DSM-5 and Evidence-Based Family Therapy?

DSM-5 and Evidence-Based FamilyTherapy?Tom Strong1 and Robbie Busch2

1 University of Calgary, Calgary

2 University of Notre Dame Australia, Perth

The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) extends a pro-fession and practice-defining direction for family therapy. Warranting and expediting this medicalised direction hasbeen a scientific and administrative coupling of diagnosed symptomatic conditions with evidence-based treatmentsfor addressing those conditions. For systemically or poststructurally oriented family therapists tensions can followfrom this direction which we elaborate upon in this article. Specifically, we examine the premises behind thismedicalised direction for family therapy, juxtaposing these premises with systemic and post-structural premises ofpractice. We relate these juxtapositions to tensions family therapists may need to reconcile in their work withfamilies. We close with an overview of this special issue’s contributions that pertain to the DSM-5 and familytherapy.

Keywords: diagnosis, evidence-based practice, family therapy, post-structural therapy

Key Points

1 The continuing symptomological and individualistic focus of DSM-5 creates tensions for family therapistswho practice from systemic and post-structuralist orientations.

2 A discursive approach enables us to understand how DSM-5 discourse both enables and constrains ourunderstanding of human concerns.

3 DSM-5 does not address relational aspects of practice and creates “linguistic poverty” in limiting under-standings of family concerns.

4 Evidence-based practice tied to a medicalised diagnostic classification framework is a seductively algorithmicpractice, which reproduces normative, standardised conversations in mapping client concerns to DSM-5-based diagnoses.

5 DSM-5-based algorithms of evidence-based practice ignore the importance of context and the ever-chang-ing conversations of human concerns and multiple practices are required to reflect, articulate and work withfamily concerns effectively.

So what is it about the biopolitics of life itself…that provides the spaces within whichbioethical authority seems to be required and simultaneously circumscribes the issues towhich such ethical concerns appear relevant? (Rose, 2007, p. 31)

Welcomed or not, the American Psychiatric Association’s (2013) Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition (DSM-5) will influence the con-versations therapists have with families. In writing about diagnostic language as itrelates to relationships, Tom Andersen (1996) long ago wrote that “language is notinnocent”. The diagnoses of DSM-5 cannot be regarded as neutral scientific discover-ies, nor can the expected diagnostic practices accompanying the DSM-5’s use be

Address for correspondence: Tom Strong, Faculty of Education, University of Calgary, 2500 UniversityWay, Calgary, Alberta, Canada, T2N 1N4. [email protected]

Australian and New Zealand Journal of Family Therapy 2013, 34, 90–103doi: 10.1002/anzf.1009

90 ª 2013 Australian Association of Family Therapy

considered benign. Considerable rancor preceded the December 2012 vote by Ameri-can Psychiatric Association members to accept the contents of the DSM-5, whichnow details the new lingua franca of mental health practice. Family therapists uneasyabout the DSM-5 might take solace in knowing that the Chairs of DSM-IV andDSM-III aligned themselves against what they saw as an excessive medicalising direc-tion in DSM-5. Regardless, the DSM-5 is upon us and in this special issue we andour contributors consider its influence on family therapy.

In this issue’s introductory article, we will consider DSM-5 and family therapyunder the umbrella term “evidence-based” practice. The diagnostic categories fur-nished by the DSM-5 acquire added medicalised (i.e., diagnose and treat) logic whenconjoined with evidence-based interventions (Conrad, 2007). Normally focused oncontextualised family members’ understandings and interactions, such a decontextua-lised orientation to practice can seem incongruous to family therapists. So, we willconsider DSM-5 in this light, highlighting tensions therapists may have to reconcilein their work with families because of what we anticipate will follow from publicationof the DSM-5. As post-structuralist practitioners, we question the notion that thereare neatly predetermined, underlying, singular and fixed structures of meaning thatwe can use to build universal, conventional and normative systems of practice (e.g.,the DSM) without regard to reflexivity or context (Young, 1981). We instead regardmeanings for experience as arising in and from how people use language to articulateand communicate experience in acceptably familiar ways (Lock & Strong, 2010).

