Tom Strong, PhD Jared French, MA Joaquín Gaete Silva, MSc Jen Eeson, B.A Inés Sametband, MSc...

Counsellors talk about the DSM

Tom Strong, PhDJared French, MA

Joaquín Gaete Silva, MScJen Eeson, B.A

Inés Sametband, MSc

Funding for this project was provided by the University of Calgary and Taos Institute

Overview

Why talk to counsellors about the DSM?

Our studies and counsellors’ responses to them

Making sense of what counsellors told us

How the DSM influences counsellors

How counsellors respond to the DSM

Our thoughts & yours on the DSM

Backdrop Counselling, a multi-theoretical field, has many

discourses of practice, each with ways of assessing and naming client concerns

DSM is a medically oriented discourse of symptoms though not all client concerns are symptom-based

Increasingly, to be paid or work institutionally, counsellors are expected to use the DSM-IV-TR

Question: How, if at all, are counsellors influenced by the DSM, and how do they respond to the DSM?

Why ask counsellors about the DSM?

To what extent is the DSM a fact in counsellors’ practices?

Mental disorders and other ways of formulating clients’ concerns?

Some counselling approaches are antithetical to DSM formulations

The poetics, politics and utility of human discourses

Vico on linguistic poverty/poetic wisdom

The world’s 24 hour clock (Geometry?)

Modern/postmodern tensions over

language and understanding

Counselling as conversational work

Counselling: single vs diverse discourses?

Some ‘contra’ quotes• “Although we assign patients …DSM-IV… diagnoses for record

keeping, for the appropriate psychiatric referrals, and for insurance purposes, we have not found that this nosology, or any other “official” diagnostic typology, is of much use in the complex environment of ongoing psychotherapy.”

Stricker & Gold, J. (2005)

• DSM-IV is a symptom “language tethered to itself”, Gary Greenberg, 2010, p. 79

• “it is my view that DSM5, despite all the debate, remains stubbornly lost in the wilderness”. Allen Frances (Task Force Chair of the DSM-IV)

• Language is not innocent – Tom Andersen

DSM benefits

Common way to diagnose client concerns

Enables payment & administration of DSM disorders as treatable health problems

Enables research into treatment effectiveness by diagnosed condition

Unites counselling with medicine

Not all counselling approaches see clients’ concerns as treatable pathologies

What about counselling and problem-solving, Skill development, etc?

Family systems & social justice concerns?

Administrative and frontline needs?

DSM/Counselling Tensions

A discursive perspective on DSM

Why any single discourse over others?

How does expected use of DSM fit with the problem formulation practices of counselling’s diverse approaches?

Institutional/official discourses & unofficial / ad hoc dialogues with clients?

DSM & the discursive therapies?

How the Study was Conducted

Overview Funding

• University of Calgary, Taos Institute, SSHRC, CIHR Website, survey, phone interviews

• Survey questions, phone interview questions Who participated

• demographics

FundingCurrent study funded by:

• University of Calgary and Taos Institute • Social Sciences and Humanities Research Council• Canadian Institutes of Health Research study

Related projects:• Counsellor Education• Understanding and practicing non-psychiatrically

oriented counselling

Data Collection

Dialogues on DSM website: • www.ucalgary.ca/DDSM • Discussion Forum• Link to the on-line survey• Phone Interviews

Dialogues on DSM Website: Discussion Forum

Discussion Forum

http://www.ucalgary.ca/ddsm/forum/2

Topic Examples: DSM and other therapeutic discourses Client responses to diagnosis The DSM-IV-TR is not a neutral language of

practice

Jennifer Eeson

Add quotes

Survey Questions Demographic information such as country of

practice, primary orientation(s), number of years in practice, education, practice setting

Information about expected use of psychiatric discourse (DSM), empirically based practice

Long answer questions – how these expectations have influenced preferred orientation to practice and how counsellors creatively deal with these influences

Phone Interview - Participants Meant to capture how Canadian counsellors

are influenced by psychiatric (DSM) discourse Approx 1 hour in length 15 questions, semi-structured

Phone Interview Questions Psychiatric Discourse: What aspects of psychiatric discourse are at

odds with your orientation to practice? Expected use of psychiatric discourse Trends? How has your practice been affected? Creative ways of practicing/managing tensions Integration

Participant Recruitment Online recruitment via list-serves:

