Australian and New Zealand Journal of Family Therapy 2013, 34, 104–113
Independent Clinical Practitioner
The Diagnostic and Statistical Manual of Mental Disorders IV – TR (DSM) is currently employed by the Mental Health Services of the Netherlands as the basis of an integrated system of keeping track of clients and their progress through psychotherapy. Using a story from a narrative therapy practice to illustrate the current situation, concerns about the use of the DSM and Routine Outcome Monitoring as policing strategies will be discussed. Ethical and moral issues relating to the medicalisation of psychotherapy practice in the Netherlands under this regime are considered.
Keywords: Diagnostic and Statistical Manual of Mental Disorders IV – TR, narrative therapy, medicalisation, routine outcome monitoring, Oppositional Defiant Disorder, Post Traumatic Stress Disorder.
1/ DSM categories can lend themselves to administrative misuse.
2/ Beware linking diagnosis with client’s national identity numbers.
3/ As therapists, ponder deeply the ramifications on your client’s privacy of any administrative system of data gathering.
4/ A diagnosis can change over time and context.
5/ Data gathered about people can be taken out of context and used for other purposes.
Fictions from A Medicalised Family Therapy Practice
In the Netherlands, a great deal of personal information about clients of psychotherapists is exchanged between the Dutch Health Authority and their personal health insurer. Most clients have no idea of the extent of this exchange. Diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM; American Psychiatric Association, 2004) are transferred along with personal identity numbers to national databases. Not being culturally Dutch and having lived and been trained as a family therapist in Australia where national registers of inhabitants and their personal identity numbers don’t exist, I find this level of governmental “knowing” about people frightening. I’d like to tell you a story from my practice in the Netherlands.
It was Clifford Geertz (1973) who helped me see that the story about my concerns regarding the Dutch health service is a fiction, in the sense that it is something made or something fashioned, not that it is false or unfactual. He states in The Interpretation of Cultures that “…anthropological writings are themselves interpretations, they are, thus, fictions” (Geertz, 1973, p. 15). What I would like to present to you is an interpretation, fashioned from my practice as a family therapist in a country where I have lived for 22 years. As an Australian working in an independent practice as a registered psychotherapist in the Netherlands, I offer therapeutic services to Dutch nationals and to foreign expatriates from all over the world. Alongside my psychotherapy practice, I carry out independent research and my methodology of preference is auto-ethnography.
Ever since I was invited into an understanding of post-structuralism during a training workshop by Michael White in 2000, I have preferred to work from a narrative perspective. Regarding all scientific knowledge as stories, for example the research that suggests that depression is as effectively treated with exercise as medication, is also a story. The DSM then is a very large storybook, which is given huge authority because of political and financial practices. The stories within it are legitimised by mental health professionals and governments, and eventually society embraces them. People with their preferences and desires become thinly described with a few words, which are then abbreviated with initials, so that before you know it, one of your best friends, or even yourself, might be associated, not by a personal name but by an epithet like ODD or PTSD.
Having conversations that open up therapeutic spaces for my clients as well as myself has offered me the opportunity to reach a deeper understanding of the preferences and values by which my clients live. Narrative therapy is a way of working that I experience as more respectful for the people who consult me and for myself than the work I was doing, based on the structuralist teachings of my clinical psychology training. However, I am working in a health system that has embraced the extremely structuralist DSM in such a thorough way that it leaves no room for any other perspectives. The system demands that I give a DSM diagnosis to all people who consult me.
The Dutch Health Service
The Netherlands has a health service that ensures that all residents can access quality short and long-term psychological services, regardless of income and social status. Psychological services are offered by community organisations, hospitals, outpatient clinics or independent practices. Psychotherapy is included in the basic health insurance that is mandatory. There are subsidies available for people on low incomes to enable them to pay the monthly premiums. Psychotherapy or short-term psychological help is not part of an extra coverage, like for example, dentistry. However, for clients to receive reimbursement from their health insurance, personal information, along with a DSM diagnosis and their own identifying number has to be registered in a national database.
Keeping Track of Everyone
National registration is very normal in the Netherlands. An elaborate system of keeping track of people is part of the Dutch social fabric. With so many people living in a tiny country (according to Statistics Netherlands (2013), the current population is 16,700 000 with a population density of 397 inhabitants per square kilometre), order needs to be kept. Every inhabitant is registered at the local town hall, with private demographic information, such as date of birth, address and marital status stored in a national database. Each resident has a Burger Service Number (BSN), a personal identity number that is the equivalent of a social security number or tax file number. In the health system, a health care provider attaches personal demographic data to a DSM diagnosis in the form of a Diagnosis Behandeling Combinatie (DBC), a diagnostic treatment code. The DBC system administers the entire national health budget, from a single-therapist independent practice like mine to the academic teaching hospitals. The funding of health care, whether it is somatic or psychological care, is diagnosis based.
Apart from the DBC system being a governmental accounting system, it is also an accounting system for the health insurance companies. Health insurance companies have access to private and confidential diagnostic information. Clients who are seen by registered psychotherapists will have the diagnosis attached to their BSN. This diagnosis will thus follow them not only throughout their medical history, but also throughout their civil existence. The implications of this system are far reaching but very rarely made explicit to the clients. Most practitioners accept the system and have no problems with it. Remember, it is regarded as normal for Dutch people that information about them is collected and coded at the town hall, and for most people, it is absolutely no problem that this extra medical information is gathered. I’ve even noticed that some people actually find it comforting that the government is in such a position of control as if there is safety in all of that surveillance. I have serious concerns about the effects of working within this system, both for the conversations I have with families and individuals, and for my clients’ personal future.
Integrated ROM/DSM System
An additional layer in this computerised system is the enthusiastic use of Routine Outcome Monitoring (ROM) by Dutch insurance companies. They are convinced that ROM use increases the “quality and transparency” of psychotherapy. I put these words in quotation marks to highlight their new status as a mantra in these times of administrative dominance. I am judged a “quality” psychotherapist if I request my clients to fill in ROM questionnaires at the beginning, middle and end of their treatment. Most of the questionnaires that are used in this pursuit of transparency were not designed for outcome measurements. I am not just talking about using paper and pencil ROM questionnaires; I am talking about an integrated computerised system where DSM diagnosis, BSN number and ROM details are all merged together. Even my professional body, the national Dutch organisation representing psychotherapists and psychologists in independent practice (NVVP), has embraced ROM and is accommodating the insurance companies’ demands to such an extent that they offer their own ROM portal and insist that a DSM diagnosis is allocated and in the client’s file before therapy can even begin. House (2005) deconstructs the professional-centred therapeutic practices that define and constitute identity within therapeutic practices. He points out that these practices deserve on-going deconstruction and examination. In this case, the NVVP is actively embracing these discourses and imposing the practices of ROM on their membership. There is absolutely no room to question these practices as acts of control, which could be harmful to the whole culture of psychotherapy. For more information about ROM use in psychotherapy, please see van Os, Kahn, Denys, Schoevers, Beekman, Hoogendijk and Leentjens (2012) and (NVVP) (n.d.).
Acts of Fossilisation
I have grave concerns about this level of integrated surveillance of psychotherapy and its effects on my clients. By allocating a diagnosis to describe a problem that is multilayered and multi-dimensional, I am engaging in an act of undue individualisation. As Rose (1993) makes explicit, the therapeutic context is located “within a genealogy of political technologies of individuality” (p. 217). By allocating an individualising diagnosis, I am legitimising the thin description of the person and the problem. In using the words of the DSM, I am creating the thin descriptions of my clients and legitimising them. In the same way, when I have to check someone’s identity and allocate a description of that person using the DSM before they receive psychotherapy, I am acting as an official of the state. I am engaging in normative practices. Within my therapeutic contacts, I am attempting to create conversations with people to thicken their descriptions of themselves, and open up possibilities for them to live their preferred life. Yet the context within which I am working is conspiring to capture only the thinnest possible description of the person. Very often, the conversations we have are about people engaging with their personal power rather than being dominated by modern power (White, 2011). I am mindful that in the context of psychotherapy in the current Dutch system, I am acting as an agent of modern power. There is no method of removing a diagnosis from the DBC system when it is no longer descriptive of a person’s behaviour. Diagnoses get trapped and fossilised in the layers of someone’s medical history and will continue to stigmatise them. Within this system, I am performing acts of fossilisation of thin descriptions of people. Let me illustrate how the current system of medicalised family therapy in the Netherlands affects people with a story from my practice.
ODD or PTSD or…as I would Prefer, Simply Tom?
I receive a call from a school social worker. Let’s call her Monique. She works in a technical high school and needs to refer a 12-year-old boy, Tom, who is in his first year there. Tom has been having angry outbursts at school during the year, but the last one was very dramatic. He threatened to kill one of his female teachers. Tom has a long history of angry outbursts at primary school and his behaviour was considered so unpredictable that he was streamed into a lower level school than his results on a national grading test would have predicted. Tom has told Monique that when he gets angry at school, he is actually ‘re-seeing’ his mother being physically abused by her former partner, not his father. He sees the violence happening all over again, despite it having happened 8 years ago. I ask Monique to ask Tom’s mother to set up an appointment with me.