A post-structuralist stance thus enables critical reflection on “acceptable meaning”,a reflection that we and other contributors to this special issue are inviting about theDSM-5 and family therapy. We also bring a systemic practice view regarding theimportance of patterned language use for how it contextualises and regulates under-standings and social interactions. It is in this sense that families can be seen to con-struct realities particular to them (Reiss, 1981), while professions and institutions canbe seen to construct and maintain realities particular to their uses of language (e.g.,Danziger, 1997). In this article, we raise questions about DSM’s science and the clini-cal applications that follow from its use. We will also close with an overview of ourcontributors and their contributions to this special issue.

When I (Tom) first proposed a special issue of the Australian and New ZealandJournal of Family Therapy to its editor, Glenn Larner, over dinner at a conference wewere attending, I still felt some of the fire that had prompted me to rant about theAmerican Psychiatric Association’s (1994) DSM-IV in Family Process 20 years earlier(Strong, 1993). As a psychologist trained in systemic approaches to therapy, who hadtaken up narrative therapy’s linguistic and post-structuralist turn, I was working inthe public mental health system in British Columbia. Increasingly at that time, thescope of conversations I was to have with clients was expected to narrow to a focuson symptoms. The problem-solving and contextual/systemic aspects of how client con-cerns could be discussed seemed subordinated to irrelevant Axis 5 details for any, thenimpending, DSM-IV disorder I could diagnose and treat. With the subsequent profes-sional uptake of the DSM-IV came a ratio-technical view that algorithms of practicecould come from melding DSM diagnoses to evidence-based treatment, whichenabled an audit culture mentality to develop within mental health administrationand govern conversations therapists have with clients (House, 2005). DSM diagnosesoffer more than a professional or administrative language, however; for Lionel Trillingthey have become part of the “slang” of popular culture (cited in Illouz, 2008, p. 10).

DSM-5 and Evidence-Based Family Therapy?

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If we don’t diagnose clients, they will do it for themselves, or each other, it increas-ingly seems. DSM-5 promises to extend such professional, administrative and culturaldevelopments.

Family therapists tend to have conversations that do not narrow on the symptomsof individual members alone. Family therapy began, in part, out of a recognition thatthe symptom-bearing patient might be caught up in unrecognised and problematicfamily members’ patterns of thought, emotion, and interaction. On DSM-5 terms, anangry child might merit a diagnosis of the new “temper dysregulation disorder”whereas a systemically oriented therapist might identify a problematic pattern thatengages child and parent in particular ways. The therapeutic direction typicallyfollowing either way of articulating the concern can be quite different, particularly ifone subscribes to the view that diagnosis prescribes only certain forms of treatment.Such ways of coupling assessment and intervention are foundational to not onlyevidence-based practice but to growing expectations for “treatment fidelity” (Drake,Goldman, Leff, Lehman, Dixon, Meuser & Torrey, 2001; Tucker & Blythe, 2008).That clients’ therapeutic concerns might be articulated and addressed in more thanone discourse of practice can seem challenging, if not sloppily unprofessional. Beinginformed or influenced by the DSM-5 is not the same as having one’s practicedetermined by the DSM-5, however.

Our Discursive Reflections on the DSM-5

We approach the DSM-5 and family therapy in a discursive way (e.g., Busch, 2012;Lock & Strong, 2012), with an eye to what is potentially constrained or enabled by anydiscourse. By discursive, we relate our early mentioned post-structuralist views to howlanguage is used in micro-dynamic (i.e., face-to-face dialogue) and macro-dynamic(institutional, professional, cultural) communications. Wary of dominant discourses orthose that claim exclusory truth status, we see discursively minded practitioners facinginescapable tensions in their conversational work with families and family members.Most importantly, however, we see an important ethic of practice in the notionthat therapists address “linguistic poverty” (Vico, 2001) wherever it arises, helpingclients to stay discursively resourceful so as to elude discursive capture (Massumi, 2011).Discursive capture, in our sense, refers to getting stuck in particular ways of thinking,acting, or communicating within the constraints of any discourse, such as the DSM-5 orfamily therapy’s models.

