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The number of people affected by a mental disorder is growing, along with vagueness around the term “mental disorder ”A recent Psychological Medicine article explores the controversy around defining what thoughts and behavior indicate a diagnosis and suggests that the psychiatric field would “benefit from developing more sharply defined indicators of dysfunction”

For those working in the mental health field, it makes it challenging, especially when they have to bill according to the DSM-5. Some choose to not work with insurance companies for this reason.

Seth Menachem, a LMFT Clinical Psychotherapist at Menachem Psychotherapy Group, considers DSM a helpful tool when it comes to determining if a client meets the criteria for diagnosis or insurance purposes, but the therapist doesn't need to assign a  diagnosis to help sometimes. He believes some have a way of being that is not serving themselves or others, and they're looking for help without needing a diagnosis first. “I think when doing this work, most of us in private pay private practice are able to work without pathologizing the client, and one of the reasons we choose not to work with insurance is their insistence on a diagnosis,” he adds.

Therapist Olivia James notes that “there is much crossover between conditions.” In order to treat trauma, Dr. James says she uses a somatic technique and encourages the client to manage their own anxiety. “You also need a human connection, and this is often missing in an overly medicalized approach to mental health,” she adds. 

“The DSM-5 can be great, but it also requires you to put people into these little boxes where all the smaller boxes are checked,” says Nicole Lacherza-Drew, owner of Vici Psychological Care, LLC. She explains that people are unique, and their symptoms might not match the DSM's predetermined criteria. Cultural differences also affect how symptoms are reported. To get mental health treatment, she says, there’s no need for a diagnosis and notes that she provides her “patients with an appropriate diagnosis and treatment plan that fits. Not what the insurance company tells her to do.” She also voices her concern when it comes to having more sharply defined indicators of dysfunction. “The more sharply defined indicators could keep us right where we are, putting people into boxes and insurance companies dictating what they will and will not cover,” she adds.

Kimberly Perlin, LCSW, from Towson, Maryland, argues that most people don't realize that the patient's self-report and clinician’s bias can often impact the diagnosis. “What one clinician may see as manic behavior; another may interpret as a personality disorder or PTSD symptoms. It depends on one's knowledge base, specialty and personal bias,” she explains. She explains that many therapists have mixed feelings about the DSM-5. It can make diagnosis and treatment easier for therapists to navigate because they have an established set of criteria that will help them identify what exactly the client needs; however it's been used against people by pharmaceutical companies and life insurance providers who are looking to exclude certain diagnoses from coverage to limit their liability risk. “Most clinicians I know that do not work with insurance (including myself) avoid insurance due to the amount of time and effort it takes to get paid,” she adds.

Therapists agree that their patients are unique and caution against putting anyone into a box for the purpose of making a diagnosis that fits the DSM. And as the study authors noted, “while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. It would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments"