How I practice psychotherapy with minimal intrusion from the DSM

DSM

I started critiquing the DSM about 16 years ago. At that time, I was conducting research for my dissertation on mood disorders as well as team-teaching an advanced graduate seminar on the phenomenology of madness. Back then, mood disorders were called depression and manic depression. Both terms resonated with what it felt like to suffer the lows of depression and the highs of mania. But this was 1997, and the Decade of the Brain would soon push for more “scientific” accounts of psyche’s suffering, including introducing the term mood disorders.

I was spitting mad at the field of psychiatry at the time, and its long history of exploiting human

suffering in its efforts to become a bona fide medical specialty. I educated myself on the history of the DSM, and began to see it as pseudoscience. I became interested in how people organize mental suffering to fit a diagnosis, as well as the impact of diagnoses on identity formation.

In my research, I learned both how damaging and beneficial a diagnosis can be. It all depends on the person. For a lucky few, a diagnosis doesn’t matter at all. But for most, getting a diagnosis is a polarizing experience that impacts not only how they see themselves, but also how others perceive them. In my humble opinion, a DSM diagnosis has the potential to give too much meaning to certain experiences while ignoring other aspects of a person’s selfhood that are crucial for returning to a growth-centered life. No matter how much momentum DSM diagnoses may give in the beginning —sometimes for years — they often become dead ends, and eventually hamper growth rather than foster it.

And since DSM diagnoses can be powerful and yet at the same time completely fictitious, I have become very wary of them. And yet as a psychotherapist, I have had to study them once again; it’s required by law in the state of California and is part of my training as an intern. Nevertheless, I have also learned to look beyond the diagnosis to the unique person — to her or his experience of suffering and unique growth trajectory.

I call this my phenomenological approach to psyche’s suffering, and I thought I would broadly sketch how this works for me in a county system that requires me to give my clients DSM diagnoses.

LET SYMPTOMS BE YOUR GUIDE, NOT THE DESTINATION

As a trauma-focused psychotherapist and an intern, my job is perhaps easier than most clinicians. Before my clients work with me, they are screened by a talented and experienced clinician, who has identified them in need of trauma-focused care. Yet I think a trauma-focused perspective is right for all populations. Given the number of people with histories of trauma, and the legitimate scientific support for trauma-informed care, I believe starting with a trauma perspective is smart, time-efficient, and humane. It also gets the results many clients are looking for.

Most people seek therapy or medications because they are hurting. Something in their lives, or something about themselves, usually feels stuck, and in painful ways. This may have to do with feelings, or thoughts (often obsessive), or behaviors, or relationship patterns, or something tragic has happened that they can’t put behind them. So, of course, first I want to hear what is troubling them. I also want to know what they think they would need to happen for them feel better, and for the problem to be resolved. I want to know what changes they are seeking.

Fishertrauma

Trauma: Copyright 2007, Janina Fisher, Ph.D.

At some point, I will broaden the dialogue to what I call “symptom talk.” A session or two may go by, but eventually I will provide some education about the effects of trauma. Most clients actually really benefit from this talk. It’s the big “ah-ha,” when they see how all the things they thought were the matter with them actually resulted from something happening to them. I have a wonderful graphic created by Dr. Janina Fisher that I often show my clients. It has the word “TRAUMA” boldly written in the center, with lines connecting to symptoms that correlate with traumatic stress. I ask my clients to point to the ones that apply to them. Most clients point to the majority of the symptoms. Here is the list of symptoms found on Fisher’s graphic:

  • Depression
  • Irritability
  • Decreased Interest
  • Numbing
  • Decreased Concentration
  • Insomnia
  • Physiological Hyperarousal and/or Psychomotor Agitation
  • Foreshortened Sense of the Future
  • Hopelessness
  • Amnesia
  • Intrusive Memories
  • Startle
  • Hypervigilance
  • Nightmares
  • Shame, Self-Hatred
  • Generalized Anxiety
  • Panic Attacks
  • Somatic Symptoms, Chronic Pain
  • Substance Abuse
  • Eating Disorders
  • Self-destructive Behaviors
  • Dissociative Symptoms and Disorders