Our discursive approach contrasts with the notion sometimes ascribed to DSMthinking, that there is a single correct way to name experience. Discursive therapists(e.g., narrative, solution-focused, collaborative) often invite clients to reflect upon andconverse beyond the linguistic poverty of any singular discourse. Representing aperson’s experience of bereavement in psychiatric discourse alone can foreclose onother ways of making sense of profound loss, for example. The human concerns thatone finds articulated in the DSM-5 represent a particular kind of history-makingfor mental health professionals, with new understandings for old concerns, andnewly identified concerns. Reflecting upon past representations of such concerns(e.g., Foucault, 2006; Grob, 1991), developments leading to the DSM-5 appear toshow a triumphant march of psychiatric science. A symptom-based discourse emergedenabling practitioners to move beyond imprecise and disrespectful terms like moronor neurotic. Concurrent with these developments, and perhaps because of the empha-

Tom Strong and Robbie Busch


sis on symptoms in patients, the diagnostic focus became increasingly biological, tothe point where normal but unwanted or unpleasant aspects of being human weremedicalised (e.g., Furedi, 2004; Rapley, Moncrieff & Dillon, 2011). Correspondingly,intervention shifted in this biological (read: pharmaceutical) direction, and not with-out considerable controversy (Angell, 2011; Whittaker, 2010). For family therapists,questions can arise about our relevance in this new therapeutic landscape.

However, psychotherapy has been the site of some nasty professional turf warsbetween psychiatric and other professionals, with the heart of the controversies beingover whether the concerns clients present should be treated as medical in nature(Grob, 1991). Psychologists felt they had much to lose if they failed to demonstratethat their ways of practice could make beneficial differences in clients’ lives (Beutler,1998; Galvin & Fernando, 2008; Task Force on Promotion & Dissemination ofPsychological Procedures, 1995). The sudden introduction of managed care in the1990s in the United States produced an impetus for psychologists to market them-selves through evidence-based interventions (Beutler, 1998). Both Australia and NewZealand seem to be following this direction, although perhaps slightly less fervently(e.g., Galvin & Fernando, 2008; Montgomery, 2003). However, the AustralianPsychological Society (Australian Psychological Society, 2010) produced a literaturereview of evidence-based therapies, matching them to ICD-10 mental disorders,using evidence criteria from the National Health and Medical Research Council andthe evidence-based practice in psychology policy from the American PsychologicalAssociation. The aim of the review (in its third edition) is for the APS to assess theevidence base for therapy, as it argues, “Government sponsored health programsquite reasonably require the use of treatment interventions that are considered tobe evidence-based as a means of discerning the allocation of funding” (AustralianPsychological Society, 2010). So, borrowing from medicine’s initiatives to establishan evidence base of effective treatments, psychologists eventually imported the scienceused by medical researchers (e.g., randomised clinical trials in laboratory circum-stances; manualised interventions) to prove the effectiveness of their clinical efforts(Busch, 2012; Levant, 2005).

Family therapists, in claiming their relevance as mental health practitioners, facedwhat Nichols and Schwartz (2008) have referred to as an “undeclared war” over theirassertions that many family members might be best (or also) treated within the con-text of the family. They, too, eventually took up the evidence-based direction (e.g.,Crane & Hafen, 2002; Pinsof & Wynne, 1995; Stratton, 2005), though not withoutconcerns expressed about what constituted evidence, or how the effectiveness of theirwork should be best evaluated (e.g., Larner, 2004).

Evidence-based Directions in Family Therapy

For post-structuralist therapists, this evidence-based direction, tethered to a medica-lised diagnostic classification system, epitomises Foucauldian concerns about “govern-mentality” (Rose, 1990). One modern scientific ideal is that the phenomena in anysphere of concern are correctly nameable, explainable, and made responsive tohumans to control them. To those sharing this ratio-technical view, therapy’s land-scape can seem like an untamed frontier urgently requiring scientific management. Itis this kind of scientific management (or “governing”) that requires diagnoses for agrid of intelligibility useful in identifying and micro-managing concerns, by practitio-



ners as well as the lay public (Hook, 2007; Illouz, 2008). To post-structuralists, theDSM-5 and its administrative coupling to evidence-based practice presents an idea-lised form of discursive capture (Massumi, 2011; Walsh & Gillett, 2011).

An extreme version of such capture can arise when diagnostic and treatmentprotocols or manuals algorithmically prescribe or delineate each conversational moveor judgment in therapy. The upshot is a particular science to legitimise particular(and curtail perceived unnecessary) articulations of concerns presented to familytherapists. For therapists informed by Deleuzian (e.g., Skott-Myhre, 2008; Winslade,2009) and hermeneutic (Cushman, 1995; Hacking, 1998) notions of practice, clients’concerns are best addressed with evolving, multiple understandings and formsof intervention which fit clients’ circumstances and preferences. Thus, one tensionaccompanying the DSM-5’s publication, for systemic or post-structural familytherapists, is how to reconcile their ways of naming and responding to client concernswith the governmentality of the DSM-5 and evidence-based practice (EBP).

