The DSM-5:A Postmodern Revision for Counseling

Jeffrey T. Guterman, Ph.D.Clayton V. Martin, M.S.

Education Session

Sunday, March 15, 2015

Hyatt Regency, Orlando

Copyright © 2015 Jeffrey T. Guterman and Clayton V. Martin

Education Session Objectives

1. Identify and review historical developments of mental illness and the DSM-5.

2. Identify and review clinical implications of the DSM-5 from a modernist epistemological framework.

3. Identify and review postmodern conceptual frameworks as a basis to resolve conflicts between the DSM-5, and both the personal values of counselors and defining features of the counseling profession.

4. Identify and review postmodern counseling techniques to assist clients in overcoming limiting and stigmatizing effects of the DSM-5.

DSM-5

• Common language

• Justifies insurances reimbursement

• Nosological system

• Diagnostic nomenclature

Trephining

Trephined skull from Chalaghantepe (Aghdam), 5th millennium BC. Museum of History of Azerbaijan, Baku. http://creativecommons.org/licenses/by-sa/3.0/

Exorcism

Painting of Saint Francis Borgia performing an exorcism by Goya (no date).

Drapetomania

Samuel A. Cartwright “discovered” drapetomania in 1851.

Drapetomania

Peter from Louisiana received what Samuel A. Cartwright called “treatment” for this condition: "whipping the devil out of them."

Lobotomy

Walter Freeman uses an ice pick to perform a lobotomy.

Psychiatric Treatments

• Hospitalization

• Lobotomy

• Eugenics

• Electroconvulsive therapy (ECT)

• Drugs

A Brief History of the DSM

“I can calculate the motion of heavenly bodies, but not the madness of people.” ~ Isaac Newton

Advantages of the DSM-5

• Common language

• Informs treatment planning

• Provides insight for some clients

• Justifies insurance reimbursement

Limitations of the DSM-5

• Common language provides a thin description

• Offers little to inform treatment planning

• Stigmatizing descriptions of problems and clients

• Insurance reimbursement may lead to over-diagnosis and misuses of the DSM-5

Limitations of the DSM-5

• DSM-5 diagnoses lack scientific validity

• DSM-5 diagnoses lack significant inter-rater reliability

• DSM-5 does not adequately account for the role of culture and historization

National Institute of Mental Health (NIMH)

• NIMH reported new Research Domain Criteria for studying mental disorders.

• NIMH has largely abandoned the DSMbecause it holds it does not lead to useful research.

• NIMH is studying how the brain and its trillions of synaptic connections work.

Signs of Struggle

• The DSM-5 remains largely a typology of mental disorders

• Counselors tend to recognize the limitations of diagnosis

• Counselor are often required to be proficient in the use of the DSM-5

• DSM-5 often conflicts with both the personal values of many counselors and defining features of the counseling profession

Medical Model (Psychiatry) Counseling

Disease/Illness Wellness

Deficits Strengths

Individual Multicultural/Relational/Systemic/Holistic

Authoritative Collaborative

American Counseling Association’s (2014) Code of Ethics : Section E

• IntroductionCounselors use assessment as one component of the counseling process, taking into account the clients’ personal and cultural context. (Section E, Introduction, p. 11)

• E.5.a. Proper DiagnosisCounselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interviews) used to determine client care (e.g., locus of treatment, type of treatment, recommended follow-up) are carefully selected and appropriately used. (Section E, p. 11)

American Counseling Association’s (2014) Code of Ethics : Section E

• E.5.b. Cultural SensitivityCounselors recognize that culture affects the manner in which clients’ problems are defined and experienced. Clients’ socioeconomic and cultural experiences are considered when diagnosing mental disorders. (E.5.b., p. 11)

• E.5.c. Historical and Social Prejudices in the Diagnosis of PathologyCounselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others. (E.5.c., p. 11)

Postmodernism and Counseling

• Postmodernism corresponds to critique against modernist conceptions of certainty, objectivity, and truth.

• Postmodernism tends to view traditional counseling models as dominant stories maintained by those in power within political institutions that disseminate privileged knowledge.

• Postmodernism tend to view traditional models of counseling, psychotherapy, and psychiatry in particular, as often stigmatizing and encourages clients to disabuse themselves from these approaches.

Postmodern Counseling Models

• Collaborative

• Narrative

• Solution-Focused

• Strengths-Based

Key Principles of Postmodern Counseling Approaches

• Reality is individually and socially constructed

• Counselors are participant-observers

• An emphasis on cooperating

• Language systems as the unit of treatment distinction

Suggested Guidelines for Using the DSM-5

• Recognize the DSM-5 is a socially constructed reality.

• Identify your own biases and see yourself as a participant-observer in language systems.

• Follow the if-then criteria of the DSM-5, do not over-diagnose

Suggested Guidelines for Using the DSM-5

• Do not label clients with a DSM-5 diagnosis.