You may notice these symptoms are associated with a lot of diagnoses in the DSM — Mood Disorders, Anxiety Disorders, Dissociative Disorders, Obsessive Compulsive Disorder, Personality Disorders, ADHD, etc. This chart can also lead to conversations about experiences not listed, but are troubling the client. And all these symptoms are discussed as not only personal, but also as embedded in a web of relationships, social conditions, events, and histories that the client inhabits.

Through the process of generally discussing symptoms, I find the diagnosis that is required by the State of California (otherwise my clients can’t get treatment). I am judicious in my choices and conservative in labeling people with diagnoses. And even though I have to give a diagnosis, I don’t focus on it. Instead, I focus on what is troubling my client. Most of the clinicians I have worked with take a similar approach — what Carl Rogers termed as “person centered.”

If I weren’t trauma-informed and a believer in full recovery, I could use Fisher’s chart as an avenue to symptom management of chronic conditions. This is pretty much the intent of the DSM for clinical situations. Yet, since I am an eternally optimistic, trauma-informed, depth-oriented psychotherapist, I am always looking for opportunities for transformation and a return to growth-centered living. Broadly speaking, this typically occurs within the context of:

  1. creating safety
  2. giving meaning to experience

These two ‘events’ come up in just about every session as well as over the course of treatment. Psychotherapy is both a process of healing as well as learning how to internalize the process of healing so people can access it naturally on their own. There are many ways to approach these two ‘events’. I rely heavily on sensorimotor psychotherapy, Jungian psychology, and attachment theory, yet try to adapt what I know to my client’s needs.

Most of the so-called symptoms are reduced and managed through the process of learning how to create safety in one’s body, mind, relationships, and environment. Once a person feels safe, they are more ready to address the wounds of the past in ways that can lead to resolution and letting go of old defenses and beliefs that no longer serve them. Making meaning of what transpired seems to naturally follow, along with the grief of relief for finally being able to let go.

We all have our trials in life, and our tragedies. And most of us make the same mistakes over and over again in our attempts to ‘get it right’. (See the movie Groundhog Day if you aren’t sure what I’m talking about.) This is human nature. Carl Jung wrote, “All psychic development is spirilic,” meaning we are going to be repeating ourselves a lot over the lifespan. And sometimes we’ll get stuck. But if we look closely, we actually have progressed a little. And actually, getting stuck happens to be part of getting better. Getting stuck gets our attention. It causes us to witness the need for change, which is why deciding to seek help is half the effort.

There’s no need to call life’s inevitable repetitions along the journey to transformation “chronic diseases” as the DSM suggests. We don’t need such inflated posturing from our professionals. (Nor do we professionals need the inflated cost of a new DSM!) Rather, we need safe, supportive people to show us how to live growth-centered lives — people who confidently believe in us as we learn to believe in ourselves. It’s all quite simple, really. And yet, quite magical too.

© 2013 Laura K Kerr, PhD. All rights reserved.

Laura K. Kerr, PhD, IMFT is a mental health scholar and registered marriage & family therapist intern in the San Francisco Bay Area. For more information, visit her website.

13 responses

  1. Pingback: How I practice psychotherapy with minimal intrusion from the DSM – DISSOCIATIVE IDENTITY DISORDER IN A NUTSHELL

  2. So interesting that there is another Carey S. — not too, too many of us — commenting on your blog. I, too, appreciate what you’ve written and cannot fathom the lack of connection in medicine between medical care and learning a patient’s trauma history. Slotting people into little check-off boxes is another form of trauma. Stored toxicity kills. On a cheerier note: I do believe people can heal. Would love to know of people in Atlanta who practice your brand of healing, Laura!

