[AtLast]

The DSM has been fraught with politics since its inception. The APA's development of diagnostic criteria for it has a long standing economic history of how do we (clinicians) get reimbursement? From private health care insurance carriers as well as public health care programs. Then, there are the internal politics of the APA and just who gets on the panels & committees to revise it. You won't find a lot of mental health professionals without medical degrees or PhD’s or one's that are not from Ivy League schools. These committees are very white and male.

It should be nothing more than a diagnostic tool that is simply part of an array of diagnostic tools to aid mental health professionals develop treatment plans. What it has become is a huge book of codes that satisfies reimbursement requirements. It can be a very helpful tool, but it also aids in over pathologizing and stigmatizing people.

Clinicians often get put in the position of having to use a more pathological diagnosis via the DSM in order for their patients to be able to utilize many services and actually receive benefits from their insurance carriers. For example, someone dealing with transgender issues could be seeking therapy for nothing more than how to deal with what is coming up for them within their family and how to handle this. They have made their own decisions about transitioning and that is just not what they are seeking to deal with in treatment. But, in order for them to utilize their insurance (or utilize a publicly funded program), the therapist is put in the position of using a diagnosis of GID ( ya know with the word disorder in it) in stead of v. codes/adjustment diagnoses.

Also, something that has always ticked me off as a clinician is the gate-keeping role therapists are put in with medical interventions (i.e., hormone treatment, surgeries) and transitioning. From my point of view, this experience is nothing more than CYA medicine for surgeons and other physicians (endocrinologists, for example). So often, these medical practitioners simply want to make certain a person has a DSM diagnosis given by a mental health clinician so that if something goes wrong with the transitioning process and the patient sues, their ass is covered! Even when all the treatment is elective! They can counter-sue the mental health professional based upon a faulty diagnosis. . Its the deep-pocket theory of law at it’s finest. Most people (based upon legal advise) will sue the deeper pocket, which is the surgeon or other medical doc (think about the cost comparison of mal-practice insurance between let's say, a licensed clinical social worker and a plastic surgeon. So, after the surgeon gets sued, they go after the mental health professional.

I am only using the GID example because it is relevant to our community- this scenario can be found throughout the medical/mental health systems and mal-practice law.

This is really a crazy-making situation when you think about the fact that a therapist (that is trained to do just that, therapy, not be a gate-keeper) is put in the position of having to code someone with a disorder (including at times a very serious diagnosis of a personality disorder) or even psychosis in order for a patient to be able get treatment about things that we all deal with in life!

I finally stopped doing any insurance work in my practice by the time I retired from it because of these kinds of things. And that didn't always feel great, either because I still felt like patients were put in a financial position that is just unfair. Also, in CA, changes in what used to be sacred
in terms of patient confidentiality became open-season for insurance companies and lawyers. Presently, patient/client records just do not have the scope of security they used to and laws were enacted that took clinician's legal safeguards away in protecting patient records in the mental health field. At one time, refusing to give any portion of a patient's therapy record was one in which a therapist could stand on without threat of legal action (with some exceptions). One could protect patient confidentiality. This is no longer true. Other changes in CA law have led to strict recording rules requiring a diagnosis be part of patient records. A diagnosis from the DSM. Consequently, if records are ordered to be turned over, and do not have all of the legally components in them, the therapist can be held negligent.

OK... my rant is over.... the DSM and how it is utilized today as well as how it is politically maneuvered, is directly contradictory in many ways to one’s training as a therapist. And look what position its miss-use can do to people just trying to get some help!

I don’t support our not having to be accountable with diagnostic criteria as that could very well hurt patients, too (with treatment options). But, the reimbursement regulations requiring that reimbursement be based upon more characterlogical and pathological diagnosing does nothing more than promote social stigma that in itself causes more problems for people dealing with some tough things already.

I should have been a gardener….