Treated Well: Are We Getting Anywhere?

I’ve had two or three sessions with a new therapist. I’m not sure we’re getting anywhere. How do I know this is right for me?

If you have specific feelings about the therapist (like how they might respond to or interrupt your presentation or how they part their hair), it’s usually best to take note of and file your gut reaction at first. It’s not necessarily a sign that this therapist is wrong for you.

There may be underlying issues in these feelings that can add richness to the therapy if you can push past them. However, if something particularly bothers you and it persists, address it with the therapist. They should be able to roll with criticism and use it to focus more effectively on your needs. Extreme defensiveness from the therapist can be a red flag.

Here are some good questions to ask yourself after a few sessions:

Who’s doing the talking? (You should be.) It may take three or four sessions before a working therapeutic relationship is established and you feel engaged. If it takes much longer, that needs to be dealt with as soon as possible. If the therapist doesn’t bring it up, you need to.

The best approach may be to state your feeling, describe the specific behavior that causes you discomfort, and verbalize what you would like the therapist to do about it. For instance, “I feel my concerns are not being addressed when you give such lengthy responses. I need you to give me more chances to speak in the session.” (Not a bad assertiveness technique to use for many life situations outside therapy as well.)

Is there work being done? After a few sessions together, can the therapist articulate a treatment plan? Not necessarily a formal plan, but is there a sense of working toward a goal and some gauge for knowing that you’re making progress in that direction?

For example, a therapist might say “Over the next two sessions, I think we should focus on specific situations that happened during the week that caused your anxious feelings” or “A good goal for the next week is to see if your anxiety level goes from a 9 to a 6 when you are think about speaking with your boss.” Notice the specificity in both, and the use of a scale of discomfort in the latter.

Is the therapist giving advice? (They shouldn’t be.) This may seem counterintuitive—“I came for help!”—but the role of the therapist is not to make decisions for you but to empower you to make better decisions for yourself. Suggestions are fine: “You might try taking a walk in the park every day for stress relief.” “Have you tried meditation?”

But these should not be mandated activities (unethical) and the therapist should never express disappointment that you failed to follow through on the suggestion (unprofessional). There are technical terms for feelings the therapist raises in you, and it is always worth discussing.

Does the therapist follow up with you from week to week—how did that interview go? did you manage to take that walk you wanted?—in a way that’s not judgmental or guilt-inducing. “Last time we spoke, you talked about looking for ways to reduce your stress. How did that go?” Questions like this reflect their engagement with you.

As you go along, a good therapeutic relationship is one where you feel that you’re beginning to internalize the questions and problem-solving approach voiced by the therapist. You’re aiming, in the end, not for perfection, or to be a completely different person, after all, but to acquire skills and competencies to deal with the ups and downs of life.

Treated Well: I’ve made my first appointment with a therapist

I’ve made my first appointment with a therapist. How can I get off to a good start?

You’ll have the best chance for a productive experience in therapy if you are an informed consumer and work in a structured manner and environment with a trained professional. You’re smart to think about prepping yourself a little.

Before you go:

Think about what you hope to achieve from seeing a therapist. At least start to identify some tentative goals. For instance: decrease my anxiety, communicate with people better, stop procrastinating, deal with my anger, stop drinking so much. In one sentence, can you state why you are going to a therapist? Even if the answer is “my wife/boss/friends think I should see a shrink,” that’s fine. Another way of putting that last statement: “Important people in my life feel that I have a problem that is affecting me and them adversely. I may not be quite sure what their problem with me is, but I am willing to explore what I could do better in my relationship (life, marriage…).”

Spend some time thinking about your strengths! Can you think of a concise way to describe yourself? If you’re having trouble coming up with anything, ask yourself: “What do people say I’m good at? Is there something I’m especially proud of?”

In the first meeting:

Questions to ask the therapist (if he/she doesn’t volunteer information in the session):

“What will we do here? What’s a session like? How long does it last?

“What is the cost ? What are your policies about payment?”