• Canadian Psychological Association• Canadian Counselling and Psychotherapy

Association• Taos Institute• British Columbia Association of Clinical

Counsellors• British Association for Counselling and

Psychotherapy

Participants Survey - 116 participants completed the online

survey Discussion Forum – approx. 10 participants Phone interviews – 10 Canadian counsellors

recruited via the online survey

Participants

62% from Canada 20% from USA 18% from Mexico, Australia, New Zealand, Britain, Norway and

South Africa

Participants

Orientation to practice

1. Client-centered2. Cognitive behavioral3. Narrative Therapy4. Solution focused therapy

Survey: Number of Years in Practice

Survey: Education 28% - Masters in counselling plus specialized

training or supervision 27% - Masters in Counselling 20% - Doctoral degree plus specialized training

and supervision 16% - Doctoral degree 9% - Masters in family therapy, social work or

clinical psychology

Survey: Practice Settings

1. Private practice (39%)2. Educational setting (18%)3. Public mental health agency (17%)4. Not-for-profit or community organization

(16%)5. Independent or group practice (10%)

Survey Extent to which you’re expected to use

psychiatric discourse to meet administrative or fee payer requirements

Survey Extent to which you’re expected to use

evidence supported interventions to meet administrative or fee payer requirements

Phone Interview - Participants BC: 8, AB: 1, ON: 1 Range of primary approaches:

• Narrative, Client-Centered, Solution-Focused, Existential, Psychodynamic, Cognitive behavioral

0-2years: 1, 2-5years: 2, 5-10years: 1 10+years: 6

1: MSW, 7: MA, 2: PhD Range of primary settings:

• Educational, Private Practice, Public Mental Health, Community, Consulting

Extent required to use DSM diagnoses:• None: 3, Some: 4, Most: 2, All: 1

Combining the Data

Phone interviews were transcribed All of the data from the surveys,

transcripts and discussion forum posts were copied and pasted into a word document

Situational Analysis: Grounded Theory After the Postmodern Turn

Traditional Grounded Theory• Adopts a perspective believing that ‘THE THEORY’ is

waiting to be uncovered.• Attempts to represent a field or situation using a few

codes or themes. • Results are presented as ‘objective’ and ‘rational’ and

researchers are thought to be separate from the data.


Rather than seeking to obtain ‘THE’ theory within a body of data, SA seeks to emphasize the following in a situation of analysis:

• Partialities, Positionalities, Complications, Tenuousness, Irregularities, Contradictions, Heterogeneities, Situatedness, Fragmentation, & Complexities

This change in focus partly represents the ‘Postmodern Turn’ that SA includes.


A key element of SA is ‘Discourse Analysis’• Which focuses on how discourses work to influence social

practices: This includes data analysis that reflects a concern with “how discourses

are produced, how we are constituted through them, and how they are performed”.

Other elements include:• Identifying the key human and non-human actants within a

situation.• Moving away from the idea of analyzing a

specific ‘context’ and adopting the view that all conditions within a situation are ‘in play’.


SA is a theory/methods package• The ‘situation’ becomes the ultimate unit of analysis

and understanding its elements and their relations are the primary goals.

• SA becomes a way of ‘knowing’ and ‘doing’ together Three kinds of maps are used in attempting to

capture and analyze the situation of interest:• 1) Situational Maps• 2) Social Worlds/Arenas Maps• 3) Positional Maps


Situational Maps:• Layout the the major human, nonhuman, discursive,

and other elements in the research situation and provoke analysis of relations among them.

• Situational Maps Include: Abstract Situational Maps or “Messy Maps” Ordered Situational Maps Relational Maps


Social Worlds/Arenas Maps• The focus is on identifying collective social action and

seeing social worlds as ‘Universes of Discourse’.• Researchers ask themselves:

“What are the patterns of collective commitment and what are the salient social worlds operating here?”

“What constraints, opportunities, and resources do they provide in the social worlds?”

Social Arena: Discursive Communities & Actors


Positional Maps• Lay out the major positions taken and not taken in the

data. ‘Positions’ are positions of discourses and represent the

heterogeneity of positions, not of individuals, groups, or institutions.

Clarke states that the three maps are not intended to be formulas for analysis, but rather as directions through which to begin and deepen analytic work as sites for engagement.

How are counsellors influenced by DSM discourse and how they creatively

respond to it?

…Starting from a “messy situation”

…Moving towards order

The Process: From messiness to positions taken by Counsellors

Situational (Ordered) Map

Relational Map

Relational Map (Simplified)

Social Arena: Discursive Communities & Actors

Positional map: How are counsellors influenced by DSM discourses?

How do cousellors creatively respond to DSM discourses’ influences?

