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Behavioral Health’s Complicated Relationship with the DSM

October 07, 2019

The behavioral healthcare field has a complicated relationship with the diagnostic and statistical manual. The DSM is both ardently followed and ignored. The field can hardly do otherwise since insurance payment necessitates diagnostic compliance, while the manual contains many islands of irrelevance. The winning formula is when diagnosis leads to treatment followed by payment. This virtuous chain is frequently broken at the connection with treatment.

Few people entering the field today could imagine the excitement felt in the 1970s about treating people with personality disorders. While cinema gave us some macabre images of antisocial personalities in “A Clockwork Orange,” the real excitement in psychoanalytic circles was treating people with narcissistic and borderline personalities. Little of this survives today apart from a skills-based approach for those with borderline features.

Fewer conference and billable hours are focused on personality disorders today, but it does not mean we should discard everything within the DSM on personality disorders. Many keen observers of the human condition made contributions to the manual, and value can be found apart from the rigors of diagnosis and treatment. If we accept that people present enduring personality features, then we can revisit these categories with a focus on just understanding people rather than changing them.

Noteworthy personalities

Few people will forget meeting someone with prominent features of a narcissistic personality. Remember the shock upon meeting someone with a grandiose sense of their self-importance, a craving for admiration and attention, an exaggerated sense of talent and uniqueness, and an inability to empathize with others? If you get too close to them, you might be incensed by their sense of entitlement and manipulative tendencies. These people are hard to like.

However, the antisocial personality, called in earlier times a psychopathic or sociopathic personality, is even more noteworthy. They are found more among a criminal than a patient population, but their lack of conscience and equanimity at violating the rights of others is amazing when brought into focus. While the narcissist may be manipulative and self-focused, the sociopath flaunts social norms with callous indifference. This may extend to hostile or aggressive behavior with no sense of remorse.

These personality constellations describe real people. Few experts today claim to have an effective treatment for the narcissist, and fewer still ever proclaimed a solution for the sociopath, but should helping them be the definitive goal? The medical model gives us this emphasis on treatment, but we must ask whether all psychological theory should aspire to this clinical goal.

Business-minded personalities

Every psychology major will recall learning about theories of personality. In fact, entire industries have been built around personality theory, as best seen in the proliferation of experts in the Myers-Briggs personality inventory. Corporate executives have paid large sums of money to discover the personality type for each member of their management team, only to realize that it had no more transformative impact for the team than any other labeling process.

The problem with personality types is much the same as personality disorders. There is a vain hope to monetize them with an intervention of some sort. Efforts like the Myers-Briggs were not empirically validated, and so bogus science will ultimately deliver business failure. I experienced the voodoo of Myers-Briggs as part of a leadership training program, and I was amazed that anyone had ever taken this formula for reducing people to multiple types so seriously.

However, there have been other efforts to market the power of personality theory. Psychological testing was a large industry a few decades ago, and yet it too suffered from an intervention deficit. Psychiatrists enjoyed reading testing reports prepared by psychologists and then proceeded to do what they intended to do in the first place.

Therapeutic personalities

Diagnosis seems a bit suspect when it involves counting symptoms. You can apparently have just so many narcissistic traits before you grow into a full-fledged narcissistic personality disorder. While the personality disorders arguably fail to advance treatment in line with their psychiatric origins, psychotherapy has flourished outside the medical model. It might even benefit from this characterological understanding of people.

Psychotherapy is simple in that the more a therapist understands, the better. Confusion interferes with efforts to establish a therapeutic bond and reduce another’s psychic pain. Psychotherapy has many models for proceeding, many of which have strong empirical support, yet none with stronger support than another. There may be no validated model for treating a specific personality disorder, but you might still be able to help the person in front of you. Knowing their personal experience helps.

Let’s embrace all insightful descriptions of people and reject spurious proposals about causation and cure. Grand theories have come and gone, but therapists are helping millions of people without them. The existence of people with enduring traits, both endearing and estranging, is useful knowledge. We should continue to help them and study them. Classification systems and therapeutic models are irresistible reflections, yet best confined to idle moments when the real work is not in progress.

Hijacked personalities

One might wonder if there was a faction present at the drafting of the DSM that pushed for any important insights about people to be codified in some way into the manual. Vain acts by self-important people became categorized under narcissistic personalities. Every shred of understanding had to be poured into the manual to enliven some classification for human excess.

The result today is that when we say someone is narcissistic or antisocial there is an expert challenging whether the criteria are really met for that statement. We shouldn’t care. Let’s not surrender discussions about personality traits to presumed experts in diagnosis. This is especially true for prominent people – let’s not hijack the debate about the consequences of their glaring personality deficits until we get a DSM referee.

Discussions of noxious personality traits belong in the public square. They have been organized in the DSM for decades and produced little benefit. Those committed to the value of the manual as a piece of scholarship and as a guide to payment can persist in their beliefs and practices. However, let’s agree to giving disordered personalities all the help available in psychotherapy, and let’s speak of their enduring qualities without worry about classification etiquette. Speaking of the phenomenon may be more important than diagnosing a disorder.

Ed Jones

Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.

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