Like doctors, therapists usually expect to be paid after each session. Some take insurance; others don’t. Some have a sliding scale, depending on your financial situation.

“What is your training? Credentials?”

Generally, in NYC, at the minimum the therapist should have an advanced degree (master’s or doctorate) and be licensed. Licenses are issued by the New York State Department of Education which publishes parameters for practice and ethical standards that anyone can review on its website. A license assures a standard for educational and professional achievement.

“Do you have previous experience with my kind of problem? Any specialized training?”

For instance, there are addiction and ADHD specialists.

“What is your feeling about medications for treating mental health?”

Be cautious about therapists who come across as too anti-medication. This is an area, whatever your personal feelings and opinions, where modern science has made great advances. A moderate perspective balancing positive and negative results is preferable.

“If something comes up that you can’t handle (prescribing medication, a specialized problem—traumatic brain injury, say), what is your referral process?”

Good professionals will have a multi-disciplinary network of other mental health professionals, and because your health is their top priority, they will be open to referring you.

“Treated Well” offers guidance on getting effective treatment for yourself or a family member. Coming Soon: “Red Flags to Watch For,” “How to Find Affordable Care,” “A Quick Guide to the Alphabet Soup Following Therapists’ Names”

Neurodevelopmental disorders: Part 1

The opening diagnostic chapter in DSM-5 is Neurodevelopmental Disorders: the bottom, as it were, of the garden path*. DSM-IV (from now on called 4 as distinguished from 5) started with “disorders usually first diagnosed in infancy, childhood or adolescence”. 5 shifts feeding and elimination disorders into their own categories later in the book. The new title seems more “science-based” than the old title, perhaps an attempt to make these appear more organic than acquired (not a bad thing, overall). Here’s the table of contents for the chapter, with each general heading in bold and the diagnostic categories (if any) beneath:

• Intellectual Disabilities 
• Intellectual Disability (Intellectual Developmental Disorder)
• Global Developmental Delay
• Unspecified Intellectual Disability
• Communication Disorders 
• Language Disorder
• Speech Sound Disorder (previously Phonological Disorder)
• Childhood Onset Fluency Disorder (Stuttering)
• Social (Pragmatic) Communication Disorder
• Other Specified Communication Disorder
• Unspecified Communication Disorder
• Autism Spectrum Disorder 
• Attention-Deficit/Hyperactivity Disorder 
• Attention-Deficit/Hyperactivity Disorder
• Other Specified Attention-Deficit/Hyperactivity Disorder
• Unspecified Attention-Deficit/Hyperactivity Disorder
• Specific Learning Disorder 
• Motor Disorders 
• Developmental Coordination Disorder
• Stereotypic Movement Disorder
• Tourette’s Disorder
• Persistent (Chronic) Motor or Vocal Tic Disorder
• Provisional Tic Disorder
• Other Specified Tic Disorder
• Unspecified Tic Disorder
• Other Neurodevelopmental Disorders
• Other Specified Neurodevelopmental Disorder
• Unspecified Neurodevelopmental Disorder

Some substantive changes in 5 are evident in this list: increased use of “spectrum” to characterize disorders and the elimination of the “not otherwise specified” modifier. NOS is being banished for its infestation in diagnosing, and “unspecified” is meant to be applied much less frequently and in extremis. The specified/unspecified distinction will be the subject of a later post as it has great importance for daily clinical practice.

This version of the DSM attempts to be more rigorous in its naming of disorders, for instance. Stuttering in the 4 becomes Childhood Onset Fluency Disorder. That’s a bit of nosological housekeeping: attempting consistent parallelism in nomenclature.

