Substance Related Disorders:Perspectives from psychopathology and existential psychotherapy

Substance Related Disorders
Perspectives from psychopathology and existential psychotherapy
Contents
Introduction and aims 1
DSM IV 2
Purpose 2
Multi-Axial 2
Stakeholders 3
Substance Disorders 4
Definition 4
Source for Criterial evidence 4
Existentialism and the DSM 4
Axioms of DSM 4
Existentialsms refutation of DSM’s axioms 4
The logical argument 5
The phenomenologial argument 5
The argument from experience 5
The transcendental argument 5
The dictionary argument 5
Spinellis Worlding and Worldview 5
Existentialism and Substance Disorder 5
DSM’s disorders are not the clients 6
Sedimentation 6
Concluding Comments 6
Bibliography 6

Introduction and aims
In this paper my aim is to understand Substance Related Disorders as defined in DSM IV, DSM hereafter. This will be done firstly through understanding the DSM, it’s purpose, methods and how it is used. Then Substance Related Disorders will be explained from its DSM definition.
From there I will open up an existential perspective both with regard to the project of the DSM and then specifically looking at Substance Related Disorders.
In summary I will then look at what can be useful from both disciplines, that of the psychiatric view of the DSM and the existential view.
When I talk of existentialism, I am not talking about a unified body of thought, rather the disparate and competing views, who label themselves, or have been labelled under this banner.
DSM IV
Purpose
The DSM is the American Associations Diagnostics and Statistical Manual written by the American Psychiatric association. It provides taxonomy of psychopathology that is a set of groupings of psychic phenomena and behaviours that have been used to create a diagnostic framework for psychiatry.
“The utility and credibility of DSM IV require that it focus on its clinical, research and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make the DSM IV practical and useful...by striving for explicit statements of the constructs embodied in criteria” DSM IV (2000 Introduction xxiii)
To clarify this statement the key aims are to provide taxonomy for diagnostic criteria for clinicians in the mental health arena, and to have an empirical, i.e. repeatable causal evidence to enable the diagnosis of a patient who presents a disorder.
Multi-Axial
The DSM doesn’t use merely atomic classification but rather uses axes to diagnose disorder. Thus they use a multiaxial assessment. There are 5 Axes, that split into three groups; the first that classify disorders and the second that isolates problems the person is having, and the third which focuses on the client’s ability to function as defined by the therapist.
Group 1
Axis 1: Clinical Disorders (e.g. Delirium, Dementia and Amnesia)
Axis 2: Personality Disorders (e.g. Obsessive Compulsive Disorders)
Group 2
Axis 3: General Medical Conditions (e.g. Post Natal Problems)
Axis IV: Psychosocial and Environmental Problems (e.g. Housing Problems)
Group 3
Axis 5: Global Assessment of Functioning (what is the overall level of functioning and its prognosis)