Tom’s mother, Helen, calls immediately, and says she is very concerned about him. She wants him to do well at school. Tom doesn’t get angry at home, so she doesn’t understand much about the explosions at school. We make an appointment with Tom and her for the following week.
Tom is small for his age, and very polite. He easily makes contact with me. Helen fills me in on their very hectic family schedule with visiting half-sisters and half-brothers, and it sounds like she manages the comings and goings of four adolescents in a complex blended family situation really well. When we talk about school, Helen becomes clearly different in her manner. She is suspicious and guarded.
Tom tells me that he is bored at school. The work is too easy and he is in a class with lots of kids who aren’t interested in getting good marks. He would like to get good marks this year so he can move into a higher-level class. He tells me that he is picked on because of his studious attitude and sometimes he cannot take the comments of certain children lightly. He has one friend, Willy, and since he and Willy have been sitting together in class, things are much better. He has only exploded a few times this year, and while he doesn’t like it, he says that the other kids cause it. Fortunately, he has a good relationship with the deputy principal of the school, Mrs Rose, and when he is about to explode, he can go to her. Sometimes however, he explodes before he can walk away.
Now, I can imagine a DSM diagnosis for Tom, and if you have any experience of allocating diagnoses, probably so can you. Remembering that all structural knowledge is just a story, I can put Oppositional Defiant Disorder (ODD) into Tom’s file and attach his BSN number, and that diagnosis will follow him all through his life. I am reluctant to do that, also because that diagnosis puts the problem squarely inside Tom. Alternatively, I could have given him an Adjustment Disorder, which has the benefit of saying less about Tom’s “inner workings” and is more descriptive of the context of the problem, but this year the Dutch health authority, perhaps noticing how many clients were receiving Adjustment Disorders, has removed Adjustment
Disorder from the list of diagnoses that can be reimbursed. Knowing that it is important for the family that the psychotherapy is reimbursed, I don’t feel I can give him an Adjustment Disorder.
During the individual sessions I had with Tom, he was very open about how he remembered witnessing his mother being physically abused by her previous partner. He was 4 years old and saw her being the victim of violence three times. He sees the link between the violence he saw his mother suffer and his sensitivity to injustice at school. He clearly has a highly developed sense of justice and is frustrated that his school doesn’t seem to share that.
After six sessions, Tom reported that things were better at school. His outbursts had stopped and he was getting good grades. At the end of the school year, his report was so good that he was moved up to a higher level in the school. We decided to be proactive and plan a session for the beginning of the new school year. I saw this as an opportunity to celebrate Tom’s achievements and put in place the structures of safe teachers to whom Tom could go, if he felt the explosive energy. I invited Tom and Helen and Monique to come for a combined double session the second week of the new school year.
I had planned that session as a definitional ceremony (White, 2000). I find definitional ceremonies rich ways of marking the changes that people make in the lives they construct. Definitional ceremonies are “strategies that provide opportunities of being seen and in one’s own terms, garnering witnesses to one’s worth, vitality, and being” (Myerhoff, 1986, p. 267). Using definitional ceremony structures meanings we can give to behaviours and preferences can be thickened so that the thin descriptions that are DSM diagnosis fade into the background. Definitional ceremonies help transcend the everyday information about people and make louder their preferences for living. Tom was to be the centre of the ceremony and Helen and Monique were to be in the outsider witnessing positions. That meant that Tom and I would have a conversation, while Monique and his mother would listen carefully. There would be no eye contact between Tom and them. That initial conversation is called a “telling” (White, 2000). After our conversation I would then turn to the witnesses and engage them in conversation about what they had just heard. During this time, Tom is asked to listen very carefully. The conversation is very specific. My questions are about what they heard in the initial conversation that touched and moved them. Then we look at what it was in particular that moved them, and how that relates to their own life and their values for living. This conversation is called a “re-telling”. After the re-telling, I then interview Tom about what he heard his mother and Monique say. This phase of the ceremony is called the “re-telling of the re-telling”. Experience has taught me to prepare the participants of a definitional ceremony very well. It is not a social situation
asking for applause but rather a deep and moving way to excavate to another layer of understanding, highlighting the hopes and preferences people have for their lives. This was not going to be an experience of applause for Tom, but hopefully a deepening of the changes he has been able to make over the last months.
Tom arrived for the session visibly older after the summer. He was taller and his voice was deeper. When he and Helen entered the room, he looked explosively disappointed.
He quickly told me his list of grievances with the school this new school year. He was in a different stream (the school was actually acknowledging the work he had done) and he was disappointed that Willy was no longer in his class. Mrs Rose was no longer working as the Deputy Principal. He felt like the school had betrayed him. He thought they knew how important Willy’s support was to him.
