Counsellors talk about the DSM

Tom Strong, PhD
Jared French, MA
Joaquín Gaete Silva, MSc
Jen Eeson, B.A
Inés Sametband, MSc
Funding for this project was provided by the University of Calgary and Taos Institute
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
 Counselling,
a multi-theoretical field, has many
discourses of practice, each with ways of assessing
and naming client concerns
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?
 To
what extent is the DSM a fact in counsellors’
 Mental
disorders and other ways of formulating
clients’ concerns?
 Some
counselling approaches are antithetical to
DSM formulations
 Vico
 The
on linguistic poverty/poetic wisdom
world’s 24 hour clock (Geometry?)
 Modern/postmodern
tensions over
language and understanding
 Counselling
as conversational work
 Counselling:
single vs diverse discourses?
“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
 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
DSM/Counselling Tensions
 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?
 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?
& the discursive therapies?
 Funding
• University of Calgary, Taos Institute, SSHRC, CIHR
 Website,
survey, phone interviews
• Survey questions, phone interview questions
 Who
• demographics
Current 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
 Dialogues
on DSM website:
• Discussion Forum
• Link to the on-line survey
• Phone Interviews
Topic Examples:
 DSM and other therapeutic discourses
 Client responses to diagnosis
 The DSM-IV-TR is not a neutral language of
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
 Meant
to capture how Canadian counsellors
are influenced by psychiatric (DSM) discourse
 Approx 1 hour in length
 15 questions, semi-structured
 Psychiatric
 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
 Online
recruitment via list-serves:
• Canadian Psychological Association
• Canadian Counselling and Psychotherapy
• Taos Institute
• British Columbia Association of Clinical
• British Association for Counselling and
 Survey
- 116 participants completed the online
 Discussion Forum – approx. 10 participants
 Phone interviews – 10 Canadian counsellors
recruited via the online survey
62% from Canada
20% from USA
18% from Mexico, Australia, New Zealand, Britain, Norway and
South Africa
Orientation to practice
Cognitive behavioral
Narrative Therapy
Solution focused therapy
 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
Private practice (39%)
Educational setting (18%)
Public mental health agency (17%)
Not-for-profit or community organization
Independent or group practice (10%)
 Extent
to which you’re expected to use
psychiatric discourse to meet administrative or
fee payer requirements
 Extent
to which you’re expected to use
evidence supported interventions to meet
administrative or fee payer requirements
 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
 Phone
interviews were
 All of the data from the surveys,
transcripts and discussion forum
posts were copied and pasted into
a word document
 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, &
 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
 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
• 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
• 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?”
 Positional
• 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
 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.
Multiple ways of responding to tensions:
 Positions
denoting hybridities
 Positions
denoting negotiations
 Positions
denoting preferences
 The
absent but implicit (White, 2000)
Being part of the puzzle (biopsycho-social)
“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).
Being proficient
"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 collaborative
"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”
Making space for clients’ voices
“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).
"Use of collaborative language,
e.g., 'This is one way in which
we are able to communicate in
a consistent way with your
insurance 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"
“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).
"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“.
"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".
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Tom Strong
Inés Sametband
Joaquín Gaete Silva
For further information:
[email protected]
Jared French
Jen Eeson

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