Coda

The dominance of DSM-IV has clouded the fact that a variety of alternative approaches have been, from time to time, put forth for diagnosing psychological problems. These approaches have been eclipsed by the attempt to standardize procedures—an effort driven more by bureaucratic and insurance pressures than by scientific goals. In a historical and critical analysis of DSM some of these motivations have been laid bare. At century's end, the economic goals of the therapeutic professions continue to favor quick categorization of patients. A convincing argument has been made that the DSMs have evolved into instruments that serve bureaucratic and financial functions more fully than they do scientific ones. When critically examined the DSM's claim to theoretical neutrality cannot be sustained. In fact, the DSM authors take pains not to conceal a strong biological bias. Critics have argued that the current dominance of DSM prematurely closes off scientific analysis. More specifically, the authors of DSM have failed to examine their underlying assumptions, particularly those embedded in their un-articulated theoretical structure and in their choice of root metaphors. Given the state of knowledge, it is premature to posit a theoretical structure that would support the notion of clearly delineated diseaselike entities. The root metaphor of mechanistic causal forces defines not only the clinical reality but human behavior in general, and it does so in a way that transforms historical actions of persons in identifiable sociocul-tural contexts into physicalistic happenings like infections and mechanical breakdowns that occur independent of human intentionality.

The narrowness of this perspective is obvious. It not only neglects most of the considerable advances made in social psychology and social anthropology in recent decades, it negates common sense views like those of Adolf Meyer half a century ago to be examined to construct systems for organizing the actions of people.

"Problems in living" are neither "mental" in any simple distinction from somatic, nor are they ''disorders'' in any obvious contrast to an order we can identify as natural. The intellectual resources available to the task of classifying people's problems in living are rich, varied, and often very much more precise and elaborate than the DSMs, but they have been neglected for reasons other than their scientific relevance to the task.

DSMs of the traditional kind are bound to become increasingly unworkable as the number of diagnoses approaches 500 and as the number of criteria approaches 2000. This development, together with the promulgation of critical inquiries that continue to illuminate the flaws in DSM systems, will direct professionals to entertain nontraditional theoretical premises. It is our belief that DSM systems will be replaced with systems based on the premise that human beings are agents that engage in intentional strategic actions to maintain their self-narratives. It is likely that scientists of the next century will look back at traditional DSMs with somewhat the same puzzlement that is now expressed about the claims of phrenology in the nineteenth century and the claims of lobotomists in the twentieth century.

Classifying Mental Disorders: Nontraditional Approaches

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