Further, something had happened just that morning at school. I stopped him there and tried to get the rhythm of the definitional ceremony in place. There was the risk that Tom’s current emotional state could derail the planned definitional ceremony. However, I was hoping that the structure of the ritual would actually be constructive. Having the school’s social worker in the room also meant an opportunity for her to hear new information that could lead to some solutions at school.
So, rather than working with the reflections about the changes he had made the previous year, I asked Tom what had happened at school that day. He began a tirade about seeing a boy destroying the CD that belonged with a textbook from the school. It was a boy in the chair in front of him and he had tried to get him to stop doing it. However, in trying to get him to stop, he had made some noise, which interrupted the teacher during her lesson. She had put Tom’s name on the board, which meant he had to stay in the class during his lunch break as punishment.
The boy destroying the CD did not have his name on the board and the teacher did not notice him. Tom felt the explosion energy, took himself out of the room and stood in the corridor outside the class. After about 10 minutes, he was able to calm himself down and returned to class. However, he had to stay in at break time. The boy who destroyed the school’s property – the CD – did not. However, in telling his frustrating story, Tom was able to focus on the abilities he had shown that morning. He had recognised the explosive energy and had taken himself out of the class before the injustice of him being punished got him to explode. He began to be pleased with himself. He was also pleased that when he was calm and had a chance, he had told the teacher how unfair he felt she had been. He was still angry that the teacher didn’t recognise the injustice that the boy who destroyed the CD was not punished.
While that wasn’t the telling of his story that I had anticipated, Tom had told quite a story. It was a very current and real story, full of his abilities to overcome his temper and his past reputation. I then turned to Monique and interviewed her specifically about what she had heard. I also asked her to imagine what the teacher might have heard. Her attention had been caught by Tom’s ability to leave the room, and calm himself down. She also had heard that Tom had accepted his punishment knowing how unfair he felt it to be. He had not expressed his anger to the teacher. I asked if Monique could imagine what the deputy principal might have heard, had she been with us. Using this technique of people-ing the outside witness group, we were able to thicken Tom’s achievements of the day. Monique imagined that Mrs Rose, the previous deputy principal, might have been struck by Tom’s sense of right behaviour in trying to get the boy to stop destroying the CD. She imagined that Mrs Rose might also have noticed that Tom was able to speak to the teacher in a civilised manner, regardless of how angry he felt at the injustice of being punished while the other boy was free to enjoy the break.
Then I interviewed Helen about what had caught her attention. She specifically was touched by Tom’s ability to give clear and polite feedback to the teacher about the injustice he felt he had experienced. She celebrated Tom standing up for himself in front of a teacher. I asked her to imagine what her husband, Tom’s stepfather, might have noticed had he been listening to Tom’s story. She thought he would have been impressed that despite being so angry at the situation, Tom had not told the teacher about the boy who had destroyed the CD.
Tom had been listening to these reflections and was visibly moved by the warmth and appreciation he was receiving – not just from the two people in the room but the others who had been peopled-in to the ceremony. When I re-interviewed him, he clearly appreciated his mother’s reflections that he had stood up for himself with the teacher, and that he now had the verbal skills to say what he thought was an injustice. He said it helped to hear what she thought his stepfather would say: that he had not got the other kid into trouble.
The diagnosis I gave Tom (which will follow him throughout his life) was Post Traumatic Stress Disorder (PTSD). I decided on this as it is descriptive of a context, and places the experiences that contribute to his problem-dominated story outside him. While the initial trauma happened when he was 4 years old, he keeps being re-traumatised when he re-experiences the injustice in the events of his life. There is no way in the DBC system to factor change into it. The diagnosis is fixed, just as Tom is stuck in a system of education where people are constantly making judgements about him, based often on his history and reputation. Because of his past explosions, the teachers are tuned into Tom having a problem, rather than looking at each new situation as it unfolds. The definitional ceremony offered Monique alternative ways of seeing Tom, and I hope that she can now share what she knows of the current situation with her colleagues. I stay involved in Tom’s life, and make regular appointments with him, to thicken the story of his ability to change and to help the school develop new ways of seeing him.
Medicalising Family Therapy
Working in a system that so totally medicalises psychotherapy, it contaminates the relationship and the actual therapeutic conversations that happen between therapist and client. Confidentiality is challenged. I cannot guarantee that the data I collect will not be misused against Tom in the future. The collected data, (i.e., his diagnosis), is said to be encrypted and accessible only through protected portals, but how many times have computer systems not been hacked? Let us also not forget that insurance companies with their economic interests have access to this information.