An Evidence-based Revolution; But What Kind?

…we can define a scientific fact as a thought-stylized conceptual relation which can beinvestigated from the point of view of history and from that of psychology, both indi-vidual and collective, but which cannot be substantively reconstructed in toto simplyfrom these points of view. (Fleck, 1979, p. 83)

In a recent editorial podcast for the Journal of Family Therapy, Mark Rivett(2013) spoke of a revolution for family therapy that he associated with evidence-basedpractice. Evidence-based practice has come to mean many things but we agree withits general premises: practitioners should be able to justify what they do according toevidence informing their actions and they should also heed what clients have to sayabout the helpfulness of their work together. So, for example, Rivett cites the impor-tant research of Crane and colleagues that convincingly makes the case for familytherapy as an economically efficacious way of responding to client concerns (e.g.,Crane, 2008; Morgan, Crane, Moore & Eggett, 2013).

Our concerns are instead focused on a view described in the evidence-based literatureof medicine and therapy that speaks of “algorithms” (e.g., Rush, 2001). An algorithmicview of practice is based on the quintessentially modern view that problems can bediagnosed and treated according to a science that disregards context and is antitheticalto methodological pluralism (Cooper & McLeod, 2010). Algorithms of this sort mapconcerns to a diagnostic procedure; and from the diagnosis to “corresponding” interven-tion manuals – standardised conversations to diagnose and treat client concerns. Theenemy from this view of practice is “variation in care” (e.g., Tannenbaum, 2013); yetthe algorithmic approach tempts therapists and clients with a compelling sense ofcertainty about how to address suffering and disharmony (cf., Amundson, Stewart, &Valentine, 1993). Rivett’s revolution brings him to advocate for CBT, largely becausethat is the primary intervention for which our field has evidence.

One of our concerns has been with how much of the evidence-based revolutionhas been underpinned by the diagnostic language of the DSM-IV, which in effectmedicalises individuals’ symptoms in what many family therapists would see as rela-tional concerns (see Denton & Bell, 2013; Kaslow, 1996). For family therapists, thisneedn’t be an either/or (symptoms or dysfunctional relating) issue, of course. How-ever, much current evidence-based research in family therapy relates to symptom relief



based on DSM diagnoses. Despite some exceptions, our field begs for more evidence-yielding research to show family therapy’s effectiveness, such as by formulating and thenresearching clients’ concerns and therapeutic outcomes, in ways reflective of our differ-ent therapeutic approaches. Many family therapy approaches are based on relationalor post-structuralist formulations of clients’ concerns, premises, and practices that dif-fer from those which inform evidence-based treatment for DSM diagnosed condi-tions. At minimum family therapists using such approaches can be informed by clientfeedback on their experiences in therapy (Gabbay & Le May, 2012; Green & Latch-ford, 2012). Changes to symptom discourse is but one of the discourses we and cli-ents turn to, to know if therapy helps.

Local Practice, Dynamic Nominalism, Preferences, and EBP

The meaning of experience is perhaps the most crucial site of political struggle overmeaning since it involves personal, psychic, and emotional investments on the part ofthe person. It plays an important role in determining the individual’s role as socialagent. (Weedon, 1987, p. 79)

The scientific view of language and experience grounding most evidence-based prac-tice is that unwanted experience needs to be articulated and addressed in standardisedways, to create what pragmatist philosopher, Richard Rorty (1989), called an “ur-lan-guage” or “final vocabulary”. The view that experiences (like concerns that familiespresent to therapists) could ultimately be named in their totality, and with certainty,concerned Rorty. Language is a humanly constructed resource for adapting to changingand challenging circumstances, not a means to name and address circumstance withfinality. The downside of such an “ur-language” is that while it may seem to enablefamiliarity and predictability, too often language (the already said and known) comesup short in addressing unanticipated circumstances. Toward the end of his life, Rortycame to be known as a “dynamic nominalist”, someone who favoured creative languageuse to enable people to aptly respond to challenging circumstances, and to each other.

