The DSM-5:A Strength-Based Re-vision

Jeffrey T. Guterman, Ph.D.

Thursday, February 18, 2016Copyright © 2016 Jeffrey T. Guterman

Session Objectives1. Participants will learn the historical developments of the DSM-5.

2. Participants will learn clinical implications of the DSM-5 from a medical model perspective.

3. Participants will learn strength-based conceptual frameworks as a basis to resolve conflicts between the DSM-5 and both their personal and professional values.

4. Participants will learn strength-based 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 DSM because 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

• Therapists tend to recognize the limitations of diagnosis

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

• DSM-5 often conflicts with both the personal and professional values of many therapists.

Medical Model (Psychiatry) Therapy

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 Therapy• Postmodernism corresponds to critique against modernist

conceptions of certainty, objectivity, and truth.

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

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

Strength-Based Therapy Models

• Collaborative• Narrative• Solution-Focused• All therapy models are potentially strength-

based

Key Principles ofStrength-Based 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-5 diagnoses 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 DiagnosisCounselors 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?