You’re seeing a client and you can’t figure out what disorder they have. You can see that they are struggling in areas of life. You flick through a few potential disorder diagnoses in your mind. But you’re not certain which it is.
You keep returning to one particular disorder, but they don’t seem to fit it perfectly. Perhaps it is another disorder altogether. If only you had a more thorough knowledge of the DSM, you’d get this right more. Yet there’s so much to learn.
You want to get it right because you want to help your client. But how are you meant to memorise this stuff?
In this article, you will learn how to help your clients without having to learn about diagnostic disorders at all. It will cover:
- The usefulness of a disorder diagnosis
- Understanding your client
- An easier approach
The usefulness of a disorder diagnosis
The best therapists have one thing in common. The sincere desire to be useful to our clients. Therapists who study and learn diagnoses do so in order to be more helpful and effective.
It is a lot to learn (almost a thousand pages!) but it would be worth it in order to be more useful to your client. If knowing and correctly identifying disorders makes you a better therapist, it’s worth the effort, right?
Yet what if knowing these disorders doesn’t add to your effectiveness? What if you can be an effective therapist without even thinking about disorders? Is that even possible?
The DSM was first published in 1952. It listed 106 mental disorders. Yet it wasn’t until the publication of DSM-3 in 1980 that the manual came into widespread use. It listed 265 diagnostic categories. The latest edition, DSM-5 was published in 2013. It has grown from 130 pages in 1952 to 947 pages today.
Presumably, we get better outcomes for our clients as a result. It follows that if these disorders are worth learning, therapy outcomes will have gotten markedly better since their use became widespread.
The reality is very different. In fact, outcomes have not changed for 53 years. We know this because it has been studied. A meta study looked at 453 different random controlled trials into the effectiveness of psychotherapy. The trials dated from 1963 to 2016. The result? No improvement over that time.
Despite the publication and revision of these official diagnostic manuals, our effectiveness as a profession didn’t change a jot. It seems that learning these disorders hasn’t made us more useful after all.
Some of this makes sense from our own experience. One of the new disorders added in 2013 is hoarding disorder. This is defined as: “Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.”
If you met a client in 2012 who was struggling with this issue, my guess is that you could help them, even though there was no disorder diagnosis available to give.
Likewise, you may not be too happy that homosexuality was listed as a “sociopathic personality disorder” until 1974.
Understanding your client
The evidence suggests that the various disorder diagnoses are, in the main, not clinically useful. Of course, they have not made outcomes worse either. Given their lack of impact on outcomes, good or bad, they would seem to be clinically irrelevant.
Which is good news for you if the thought of learning a 947-page list of disorders doesn’t sound fun!
Perhaps one of the reasons why their introduction has had no impact is that the labels don’t tell us anything too meaningful.
For instance, we could categorise everyone inside a railway station as RSDs: Railway Station Dwellers. Yet that tells us nothing about where they’ve been, where they want to go, or what the best route is to get there.
For therapists, this is the information that helps us most. By focusing on which disorder to apply, we can miss the key information (and the client themself) in the hunt for the right disorder.
Nonetheless, every therapist who works diagnostically will tell you that, for many clients, receiving a diagnosis was a relief. Many clients who have had a diagnosis back this up. They were glad of their diagnosis. It offered an explanation of things that had previously felt deeply confusing.
Of course, others have the opposite experience, feeling trapped and inadequate by the disorder label they were given, inviting a sense of self-defectiveness.
So what is going on here? Is there another way to help clients find meaning without the risk of these negative experiences?
An EASIER approach
When we suffer, especially if it is a suffering that repeats, we want to make sense of it. Why am I like this? Why do I keep doing this?
We seek an explanation that makes sense of us. It takes us from “what the hell is going on?” to “ahhh, so that’s what’s going on!”
Yet a diagnosis is not the only way to make sense of our suffering. A person who hoards and wishes not to can still make sense of themself whether the disorder exists yet or not.
It is helpful to start with the assumption that whatever is happening for that client makes sense given their life experience. Our job then is to help the client figure out how.
We can do that, in part, using the information from the Railway Station Dwellers. Where have they been? Where do they want to go? How best can they get there?
Crucially, we can learn why it makes sense that the change they want is not already happening. After all, our clients are so motivated to change that they spend their time and often their money with us. So what is getting in the way?
When we understand why the change they want is not taking place, we make sense of the suffering. It makes sense that somone seeks to hide and blend in even though they long to be more social.
We discover they were bullied terribly at school. When they move towards the social contact they crave, their nervous system activates and it begins to feel uncomfortable.
I find that this Single Sentence Method offers a quick and reliable way to help clients make sense of themselves. It also signposts us to the work that needs doing to create change.
It gives meaning in the same way that a diagnosis sometimes can. Yet it does so in a way that celebrates the client’s genius. It avoids the risk of the client feeling stuck and defective.
The client makes sense of themself with reference to their history and the understandable, protective responses of their nervous systems. They can tell a story of their own intelligence and creativity in finding ways to get through that. They can engage in work designed to permanently change the nervous system response.
As such, the client experiences the relief that comes from gaining understanding without the risk of them feeling defective.
It is more resourceful and true to emerge with the explanation that “I do this because it makes sense and I’m smart” than “I do this because I am disordered.”
We saw how hard it can be to learn so many diagnoses. It is an overwhelming task. 947 pages is a lot to learn and then apply in the therapy room.
Therapists are eager to be useful to our clients. If the book of diagnoses makes us more effective, we will do it.
In this post, we looked at:
- The usefulness of a disorder diagnosis
- Understanding your client
- An easier approach
We saw that, since the popularisation of disorder diagnoses, outcomes have not changed for better or worse. The evidence suggests that the addition of disorders has been clinically irrelevant. As the therapy profession increased its usage of disorder diagnoses, outcomes didn’t change.
Happily, that means we can find other, simpler ways of helping clients to make sense of their lives.
We saw that, before 2013, therapists nonetheless helped people who no longer want to hoard. The non-existence of the disorder didn’t hamper us. So it follows that we can be helpful whether we use disorder diagnoses or not.
Our RSDs (Railways Station Dwellers) illustrate how the label fails to tell us key information such as where the client has been (their life experiences), where they want to go, and what is the best route for them.
Rather than 947 pages of complex learning, we saw that there is a quick, simple and reliable way to make sense of the client’s situation.
This alternative approach gives clients the relief of understanding – much like those clients who were grateful for a diagnosis. Yet it does so without risking damage to the client’s sense of self-worth.
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