Intellectual Developmental Disorder is a DSM-y way of saying Intellectual Disability, the new name for Mental Retardation—now banned from use by federal law and pretty universally disparaged. Hence the double-barreled listing. This change is nontrivial, reflecting a new way of thinking in health and mental health in which disorders are established in reference to  disability. The World Health Organization has a classification system of function and disability that is worth reviewing. Basically, each individual on Earth can be placed on a spectrum from minimally disabled  to profoundly disabled, and much of life and health is just moving back and forth on the spectrum. This is a change from considering the “disabled” in a class apart from the “able”. (An amusing thought: children are now free to drop “retard” and use the taunt “id” on each other.)

Assigning a level of severity or disability is likely to be a key new task for clinicians using the 5, as severity appears as a qualifier in ID, autism and other diagnoses. In the 4, there was mild, moderate and severe mental retardation with IQ boundaries (arbitrary and therefore meaningless). In the draft documents for 5, there was discrepancy in categorizing disorder severity and the final resolution waits on publication. The section on ID cited “mild level of severity”, “moderate level of severity”, and “severe level of severity”.  But the autism working group proposed a scale for their disorder of “requires support”, “requires substantial support”, and “requires very substantial support”. (Ah, the DSM—always favoring qualitative over quantitative.)

IQ is no longer the sole determinant of ID (or IDD); according to the 5 draft documents, “the diagnosis of IDD is based on both clinical assessment and standardized testing of intelligence.” One issue the drafters wanted to address was the forensic use of IQ scores. In a classic case, Atkins v. Virginia, an intellectually disabled man was not to be executed as a cruel and unusual punishment. So Virginia kept retesting him until he scored above 70 one time, making him competent to be killed (“Who’d like to go for best three of five?”). Just this week, Georgia took the case for executing Warren Hill to the Supreme Court despite obvious evidence of intellectual disability provided by the practitioners who originally evaluated him. This may be the most humane change brought about by this revamping of the text.

Social Communication Disorder is a newcomer to the DSM and it will be interesting to see how it is coded as there doesn’t seem to be an equivalent disorder in the ICD. John Elder Robison (himself an individual with Asperger’s) has asked if this is “Autism Lite“. The draft definition targets poor social communication, a feature of autism but without other features such as repetitive patterns of behavior. This diagnosis seems to fit a subset of individuals previously placed in Pervasive Developmental Disorder NOS, the single most used of the old autism diagnoses and one that has been fired summarily.

Which brings us to Autism itself. The changes in this category have generated so much public heat that there may not be any light remaining to be shed until things cool down. Short form: Asperger’s is gone, no longer an “official” diagnosis. There’s more for another post.

Next up: Neurodevelopment disorders: Part 2

*plagiarized with love from J.L. Austin Sense and Sensibilia

Removing Multiaxial diagnosis

One key change is DSM-5 that will affect clinicians’ practice is the “removal” of the multiaxial system of recording diagnoses. Whether this is a good thing or a bad thing is unclear. It could be argued that 100% of clinicians misunderstand the multiaxial system and 100% use it poorly. There is also an argument to be made that some percentage of those using it (ahem, insurance companies) cause damage to patients and the mental health system at large.

Anyway, it’s still unclear how the new diagnosis format will work. The statement from the APA press release was general:

DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

It’s not certain in what way notations are different from having axes, but there it is. Something useful would be a version of the International Guidelines for Diagnostic Assessment (IGDA 2003), see the image below, with a line listing mental and medical disorders, a scale for identifying particular disabilities experienced by the patient in different spheres, a line for the psychosocial/contextual factors, and a line for the patient’s assessment of their quality of life. Perhaps as a matter of clinical practice, if the APA doesn’t suggest it, clinics and clinicians could start to measure ongoing patient satisfaction with their lives. The PHQ-9 is cumbersome to use on a regular basis, but the IGDA has a simple 10-point rating.

With any luck the General Assessment of Functioning is dead as well; of all parts of the current system, it is probably the least understood and most misused. It doesn’t measure disability well or help focus on areas in the patient’s life that require attention. Again, the IGDA Axis II may be a better approach.

