Diagnostic and Statistical Manual of Mental Disorders (DSM) #
Most of this page is copied verbatim from Anderson, Sweezy, & Schwartz (2017, pp. 13-14).
Anderson, F. G., Sweezy, M., & Schwartz, R. (2017). Internal Family Systems Skills Training Manual: Trauma-Informed Treatment for Anxiety, Depression, PTSD & Substance Abuse. PESI publishing & media.
The American Psychiatric Association developed the DSM to ground psychiatric treatment in science. Given their methodology—DSM diagnoses are based on lists of symptoms that are periodically chosen by committees of professionals who are picked by the American Psychiatric Association—this effort remains controversial.1 Nevertheless, because the terms of the DSM continue to be widely used, the medical model approach continues to be a strong influence on the field of mental health.
A different approach to trauma #
In IFS we simply see DSM diagnoses as various ways of describing the behaviors of activated parts. And rather than pathologizing symptomatic behaviors we view them as natural efforts to solve problems: to cope, stay safe and survive. Trauma diagnoses include post-traumatic stress disorder (PTSD), dissociative identity disorder (DID), both listed in the DSM, and complex trauma or developmental trauma disorder, which is also widely used, including by the International Society for Traumatic Stress Studies (ISTSS).
Here is an IFS perspective on several diagnoses that are often given to traumatized individuals before (or in lieu of, or in addition to) receiving one of the more specifically trauma related diagnoses listed above.
- Borderline personality discorder: This diagnosis offers a portrait of the consecutive blending of exiles (desperate young parts, internally shunned, longing for rescue and redemption) and protectors, most notoriously (though not exclusively) the ones who forbid the risks of intimacy and the ones who believe that dying is the only way to end emotional pain.
- Narcissistic personality disorder: This diagnosis shows the efforts of a hard-working protector as it holds up a gilded self-portrait as a shield against the arrows of shaming – mostly inner shaming in response to feelings of inadequacy.
- Depression: Mood disorders are heritable but not all post-trauma depression is evidence of a genetically-based mood disorder. Since depression suppresses the body’s emotional signals, deadening physical and emotional experiencing in a paralyzing (if excruciating) way, a protector who amplifies depression generally aims to inhibit while an exile who feels depressed is being inhibited.
- To assess the client’s situation, we ask: “Is this a part of you who feels depressed (exile) or a protective part who is using or magnifying depression for a reason?” The only way to discover the function of any part you encounter is to ask.
- Anxiety: As temperament research indicates2, our genes can also make us vulnerable to anxiety. And, as with depression, protectors can push this lever to exert influence.
- “Is this a part (an exile) who feels anxious or a part (a protector) who has some reason to magnify anxiety?” Many protective parts are rooted in fear and carry some percentage of anxiety within them. Again, to find out we ask.
- Obsessive-compulsive disorder: OCD behaviors are generally geared toward managing anxiety. In the case of trauma, the preoccupation or behavioral repetition of OCD serves to distract from emotional pain.
- As with depression and anxiety, to find out how a behavior serves or what story it can tell, we must ask.
- Sociopathy: Unless sociopathy is a product of brain damage, it is a protective part.3 With their telescopic focus and determination to suppress inner vulnerability, sociopathic protectors are paranoid, extreme and rejecting of both empathy and compassion as weakening. While they protect exiles who they view as unbearably impotent and tender, they are often polarized with other protectors whom they consider weak or caretaking. On this topic, Schwartz wrote:
- “A perpetrator part can be thoroughly blended all the time, in which case the individual is likely to meet criteria for a DSM-5 diagnosis of antisocial personality disorder. When a perpetrator part stays blended all the time in this way and the client has no access to other parts, we consider it a manager rather than a firefighter.” (2016, p.113)
Addictive disorders: #
- Drugs or alcohol: The reactive protector who uses a drug or alcohol to distract from emotional pain can also settle into being a proactive protector who uses them to avoid feeling anything at all. This addict part is not a lone actor but is an actor in an inner dynamic.
- Cykes (2016) elucidates the IFS perspective: “Rather than defining addiction as the behavior of one acting-out part, I define it as a systemic, cyclical process that is characterized by a power struggle between two teams of protective parts, each valiantly struggling to maintain a balanced inner system. One team is critical and judging, the other impulsive and compulsive. Their chronic, escalating struggle is intended to block… emotional pain.” (p. 47)
- Eating disorders: ED’s illustrate a protector polarity, with excess on one side and inhibition on the other.
- Bulimia illustrates both sides of this polarity.
- Anorexia illustrates inhibition in the driver’s seat.
- Binge eating illustrates disinhibition in the driver’s seat.
- Over-exercising illustrates inhibition in the driver’s seat. Catanzaro (2016) describes the IFS lens on ED phenomena: “ED protectors always polarize into two camps: parts who push for restriction and control of the body and parts who reject this control and push for less restraint. Their tug-of-war keeps the client from being aware of the intense negative feelings and memories of exiled parts. While an individual’s specific ED diagnosis depends on which parts dominate at any given time, the overall symptom picture, even if it isn’t obvious from the client’s physical appearance or self-report, always involves this dialectic between restraint and rebellion against restraint.” (p. 51)
Oregon’s definition of Practice of psychology #
“Practice of psychology” means rendering or offering to render supervision, consultation, evaluation or therapy services to individuals, groups or organizations for the purpose of diagnosing or treating behavioral, emotional or mental disorders. ORS 675.010
From an IFS perspective, there are no disorders but only natural reactions to extreme situations.
Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. Penguin. ↩︎
Kagan, J. (2010). The temperamental thread: How genes, culture, time, and luck make us who we are. Dana Press. ↩︎
Schwartz, R. C. (2016). Perpetrator parts. In Innovations and elaborations in internal family systems therapy (pp. 109-123). Routledge. ↩︎