Among a growing number of philosophers of science (e.g., Hacking, 1983) adynamic and more human view of language, for scientific research and its subsequentapplications, has been emerging. Humans, for their particular purposes, agree to nameexperiences in particular ways enabling such developments as temperature or theworld clock (Chang, 2007; Galison, 2004). This is a different view than the view thatthe correct meaning for experience awaits discovery – as if experiences like “opposi-tional defiant disorder” could name themselves, or that our methods of diagnosisenabled us to recognise them “as they were” so to speak. Contentious arguments even-tually resolved how time and temperature would be measured globally, and any read-ers following the process leading to the DSM-5 would know that a slew of debatesaccompanied its political adoption by members of the American Psychiatric Association.

These points relate to a post-structuralist view on concerns and how they arearticulated (Butler, 1997; Weedon, 1987). In the words, of quantum physicist andfeminist, Karen Barad (2007), “Matter and meaning are not separate elements” (p. 3).How scientists represent experience and intervene to influence experience, based ontheir representations, is at the heart of contemporary science (Hacking, 1983). Thechallenges begin when different articulations of experience compete for legitimation(cf., Habermas, 1975). In considering human concerns, are therapists and clients best



served by biochemical, genetic, anthropological, or spiritual discourses; or might it bethe case that each discourse offers potentially useful articulations and resources? Toreturn to Rorty (1989), what matters in such cases are effective discourses becausehuman language is incapable of representing experience correctly. Some of the anxi-eties that contributors Chambers, MacDonald and Mikes-Liu (2013) point to overDSM-5, for post-structuralist therapists, relate to how the DSM-5 could conceivablybecome therapy’s only legitimate language with respect to payment or professionalethics.

Across the therapeutic spectrum one finds many ways to recognise and articulateclient concerns. This kind of pluralism is welcomed by many therapists (e.g., Cooper& McLeod, 2010), but runs counter to efforts to standardise the diagnostic languageused by therapists. Efforts to contextualise client symptom presentations are typicallysubordinated to Axis 5, despite efforts by Denton and others to advocate for relationalcircumstances as part of the diagnostic process (see Denton & Bell, 2013; Kaslow,1996). Algorithms of practice, like those described earlier, are easier to operationalisefor a single diagnostic language, particularly when evidence-based interventions arecoupled with the diagnoses. Such algorithms enable therapy-rationing schemes, offermeans to monitor scientifically legitimated practice, warrant the bases upon whichcorrect training and supervision is seen to be offered, and telegraph to the public clin-ically approved ways to manage oneself and others (House, 2005). Underpinning suchalgorithms is the symptom language of the DSM-5. A Foucaultian nightmare versionof practice management is offered up on this theme by Nobbs (2013).

Part of a post-structuralist approach to practice, evident in such approaches asnarrative therapy (Simblett, 2013), proceeds from understandings of client concerns thatdo not fit within a pathologising, decontextualised, or algorithmic approach to namingand addressing client concerns. Instead, problem names, and even the kinds of conversa-tions post-structuralist therapists discuss with their clients, are more fluid and contextua-lised than those required for algorithmic adherence to diagnostic interview schedulesand manualised intervention protocols. Missing from a post-structuralist view of practiceis a common diagnostic language for client concerns and evidence-based interventionsaddressing those diagnosed concerns. To those preferring an algorithmic approach, post-structuralist practice sounds like professional anarchy or unethical practice.

The flipside of EBP (what therapists should already know) is practice-basedevidence (PBE) derived from clients to make therapy relevant and effective for them(Green & Latchford, 2012). The most conclusive evidence we have about therapy isthat interventions, while important, matter less than the quality of the therapeuticrelationships in which they are used (Hubble, Duncan & Miller, 1999). Therapistresponsiveness to how clients respond to any intervention is critical (Stiles, 2009). Forus, collaborative and ‘local’ dimensions of post-structuralist practice come togetheraround how therapists and clients name problems in ways that enable contextualiseddecisions about how to address clients’ concerns. Practice-based evidence from clients’views of the helpfulness of therapy, and feedback from clients that can optimise thathelpfulness, also makes therapy evidence-informed – without tethering practice toconversational scripts and names embedded in an algorithmic matrix.