Relational Map

Positional Map: Creative responses

How do counsellors creatively respond to DSM discourses’ influences?

Multiple ways of responding to tensions:

Positions denoting hybridities

Positions denoting negotiations

Positions denoting preferences

The absent but implicit (White, 2000)


Being proficient

“So that everyone kind of knows what part of the healing practice are we in with the client, so that we can sort of work together and make it make sense”. Like we all, I think, think that we're all doing the best for the client" (interview).

"I often have experienced myself "doing" apathetic obedience. I appreciate knowing someone else also has times where this a response that helps us continue in our work" (blog).

Being part of the puzzle (bio-psycho-social)


"So, you know, in staff meetings or in case consultations with clients present, challenging some of those dominant ideas about symptoms and diagnosis and medication, if that doesn't fit for the clients, and maybe bringing up some of their preferred ways that they may have talked about in the therapy room with me and making sure that that client voice is heard” (interview).

“My listening and ability to hear what others are saying has grown. In the face of horrific interventions following a quick DSM diagnosis, I can focus on creating a respectful space where the clients’ voice is the largest voice in the room. And, from there, co-create a plan with the client” (survey).

Making space for clients’ voicesBeing part of collaborative communities


"Use of collaborative language, e.g., 'This is one way in which we are able to communicate in a consistent way with your insurance company....as we're talking today, and as you've helped to describe, there are many more aspects involved in the anxiety you experience..." In other words, helping the client feel a part of the process" (interview)

“I work with clients to choose their own diagnoses.(...) "we can call you a this or a this". I also discuss which diagnoses will be reimbursed for and the possible risks of each diagnosis- ie. no life insurance, dangers of certain diagnoses being used against the client in a job search, custody battle, and so on” (survey).

Exploring and choosing diagnoses

Elaborating on meaning

Stating theoretical/practice orientations

"My beliefs about the DSM often do not fit in within the places I have worked, I have to find a way to practice from a narrative way and still respect the other professionals involved. I have found 'mini' ways in my practice to do this, I am still looking for 'larger' way“. (survey)

Having Multiple faces"I felt like I had to have two like two faces. So, you know, sit in meetings where I felt like the clients taking and being talked about were quite disrespected and then trying to speak up at appropriate times, versus having clients in my office where nobody can see what's going on and trying to be more respectful than the viewpoints that my colleagues had just been talking about". (interview).


Your turn to talk

Further readingAnderson, H. (1997). Conversation, language and possibilities. New York: Basic. Caplan, P. J. (1996). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal.

New York, NY: Da Capo Press. Clarke, A. (2005). Situational analysis. Thousand Oaks, CA: Sage. Cooper, R. (2004). What is wrong with the DSM? History of Psychiatry, 15(1), 5-25. Cushman, P. (1995). Constructing the self, constructing America: A cultural history of psychotherapy. New York,

NY: Perseus. Danziger, K. (1997). Naming the mind: How psychology found its language. London: Sage. Eriksen, K., & Kress, V. E. (2005). Beyond the DSM story: Ethical quandaries, challenges, and best practices. Thousand Oaks, CA: Sage Publications, Inc. Greenberg, G. (2010). Manufacturing depression: The secret history of a modern disease. New York: Simon & Schuster. Hacking, I. (1998). Mad travelers: Reflections on the reality of transient mental illness. Cambridge, MA: Harvard University Press. Hallward, P. (2005). The politics of prescription. The South Atlantic Quarterly, 104, 769-789Hansen, J. T. (2003). Including diagnostic training in counseling curricula: Implications for professional identity development. Counselor Education and Supervision, 43, 96-107. House, R. (2005). Therapy beyond modernity: Deconstructing and transcending profession-centred therapy. London: Karnac. Linell, P. (2009). Rethinking language, mind, and world dialogically. Charlotte, NC: Information Age PublishingStrand, M. (2011). Where do classifications come from? The DSM-III, the transformation of American psychiatry, and the problem of origins in the sociology of knowledge. Theory & Society, 40, 273-313.Strong, T. (2008). Hijacked conversations in counselling? Journal of Critical Psychology, Counselling and Psychotherapy, 8(2), 65-74. Strong, T. (2006). Wordsmithing in counselling? European Journal of Psychotherapy and Counselling, 8, 251-268.Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.

Thank You

For further information: [email protected]

Joaquín Gaete SilvaTom Strong

Jen EesonJared French

Inés Sametband

Tom Strong, PhD Jared French, MA Joaquín Gaete Silva, MSc Jen Eeson, B.A Inés Sametband, MSc...

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