD has problems as well, I think we would do better with the ICD than the DSM.”