In the mental health system of Norway, for example, clients use outcome ratingscales to evaluate and inform practice (Duncan, Miller & Sparks, 2004; Owen,Duncan, Anker & Sparks, 2012; Sundet, 2012). Further, the names given to clientconcerns using the outcome rating scale are collaboratively developed with family



therapists; client satisfaction with the process is what matters. A different kind of evi-dence-base can emerge; one informed by client satisfaction with process and outcomesand the quality of therapeutic relationships without being prescriptive. Among somehealth-care providers a new kind of evidence-informed (both EBP and PBE) practiceis emerging in response to some of the algorithmic or script-like excesses of EBP; inwhat Gabbay and Le May (2012) refer to as “clinical mindlines” of practice.

It is important to remember that DSM-I began first as a language for researchersand only later was appropriated by clinicians, administrators, courts, and the public(Grob, 1991). However, further evolutions of this language have brought us to theDSM-5, and along the way not only has a particular dominant view of therapyemerged from these evolutions, but a way the media-savvy public regards, monitorsand “treats” themselves and each other has followed (Illouz, 2008). This is the concernof Epstein, Wiesner and Duda (2013) who invite us to ponder where the DSM journeyis taking not just family therapists, but families and their members. That funded helpto families is offered only on the basis of diagnosed DSM conditions in many parts ofthe world is a by-product of this journey, and one of the ethical dilemmas many thera-pists must address in trying to be helpful (e.g., Moses, 2000).

This Special Issue

In the articles which follow, our contributors offer different experiences and opinionson the DSMV. Nobbs (2013) article shares ethical dilemmas of diagnosis that shefaces in her practice. Writing from the position of an Australian systemic family ther-apist working in the Netherlands, and informed by a narrative perspective, Nobbsargues that family therapy practice is constrained and medicalised within a multilay-ered health classification system. This system merges national citizen registration withDSM diagnoses as well as outcome monitoring of psychotherapy by Dutch insurancecompanies, which privilege DSM diagnoses for reimbursement. This multilayeredsystem of classification creates, what Rom Harr�e (1983) would argue as, a file self – adecontextualised record that constitutes the identity of one person. Illustrating thechallenges of working within the constraints of DSM diagnosis, Nobbs argues thatone can feel compelled to (mis)fit diagnoses to family issues. This is because theDutch health system legitimises and funds DSM diagnosed individuals, which is chal-lenging for systemic therapists working from a narrative perspective and wishing toavoid individualistic pathologisation. She raises important issues around the potentialfor DSM-focused diagnoses to become a globally pervasive and unquestioned culturalnorm that might negatively discriminate and potentially harm clients.

Simblett’s (2013) article also looks at the ethical dilemma of working from a dif-ferent philosophical perspective to the pervasive DSM values that inform the eco-nomic foundation of mental health care. However, he argues that very little is writtenabout how to assist practitioners who work in such dilemmas. Simblett reflexivelyexamines his position as a post-structuralist and narrative-informed psychiatrist whoworks with families under the dominance of the DSM, identifying new discursivespaces to negotiate between two seemingly diametrically opposed discourses: narrativeand the DSM. Simblett uses the Foucaultian notion that if uncertainty builds as aform of resistance within a system of knowledge and therefore power, the dominantdiscourse that pervades that system is weakened. He uses a dance metaphor to reflect



on the fluid positions or “dance styles” that he chooses to take up as a narrative-informed practitioner, dancing with the DSM as his partner.

This clever metaphor is used to examine the ethical complexity of being a narrativepsychiatrist. Sometimes he feels ethically bound to tango closely with DSM discourse(e.g., when medication would be helpful or when a diagnosis is needed for evidence-based treatment funding). On the other hand, a more distant jive, enabling space fornarrative discourse, loosens the tight hold DSM discourse has on constructing thetruth, identity and realities of persons within families and enables a more contextualunderstanding. Simblett argues that these different dance strategies (tango, jive, hijack-ing, backleading, and declining – along with its risks) have enabled creative work-arounds for manoeuvring between and within two dissimilar epistemological stances.

Chambers, MacDonald and Mikes-Liu (2013) also highlight the complexity ofhaving to work within multiple paradigms, but focus their argument on the need tofoster a constructive dialogue about DSM issues in relation to family therapy withoutemotional reactivity. Their concern is that opponent and proponent arguments onthe issues and controversies of the DSM are emotionally charged and reactionist.They draw from Bowen family systems theory to understand how processes of emo-tional reactivity (e.g., anxiety as an emotional and relational threat) can be unhelpfulto professional and practitioner-client interactions. Chambers, MacDonald andMikes-Liu argue that when perspectives are expressed through heightened emotionalreactivity, they create an anxious focus or a selective judgement of others, whichimpedes constructive dialogue. Although they provide suggestions to manage emotionalreactivity (e.g., maintaining an openness to diverse paradigms and being aware of ourcultural and personal biases), they also concede that solutions are complex anddilemmas exist (e.g., each time a practitioner privileges particular paradigms thatmake sense of family problems and family therapy, he/she diminishes the importanceof others).

