The DSM5: A Strength-Based Re-Vision

1. The DSM-5:
A Strength-Based Re-vision
Jeffrey T. Guterman, Ph.D.
Thursday, February 18, 2016
Copyright © 2016 Jeffrey T. Guterman

2. Session Objectives
1. 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.

3. DSM-5
• Common language
• Justifies insurances reimbursement
• Nosological system
• Diagnostic nomenclature

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

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

6. Drapetomania
Samuel A. Cartwright “discovered” drapetomania in 1851.

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

8. Lobotomy
Walter Freeman uses an ice pick to perform a lobotomy.

9. Psychiatric Treatments
• Hospitalization
• Lobotomy
• Eugenics
• Electroconvulsive therapy (ECT)
• Drugs

10. A Brief History of the DSM

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

12. Advantages of the DSM-5
• Common language
• Informs treatment planning
• Provides insight for some clients
• Justifies insurance reimbursement

13. 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

14. 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

15. 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.

16. 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.

17. Medical Model (Psychiatry) Therapy
Disease/Illness Wellness
Deficits Strengths
Individual Multicultural/Relational/Systemic/Holistic
Authoritative Collaborative

18. American Counseling Association’s
(2014) Code of Ethics : Section E
• Introduction
Counselors 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 Diagnosis
Counselors 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)

19. American Counseling Association’s
(2014) Code of Ethics : Section E
• E.5.b. Cultural Sensitivity
Counselors 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 Pathology
Counselors 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)

20. 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.

21. Strength-Based Therapy Models
• Collaborative
• Narrative
• Solution-Focused
• All therapy models are potentially strength-
based

22. Key Principles of
Strength-Based Approaches
• Reality is individually and socially constructed
• Counselors are participant-observers
• An emphasis on cooperating
• Language systems as the unit of treatment
distinction

23. 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

24. 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.

25. 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)

26. Defining Problems, Including Problems
Related to Diagnosis
• Look to the client for direction when defining
problems.
• Help client define problems that are solvable.

27. Setting Goals, Including Goals
Related 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

28. S.M.A.R.T. Goals
• Specific
– Small
– Incremental
• Measurable
• Attainable
• Relevant
• Time-based

29. Mapping the Influences of the Problem,
Including Problems Related to Diagnosis
• Identifying potential exceptions
• Externalizing the problem
– Naming the problem

30. 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

31. 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?