When the DBC system was introduced into the mental health arm of the health service in 2008, one in four Dutch psychotherapists and psychiatrists in private practice closed their practices. That was a reaction to the payment methods (only being able to bill at the end of the work or after 1 year) and to the layer of administration that was demanded – and possibly to the underlying philosophy of the system. I chose not to close my practice. I have chosen, despite the trying and worrying circumstances, to keep offering a service to people like Tom and his mother, and to make the medicalised system, as far as I can, transparent to them. So, they know that Tom will have the diagnosis PTSD attached to his BSN number. I have discussed my concerns with them about the structuring of the service and I have tried to be as clear as possible about the way I see Tom and his “problems”. However, given that this is just one more piece of information already collected about Tom in his 12 years, they were not particularly worried about it. Often my clients ask me why I am worried. When I tell them that I cannot protect the information that I have sent to the Health Authority and that possibly in the future insurance companies might use it against them in some way, I am seen as a slightly paranoid foreigner.
The consequences of these practices for systemic therapists are very serious. It is possible that soon multi-problem families won’t be accepted for therapy because therapists’ outcome results may not look good if some of the problems that are unquantifiable do not respond to treatment. Not even a superb therapist can “fix” problems like poverty and social exclusion. Therapists or organisations may not see clients with complicated or serious problems, as such clients could have a bad effect on the therapists’ ROM ratings. It follows then that therapists who work with families or individuals with problem-dominated stories won’t be paid as much as therapists who follow thin descriptions/diagnoses and treat problems that can be formulated in measurable ways. The system supports, encourages and totally assumes that therapists are working in evidence-based practice ways, following protocols. The underlying assumption is that we can neatly measure what happens within a psychotherapeutic conversation and that people are machine like and do well when they are treated like machines. This system is based on the mythology that all psychotherapy is replicable and that the relationship between the therapist and client is not important, and it is not particular to the people within that relationship.
I can imagine some people might accuse me of being unethical, continuing to work within such a medicalised system. I have pondered this long and hard. Working outside the health system, without the possibility of medical rebates for my clients is also unethical. The vast majority of my clients would not be able to pay themselves. While I can’t guarantee the safety of their private information, I can be transparent about my concerns, and urge them to take up their concerns with their elected members of parliament. As a systemic therapist, I feel I am in a position to take a meta stance and make the actual system we are working in visible to the clients. By making it visible, and naming it, it becomes something that can come under scrutiny.
Let Us Not Forget
Let’s go back in time. It’s 1940 and in a matter of 5 days the Netherlands is overrun by the invading German forces. From 1941 until 1943, Dutch Jews are methodically found and segregated with the help of the system of registration that existed, and still exists, in each town hall. In those days, people were registered not only with demographic information like addresses but also religion. The registrations were in large bound books. The workers at the town hall could not have imagined what the contents of the books could be used for. The segregation and collection of the Dutch Jews was systematic and effective. One-hundred-and-four-thousand of them were eliminated slowly and deliberately from Dutch society.
While I am not suggesting that anything of this nature will happen again, I am concerned that we have no idea how the technology that is being used to register clients, their DSM diagnosis and the ROM measurements, could be used for in the future. We don’t know how the data could be used for a purpose for which it was not designed. However, we do know that misuse has happened in the past. This warning is reiterated in a book that was published to commemorate Holocaust Memorial Day on 27 January, 2008 (Lipschits, 2008). Isaac Lipschits, who lost his entire family in the Second World War, warns that we have to be careful of our privacy and no longer make registers of people at the town hall. Even if we don’t accept the assumption that anything of this gravity will happen again, data can always fall into the wrong hands. It can be put to unauthorised use, even if it is only the insurance companies deciding, for example, to identify high-risk categories of people who, based on their previous diagnosis, could then be asked to pay higher premiums.
Surely, in a country with such a vivid recent experience of information getting into the wrong hands and being misused, we could well imagine that there would be some resistance to the collection of such data. It is hard for Dutch people to understand that not all countries have such systems of registration of residents. To stay working within the Dutch health system was certainly not an easy choice, but the choice I made was to try to make people aware of its existence and its potential repercussions.
I tell my clients as well as my colleagues to ponder the practices that are imposed on us, and to beware the ever-expanding technologies that can track and check people. Therapists need to be mindful of the technologies of control that are imposed on them and be mindful of the consequences of their work in terms of re-creating normalising identities. As family therapists, we can encourage our clients to embrace their personal power and exercise choice over the practices of modern power.
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White, M. (2011). Narrative practice: Continuing the conversations. New York, NY: W. W. Norton & Company.