Therefore diagnosis would see a person’s behaviour plotted on the axes against the following criteria, for defining the symptoms in the first group:
1. Mild
2. Moderate
3. Severe
4. In Partial Remission (They used to have the disorder, but now only have a few symptoms)
5. In Full Remission(They used to have the disorder, don’t anymore, but it is clinically useful to remember they did)
A couple of points should be noted about the application of the DSM diagnostic criteria:
1. “There is no assumption that all individuals described as having the same mental disorder are alike in all important ways” DSM[Introduction xxxi]
2. “DSM IV often includes polythetic criteria sets, in which the individual need only present with a subset of a longer list” DSM[Introduction xxxii]
In other words the diagnosis only provides a heuristic tool and does not define the individual’s behaviour and that there need be no absolute match between all criteria, and it is down to the interpretation of the diagnostician which are to be significant.
Stakeholders
The DSM then gives common concepts and language for all those who are involved in the discourse of mental disorder. Here I use discourse in Foucault’s ideology in the sense of the combination of concepts, language, action and institution, the manifestation of power.
The people involved in this discourse are wide ranging. Directly the psychotherapist and their client will be involved in it. The therapist who will use the DSM to diagnose the client’s malady. The client, who will be led to this understanding of their condition. Thus the psychotherapist might say you have a bi-polar condition, and then explain this to the client. The advantages to both sides can be that they provide a degree of certainty. The client, who may be distressed, feeling they are going mad and going to implode, now has some structure to understand their existence. Likewise the therapist faced with the complexity of human behaviour, can provide help that is legitimised via the empirical evidence that supports his diagnosis. The other significant people to mention are:
1. The legal profession
a. Who whilst use experts to define diminished responsibilities, will in turn refer to the DSM to provide empirical support
b. To substantiate claims for Post Traumatic Stress Disorder, e.g. Vietnam Veterans
2. The gatekeepers at mental institutions, who will admit, or section people based on diagnosis from the DSM
3. Medical companies, who will target the symptoms of these disorders to produce products
4. Governments, who can monitor the levels of mental health in a country and act accordingly
Substance Disorders
Definition
Now we have an idea of the workings of the DSM let’s see it in action when used in Substance Disorders.
“Substance Dependence is a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues use of the substance despite significant substance related problems. There is a pattern of repeated self administration that can result in tolerance, withdrawal, and compulsive drug taking behaviour” DSM [P192]
Thus DSM defines the behaviour of someone who has a Substance Disorder. It then specifies the criteria for the key elements of:
1. Dependence
2. Abuse
3. Intoxication
4. Withdrawal
The other criteria they use is whether there is or isn’t physiological dependence, which means evidence of tolerance and withdrawal.
Source for Criterial evidence
The criteria that are used are indicated by the client and a constellation of people around them, from diagnostician, to family, friends, work colleagues and members of the social and legal professions who will testify to the clients mood and behaviour, which if maladaptive will mean they are classifiable under the above criteria. The other aspect that is included is Culture, age and gender features, which will help define the disorder by classifying what normal behaviour is.
Existentialism and the DSM
Axioms of DSM
The DSM has a wide ranging theoretical underpinning. The major one is that of subject and object. This can be seen by their use of diagnosis of the client. The client has a disorder which the therapist, through use of interpretative skill and knowledge diagnoses. Thus the client and therapist are separate and there is a distinct client (the subject) that has the disorder the object. The extension of this, albeit implicit, is that subjects live in a box called world where they can bump into other subjects or objects.
Existentialism's refutation of DSM’s axioms
Existentialists see this in another way, that of inter-relation and interpretation.
“We ... understand ... human beings through their inter-relational context” Spinelli (2007, P12)
This argument can be supported in the following ways using logic, experience, Immanuel Kant’s work and a dictionary.
The logical argument
Subject, Object and World concepts and relations must logically be a theoretical standpoint as you would need to stand outside them (take Gods eye view) to be able to define them.
The phenomenological argument
Perception or experience are always of something, you never experience the subject object split, but rather there is experience, which whilst can change I am fully immersed in.
The argument from experience
As people interact with their world thus there being changes, as new possibilities are shown and old possibilities removed. Indeed the past provides the possibilities that provide the actions in the present which are involved in our futural projects. These changes happen through interactions within a person’s world.
The transcendental argument
In the Critique of Pure Reason Kant brings us the following. All experience is understood in terms of space and time, therefore space and time are conditions of experience and not facts for experience. Therefore all you have is interpretation as space and time do not exist in themselves. As space and time do not exist therefore all we are doing is interpreting the noumena with our categories.
The dictionary argument
In a dictionary all you is circular explanation. To understand dog, it points you to the entry on animal, on animal it points you to other definitions and so on, and thus it is circular. To say well I can point at a dog, is to presuppose the meaning you are trying to prove. Therefore all there is, is an interrelation between interpretations of our experience, there is no fact to work from.
Spinelli's Worlding and Worldview
On the basis that all we have is interpretation and that this only makes sense when taken as a whole. This is show within the ideas Worlding and Worldview from Spinelli. Worlding being the experience of Being and Worldview, being how we essentialise it, or interpret: “Worlding is the term that I am employing to express the process-like experiencing of the ontological conditions of human existence” Spinelli (2007 P31)“Worldview expresses the selective focus or bias imposed upon the ontic experience of Worlding” Spinelli (2007 P32).
So using the above thoughts the DSM is entirely misguided. It takes a disorder as being a discrete if complex aspect of the human that is a disorder that should be removed. The danger of this approach, is without fully understanding the behaviour, and how it fits in with the overall Worldview of a person, you may remove a thorn, to expose a greater and more gaping wound.
Existentialism and Substance Disorder
As discussed in the preceding section, an existential approach to substance disorder, would seek to understand how a person’s problems and conflicts fit into their overall Worldview. In doing so they would understand what it means to them, it would highlight their values in the world, and then if the client sees that their behaviour is not what they want then change would happen.
DSM’s disorders are not the clients
This is in distinction to the work of the DSM and psychopathology. Part of the defining criteria that the DSM uses for Substance Abuse is the testimony of those around the client. The therapist as part of this constellation is also the one who pronounces the disorder on the basis of diagnosis, which is then given to the client. In this way the client doesn’t own their behaviour, rather they are given it as outside things, such they might say “I have an alcohol dependence” or “I am an addict”. The changes that come from this depend on their levels of introjections, as a Kleinian might think, their willingness to accept and identify with the truths of others.
Sedimentation
One concept that an existentialist may use with Substance Dependence would be the notion of Sedimentation that comes up in Spinelli’s thought. “Sedimentation refers to fixed patterns of rigid dispositional stances maintained by the Worldview. For example: ‘I can’t tolerate making mistakes’” Spinelli (2007 P 35). This sedimentation which is an essential aspect of a person’s Worldview may be more or less articulated, or present to the consciousness of a person. In issues of substance dependence you have some very strongly sedimented positions: I must drink, I can’t survive without a drink. The use of imperatives in an “addicts” vocabulary is large. Indeed whilst I presuppose an “addicts” world, there are more than likely some other sedimented positions underlying these, such as No one will love me, and that the use of the substance, is there to manage the pain generated by how the world is, the Worlding and how it is for you, the Worldview.
Concluding Comments
A pleasing story is generally one with a denouement, where thesis and anti-thesis have been synthesised. Here I struggle as the worlds of psychopathology and existentialism diverge so strongly in their underlying theory and practice. The world of psychopathology however is more widely accepted and engaged with by professionals and the general populace than is existentialism. For someone practising existentially they may well find themselves with a client who speaks from the psychopathological world, I am bulimic, or I am bi polar. If this is something the client wants to work with then what is important is to find out what they mean by these words, not what the DSM states, as you are working with their world, and not the world of the DSM.
Bibliography
1. DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders 4th Edition (2000)
2. Spinelli(2007) Practising Existential Psychotherapy, The Relational World
3. Immanuel Kant’s Critique of Pure Reason Translated by Norman Kemp Smith (1929)