Editor's Notes

DSM·IV in Clinical Practice Today

Len Sperry

Though the memory is fading a bit I recall the first time I encountered
Ihl' DSM. Acurious plain brown package had arrived in the morning mail in
Fehruary 1')80. II was only as I unpacked it that I realized what it was. I had
nearly forgntten that three months previously I had ordered a prepublication
copy of DSM-II/. The ad and order blank had heralded it as the most defini-
tiVl.' refl'rence manual in ml'ntal ht>alth. My curiosity had been aroused, and
I had ordered il. It was not exactly a manual but rather a 700-page book, and
its serenl' green and yellow cover belied its revolutionary content and subse-
quent impact.
Isay revolutionary bec:auSl' DSM-II/ soon influenced nearly every aspect
of ml'ntal health lreatment and l'Vt!n thl' mental health profession itself. With
regard 10 trealment. D5A1-11/ diagnoses would soon be required for insurance
reimbul5emPnt. The generic "Adjustml'nt Reaction" diagnosis that many of
my colleagues h.ld heretofore given to all or many of their clients or patients
would no longer suffice. In thl' 1!/b05 and 19705. diagnostic labels such as
depressive neurosis, anxil'ly nl'urosis. disorders. or hysterical personality dis-
orders welt' considered 100 stigmatizing. and many of us essentially refused
to use DSM diagnoses and if required 10 specify a diagnosis used the benign
"Adjustment Reaction" dl'signation. That all changed. Lall'r, reimbursement
ami l'Vt!n authorization for Sl'rvin''; were denied if the diagnosis was not
Sl'Yere enouRh to ml!l't thl' critl'ria of "medical necessity."
Thl' profession of ml'ntal heallh changed as "newcomers" joined the ranks
of mPntal heallh prufessionals. A nl'\V specialty within the counseling profes-
sion emerged: mental health counseling. Previously, the counseling profession
had taken great pride in differt'flliating itsl'lf from "pathology: and the "medical
model" had now embraced mudl uf what DSM-II/ stood for: therapeutic treat-
mt'nt for psychiatric conditions and disorders. DSM-III workshops tor
practicinll counselors were hl'ld in major cities several weekends a year.
Gr.ldudle programs in l"OunSl'ling that had been 3lJ.credit-hour programs now
Wt're douhled in length 5/1 that Ilraduates could sit for a national exam to

n. .""'..".• ".b"d",,1 I'Mdllllr.w;:I. \"IJI III Ni, ... WlnM .!002

." .!'I'': I" rh.·llnlWl..." ... ~ ........-. I"tl tII.\ ·.1". \Ullin. T\ "1'I~11·:"III'"
354 Len Sperry

qualify for licensure. Licensure as a professional counselor entitled one 10

practice psychotherapy independently and 10 bill insurance companies and
oIher third-party payers for psycholherapeulic services rendered. A similar
development occurred within the profession of marital and family therapy.
My first recollection of DSM-llwas even more faded. Iwaslllam leaching a
graduate course in psychopathology with Dr. Richard Cox in the fall of 1975.
He had chosen the books for the course, one of which was a standard text on
abnormal psychology and the other was DSM-II. This DSM was thin, a mere
134 pages long. and sported mustard yellow cowrs with a white plastic bind-
ing. Outofcuriosity Itried 10 locate the original DSM and found it in the unillersity
library's armiws. Of course, it was not designated as DSM-I in 1952. It was a
few pages lonlll!l'than DSM-II but provided the same fonnat: short descriptions
of each disorder without any criteria or epidemiological information, as would
be the distinguishing feature of DSM-III and its successors. I dare say I only
flipped through these first two editions because Richard had made allusions 10
the class of some historical changes in diagnostic labeling in the 16-year period
from DSM-I (first published in 1952) 10 DSM-II (first published in 1968). Irecall
thinking that these classification manuals were basically useless for students
and clinicians. For students they provided only vague and seemingly arbitrary
descriptions of clinical conditions with no discussion of demolPaphics and eti-
ology, as did psychopathology textbooks. For clinicians, there was no di5CU55ion
of differential diagnosis nor of treatment strategies, as would be found in psy-
chopathology and other texts. I recall thinking how useless they seen led 10 be
for not only clinicians but also researd1ers. If Richard Cox had not brought this
document 10 my attention, I doubt Iwould have even known of its existence. At.
that time, DSM was not ·required· for record keeping or reimbursement and I
eenainly would have no reason 10 use it. That was in 1975. Five years later. my
altitudes and my clinical practice pallern&--;lnd that of all of my colleagues
would change dramatically.
This special issue of The Journal of Individual Psyc/IoIogy besan as an
invitation from the journal's edilors. They asked me 10 consider addressing
the concerns and challenges that DSM-IVposes in the current milieu of the
everyday practice of mental health clinicians. There is no shortage of opin.
ions about DSM-IV and the recently released DSM·IV·Tex' Revision
(D~/V- TR). There are some clinicians who are strong advocates of DSM.
There are, however, a number of very vocal clinicians who are quite critical
of DSM and everything it represents. Nevenheless, the majority of clinicians
appear 10 have come 10 accept and 10 accommodate DSM in their everyday
practices. This special issue is not intended 10 catalog an extensive litany of
praises or curses leveled at DSM. Rather it offers a variety of viewpoints re-
garding the clinical utility and value of DSM-IVfrom clinicians who practice
from a cognitive, dynamic, and/or systemic perspective.
 Editor's Noles 355

In Ihe opening article. Maniac:c;j provides a succinci overview of the ra-

tionalt' for the DSM. He note!. thai while it proposes a universal language of
psychopathology. il bOlh sucCPeds and fails because it embraces an
alheorelical posilion. Ht' Ihen suggests ways of incorporating DSM into clini-
cal practiCt' from an Individual Psychology viewpoint.
In Ihe next article. Duffy. Gillig. Tureen. and Ybarra provide a very suc-
cinct and readable crilique of the DSM from a Iht'OIy of knowledge perspectiw.
Poslposilivisl and social conslruclionisl Ihl'Ol'ies 01 knowledge are used 10
review objeclions to the DSM lrom both perspeclives. As a metanarralive.
DSM is discussed wilh special altt'nlion to Ihe practical implications of diag-
nosis for tht'rapists. their c1ienls. and sludents in Iraining.
Nt'xi. Mansager considPrs tilt' adequacy and clinical use of the DSM-IV
V-<ode. HRt'ligious and Spirilual Problems." He deftly describes how Ihis
particular clinical enlily gave rise 10 a DSM committee and ilS evenlual diag-
noslic classification. UsinA SIX ial inleresl as Iht' norm of mental heallh. he
proposes specilic c:rill.'l"ia for dt'tt'rmining religious or spiritual health and
their applicalion in lrealment.
In tht' nexl article. Maniacci imd Sackell-Maniacci t'Xplore the clinical
uses of Ihe DSM from an Individual Psychology perspeclive. They describP
and illuslrale its relt'Vanct' wilh lwo clinical cases. Acognilive-dynamic-5Ys-
lemil' case felrmulalion and a fivt'-5lep trealmenl outline demonslrale how
Ihe mulli-axial syslem can bP used in treatmt'llt planning.
In Ihe nt'X1 article. I compare DSMs underlying pathology model wilh
Ihe dt'llelopmenlal or growth modt'1. I discuss Ihe developmental model's
displacemt'nl by DSM and Ihe currml relrieval of the developmental model
and suggesl thai clinicians would do well to consider both models in their
formulalion and trealmenl planning. Itht'n describP a developmental line for
each of Ihe common personalily slvll.'5ldisorders ree:ognized in clinical prac-
Iil"l~ as well as in DSM-IV. Acase srudy iIIuslrates the clinical applicalion of
lhese dt'llelopmentallines in guiding Iht' goals and process of Iherapy.
Nl'X1, Miranda and FraSt'r describe cullure-bound syndromes as disor-
ders specilic 10 a cullure. They conceplualizt' these disorders in lerms 01 the
consirucis of social inlt'reol and lifestyle. and they address how such con-
slrucls may assist clinicians in .1ddressing cullure-bound syndromes.
Finally, I briefly descrihP sumt' criliques of DSM Ihal affecl clinical prac-
IiCt'. sue'h as reimbursemenl. the psychopalhologizing of t'IIeryday life. the
unreliability of DSM diallnOSt'S among clinicians. and its nonconceptual ba-
sis. I Iht'n sUllllesl two W.l\'l' in whil:h DSM can bP used so Ihal il is more
clinician-friendly.
Copyright of Journal of Individual Psychology is the property of University of Texas
Press and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.