The Perils of “Adjustment Disorder” as a Diagnostic Category

"Adjustment disorder" occupies a peculiar position in the diagnostic system of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) straddling the boundary between normal and abnormal psychology. A more human-centered approach in counseling offers a defense of "normal" adjustment as demonstrating human adaptation in life. The deeper philosophical and clinical implications of this position are explored. ********** This article explores the definition and strategic position of "adjustment disorder" within the diagnostic system of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) and how it functions covertly as a progression threshold from normal human adaptation under conditions of stress, change, and loss, into the dark web of "mental illness." Although psychiatry and diagnostic psychotherapy certainly have their place among the array of psychotherapies available today, there seems to be a shared assumption in the popular culture that diagnosing and treating disorders is what all mental health professionals (i.e., therapists) do. The "art of counseling," in fact, has a deep heritage in the West, oriented on such key principles as balance, insight, integration, transcendence, and freedom, but these have been pushed to the margins in favor of coding the problem and prescribing a treatment program, or so I argue. With coinsurance selecting for "brief therapy" protocols, and given the indisputable fact that pharmacotherapy can deliver quick and dramatic results, many counselors are feeling urged into a more diagnostic mode than perhaps their training and intuition comfortably allow. As an essentially humanistic enterprise, counseling is justified in defending a standard that is higher than merely identifying and treating deficits in mental functioning. SCIENTIFIC MATERIALISM AND DIAGNOSTIC PSYCHOTHERAPY The DSM-IV-TR (APA, 2000) has been in use, in one or another of its four editions, since 1952, when psychiatry began to define itself as a branch of medicine rather than psychotherapy (Kutchins & Kirk, 1997). As the DSM evolved through its expanded editions, the notion of disorder has come under fire as being too ambiguous a term, especially because the entire diagnostic system relies on it so completely (Wakefield, 1992a). The concept of disorder becomes doubly problematic because the sheer number of mental maladies has increased dramatically over recent decades. This has not only stretched the definition of disorder around a vastly expanded set of conditions (which logically diminishes its precision and technical usefulness), but it has also had the effect of elevating the background idea of order (against which disorder is operationalized and measured) to the status of an unquestioned assumption. Ironically, the psychiatric notion of disorder in the West is itself a symptom of how order has come to be conceptualized in the larger culture. In general, the drift of Western science for 500 years has been in the direction of searching for the physical foundations of what individuals experience as reality (Maxwell, 2003). In addition, this preference for materialism as a theoretical framework was joined early on to a reductionistic research strategy, where these foundations were penetrated by breaking up and going deeper into the composition of matter (Capra, 1996; Maxwell, 2003). Instead of expanding into a more contextual and unitive model of reality, the Western worldview, as shaped by classical science, had come to see the universe as a composition of "smallest parts" no longer capable of further division (atom and individual both refer to something taken as a fundamental unit). Once this ultimate foundation was reached, science--along with philosophy, politics, and religion in its train--set out to explain reality in terms of these basic units (Capra, 1996; Tarnas, 1991). …