• Follow treatment protocols for DSM-5diagnoses or clearly document rationales for not doing so.

• Enrich a DSM-5 diagnosis with relevant case formulations, goals, and interventions.

American Counseling Association’s (2014) Code of Ethics : Section E

• E.5.d. Refraining from Diagnosis

Counselors may refrain from making and/or reporting a diagnosis if they believe that it would cause harm to the client or others. Counselors carefully consider both the positive and negative implications of a diagnosis. (E.5.d., p. 11)

Defining Problems, Including Problems Related to Diagnosis

• Look to the client for direction when defining problems.

• Help client define problems that are solvable.

Setting Goals, Including GoalsRelated to Diagnosis

• State goals in positive, rather than negative language (i.e., as an increase of something, rather than as a decrease of something).

• Video description of goal happening

S.M.A.R.T. Goals

• Specific

– Small

– Incremental

• Measurable

• Attainable

• Relevant

• Time-based

Mapping the Influences of the Problem, Including Problems Related to Diagnosis

• Identifying potential exceptions

• Externalizing the problem

– Naming the problem

Identifying and Amplifying Exceptions in Relation to Problems, Including Problems Related to Diagnosis

• Exceptions refer to times when the problem is not happening

• Use presuppositional questioning

• Identify small exceptions

• Identify potential exceptions

Identifying and Amplifying Exceptions in Relation to Problems, Including Problems Related to Diagnosis

• Amplifying Questions• How did you make it happen?

• How is that different from how you have dealt with the problem in the past?

• How did it make your day go differently?

• Who else noticed?

• What did you tell yourself to make it happen?

• What does this say about you and your ability to deal with the problem?

• What are the possibilities?

Suggestions and Considerations forUsing Rating Scales and Client Feedback

• Introduce the rating scales to clients by describing their purposes in clear and simple language.

• Openly discuss the ratings with clients, and be prepared to take the ratings seriously, but not personally.

• Adapt and revise counseling sessions based on the ratings and feedback received from clients.

• When clients have difficulty reading or are otherwise unable to understand the rating scales, especially children, counselors should consider explaining the rating scales to clients.

References and Suggested ReadingsBerg, I.K., & Miller, S.D. (1992). Working with the problem drinker: A solution-focused approach. New York: Norton.de Castro, S., & Guterman, J.T. (2008). Solution-focused therapy for families coping with suicide. Journal of Marital and Family

Therapy, 34, 93-106.de Shazer, S. (1982). Patterns of brief family therapy. New York: Norton.de Shazer, S. (1984). The death of resistance. Family Process, 23, 11-17. de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton. de Shazer, S. (1991). Putting difference to work. New York: Norton. de Shazer, S. (1994). Words were originally magic. New York: Norton. de Shazer, S. (1997). Commentary: Radical acceptance. Families, Systems, & Health, 15, 375-378.de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar E., Gingerich, K., & Weiner-Davis, M. (1986). Brief therapy: Focused

solution development. Family Process, 25, 207-222. Duncan, B. (2014). On becoming a better therapist: Evidence based practice one client at a time. (2nd edition). Washington DC:

American Psychological AssociationDuncan, B.L., Miller, S., Huggins, A., & Sparks, J. (2003a). Young child outcome rating scale. Chicago: Author. Duncan, B.L., Miller, S., Huggins, A., & Sparks, J. (2003b). Young child session rating scale. Chicago: Author. Duncan. B.L., Miller, S.D., & Sparks, J. (2003). Child outcome rating scale. Chicago: Author.Duncan. B.L., Miller, S.D., & Sparks, J.A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-

directed, outcome-informed therapy. San Francisco: Jossey-Bass. Duncan, B.L., Miller, S.D., Sparks, J.A., & Johnson, L.D. (2003). Child session rating scale. Fort Lauderdale, FL: Author.Franklin, C., Trepper, T.S., McCollum, E.E., & Gingerich, W.J. (2011). Solution-focused brief therapy: A handbook of evidence-based

practice. New York: Oxford University Press.Gergen, K.J. (2009). An invitation to social construction (2nd ed.). Thousand Oaks, CA: Sage.Guterman, J. T. (1994). A social constructionist position for mental health counseling. Journal of Mental Health Counseling, 16,

226-244.

Suggested Internet Resources

Jeffrey T. Guterman, Ph.D.Homepage: http://JeffreyGuterman.comTwitter: http://twitter.com/JeffreyGutermanFacebook: http://facebook.com/jeffreygutermanpage

International Center for Clinical Excellence (ICCE)http://www.centerforclinicalexcellence.com

Scott D. Miller, Ph.D.http://www.scottdmiller.com

Institute for Solution-Focused Therapyhttp://www.solutionfocused.net

Solution-Focused Brief Therapy Association (SFBTA)http://www.sfbta.org