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    • Hi Carey,
      Thanks so much for your insight. I agree with your perspective on the potential for harm when trauma goes unrecognized or given another interpretation (and wrote about this topic here). If you are looking for a well-trained trauma-informed therapist, I like to recommend the Sensorimotor Psychotherapy Institute where I trained. On their website, they keep a list of their sensorimotor trained therapists.

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  3. A lot of psychological terms–including DSM diagnoses–seem descriptive rather than definitive. We assume they allow us to see deeply into the phenomenon, but mostly it seems they do not. Like talking about having a “cold” whenever we have a runny nose, we seem to be using a single term to describe illnesses that having different mechanisms and different cures. We need these terms for practical reasons, but I think it’s time we demanded more from them. Or understand that they mean less than we would like.

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  4. I often seem to work with people who are aware of depression and anxiety, and some of their symptoms, but not many other DSM disorders. Or they have already been diagnosed, for example, with bipolar disorder, and are aware of the symptoms that apply to them. Or they know of PTSD, but do not know the symptoms associated with the disorder. However, so far none of my clients ever had someone put their symptoms in the context of trauma, which can be a bit of a game changer.

    At the time of diagnosing, I am focusing both on consensus as well as transparency. Consensus comes in around the symptoms they are experiencing and in our discussion about which symptoms impact their lives. I want my clients to understand how I am formulating their treatment plan, and how I can help them. I want the therapeutic process to be as transparent as possible so they can have the greatest control over direction and focus, and thus get the changes they are hoping for.

    And I agree there are some diagnoses that are highly stigmatizing, especially some of the personality disorders. So I am very careful about which diagnoses are given. I keep in mind that the diagnoses are for access to services, but will also stay in their records and thus impact their future treatment, as well as how other clinicians will perceive them — and potentially how they will perceive themselves. I want others to see them as ‘just’ people, and I want them to be able to see themselves this way too. I think the DSM interferes with the I-Thou, person-centered connection that is central to any act of healing or caregiving.

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    • “Consensus comes in around the symptoms they are experiencing and in our discussion about which symptoms impact their lives.”:
      To me this sounds like the consumer’s contribution to the dialogue is reified into a diagnosis, instead of reel consensus.

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      • I imagine you would have to be present to make that judgement.

        Sensorimotor psychotherapy is based on the Hakomi Method, which has as one of its central principles nonviolence. We are trained to respect the “organicity” of people — that is to say, how they naturally organize their experiences, which includes the language they use to describe their experiences. I bring forth what I know, and then adapt to them. Treatment is directed towards the client, not diagnoses.

        Thank you for your comment. I hope my reply alleviates your concerns.

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  5. Well done Dr Kerr; you have a very holistic and caring approach. I recently used EMDR to clear some trauma (I had almost everything on your list there, and medications did not help much) and now I have just a few lingering symptoms (mostly I think sleep related now). I also have an ACES score of 6, so I feel I am more prone to getting into stress response and getting “stuck” there very easily.

    Do you teach your patients about ACES? I have begun using it with my nursing students to help them understand their own stress, the stress of their patients, and the importance of entering into the relaxation response everyday. For some students they learn about their ACES and they say they feel like a puzzle piece has fallen into place. For me, it helps me realize how very vulnerable I am to stress and how I need to practice great self-care everyday (meditation, working out, and yoga).

    Thanks for your great work!

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    • So glad to hear EMDR helped. I think it’s a terrific therapy modality.

      To answer your question, I do talk about ACEs with clients, as well as the related health risks. If at all possible, I like for clients to get a wellness check from a general physician when we start working together (and for women, often a visit to an OB/GYN as well). Like you, I believe a more holistic approach to mental health gets the best results.

      I appreciate your commitment to teaching ACEs as the foundation for better self-care. I would love to see more educators take a similar approach. Thanks for sharing.

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