An awareness of paradigmatic changes in the DSM enables us to contextuallyunderstand how the DSM emerged and where it could be heading in relation to fam-ily therapy. Denton and Bell (2013) address this issue by outlining a concise historicaloverview of paradigm shifts that have constituted the DSM since its inception andexamine implications of the latest shifts on family therapists. They argue that theDSM-I was the most systemic of all versions because it conceptualised mental disor-der as mainly reactive to the environment; it was a product of the dual influence ofenvironmental stressors and biological susceptibility. The DSM increasingly becameless systemic through psychoanalytic and descriptive paradigm shifts where mental dis-order was viewed as something existing within an individual, and where family issueswere marginally addressed through Axis V codes. Denton and Bell note a recentparadigm shift in diagnostic classification from neuroscience research where theNational Institute of Mental Health have been developing new methods of classifyingmental disorders from observations of behaviour and neurobiology. This new possibleshift, called the Research Domain Criteria (RDoC) project, conceptualises mentaldisorder as a brain dysfunction that also takes into account relational processes andsystems of functioning. This new view of mental disorder, Denton and Bell argue,may provide a welcome space for some family therapists because it deviates somewhatfrom the current DSMs’ reductionist and individualist notions of mental disorder.

Epstein, Wiesner and Duda’s (2013) take a different approach to examining theconstraints of the DSM by arguing that there are certain aspects of the language of



the DSM that are recursive, which limits the construction of self-identity. They areconcerned by a global uniformity and decontextualisation of possible identitiesthrough the current therapeutic state, and argue that diagnosis is a MacGuffin – anobject (from director, Alfred Hitchcock) that is irrelevant but yet essential to a plot.It is a recurring central object but there is no meaning behind it. The mere recurrenceof the object enables an assumption that it is important or fundamental. Epstein,Wiesner and Duda argue that because diagnosis is a MacGuffin, it anaesthetises usfrom questioning the assumptions that contribute to its existence, which then serve tonegate any contextual examination of family issues. They suggest a post-therapeuticstate could be a way forward, one that privileges a plurality of meaning and culturethat therefore is not constrained through the discursive dominance of diagnosticvocabularies and psychiatric categorisations.

Discussion

All our mental categories without exception have been evolved because of their fruitful-ness for life, and owe their being to historic circumstances, just as much as do thenouns and verbs and adjectives in which our languages clothe them. (William James,1987, p. 551)

The DSM-5 would not be worth a special issue of the Australian and New Zea-land Journal of Family Therapy were it not for some of the concerns that we and ourcontributors are raising. Undeniably, the diagnoses enabled by previous DSMs have,in many circumstances, been helpful (Grunebaum & Chasin, 1978); our concernin this article has been over its dominance as a discourse of practice. How familytherapists come to terms with the DSM-5 – or if they even need to – relates to ourview of practice that is part systemic and part post-structuralist. On the systemic side,we have concerns for what an individualised basis for practice offered by the DSM-5translates to for a relational conception of practice. On the post-structuralist side, ourconcerns relate in part to what Vico (2001)/1744 raised centuries ago about “linguisticpoverty”; circumstances where existing language was proving inadequate to addressinghuman challenges. For Vico, such circumstances required what he termed “poeticwisdom”, and we believe that this relates to the quote above from pragmatic philosopherand early psychologist, William James.

A dominating language of human concerns tethering the conversations and inter-ventions of families and family therapists has animated our efforts in this contributionto this special issue on the DSM-5 and family therapy. In reading other articles ofthis issue we invite readers to reflect on how their conversations with families havebeen possibly shaped in ways by previous DSM editions, and how they will practice,given the global influence (Watters, 2010) of this way of understanding and respond-ing to human concerns.

Acknowledgements

The writing of this article was supported by funding from the Social Sciences andHumanities Research Council of Canada. With thanks to the Taos Institute, theUniversity of Calgary, and the Social Sciences and Humanities Research Council ofCanada



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DSM-5 and Evidence-Based Family Therapy?

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