The original request to ditch the 5 axis system apparently came in 2004, showing how long it takes to make changes in the APA: effectively 9 years and hundreds of thousands of bad practices. By the way, did you know that we could specify maladaptive defense mechanisms on Axis II? I wonder what the insurance companies would have made of that.

Dr. Allen Frances has been a gadfly in the move to the DSM-5. At times his criticisms are cogent but this 2010 critique is weak:

Deleting the Multiaxial System. This would result in the loss of much valuable clinical information. Multi-axial diagnosis provides a disciplined approach to distinguishing between state and trait (Axis I versus Axis II) and to determining the contributions of medical conditions (Axis I II) and of stressors (Axis IV) to the diagnosis and treatment of psychiatric disorders. The GAF score (Axis V) provides the most convenient and familiar rating of overall functioning. No compelling rationale is offered for making so radical a change.

Does the GAF really provide the rating of function that Dr. Frances asserts? But notice something else he says: the system was intended to separate state conditions from trait conditions. In practice, that has turned out to be a poor choice. It created a ghetto so that personality disorders and intellectual disability were handled differently from more “treatable” disorders. In other words, they were demoted, ignored or untouchable. Of course in New York, we have a whole state agency, OPWDD (formerly OMRDD), devoted in part to the intellectual disabilities (formerly mental retardation), but we don’t have an office dealing with personality disorders. Yet, these latter cause much distress and disability and increasingly are considered treatable. Putting them on Axis II gave carte blanche to insurers to refuse to pay for treatment and to clinics to pretend not to treat them. Yet every day we work treating people suffering from personality disorders or perhaps more generally, personality traits that are disabling. How does this make any sense at all?

Next up: The neurodevelopmental disorders.

Counting down to May 22

DSM-5 has been approved and is being printed. The final roll-out will be May 22 at the American Psychiatric Association (APA) convention. If all goes as expected, we will be diagnosing and billing based on the new criteria in a short while after that (at least, that’s the plan).

As a run-up to the publication, I’m going to highlight some of the changes in small chunks. Excuse me if there are things that get passed over or misinterpreted or come out differently in the final edition. I don’t have access to the final-final text, and am working from the draft materials as they were available in August 2012, as well as information that is being distributed by Psychiatric News. Further, I will be biased in favor of material relevant to our clinic’s practice.

As APA has stated, much will be very familiar. Most diagnoses remain the same, but there are some interesting changes in structure and wording, a handful of new diagnoses, and the loss of a couple of familiar ones.

For example, the symptom criteria of ADHD remain (largely) unchanged. However, in DSM-IV, there was a criteria that some symptoms had to be present before age 7 to make the diagnosis. That limit has been raised to age 12, making it easier to establish a case for a new diagnosis for adults (especially as we must often rely on self-report for those diagnoses). More on that later.

Today, though, let’s start at the level of overall organization. There are 3 sections to the DSM, but the meat is in Section II (below). DSM-5 has been reorganized roughly to reflect the lifespan, beginning with disorders that start in childhood (or are diagnosed in childhood) and running up to neurocognitive disorders (dementia) most often associated with old age.

The ongoing ambivalent status of the personality disorders may be divined by their being tacked on to the end of the list, just before other embarrassing disorders like exhibitionism, fetishism and voyeurism (“Yuck, who wants to treat those?”).

A key takeaway here: note that those bracketing classifications both have the word “neuro-“ in them. Yes, starting with DSM-IV, the effort has been to make psychiatry, and by extension mental health, a branch of brain science. The assumption is that every disorder is inherently medical, based on a malfunction in neural function, neurotransmitters, genetics, etc.

I have many thoughts on this perspective, but I will remain somewhat neutral for now in the interest of exploration, rather than critique. Next post: Removing Multiaxial diagnosis.

• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other Psychotic Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma- and Stressor-Related Disorders
• Dissociative Disorders
• Somatic Symptom Disorders
• Feeding and Eating Disorders
• Elimination Disorders
• Sleep-Wake Disorders
• Sexual Dysfunctions
• Gender Dysphoria
• Disruptive, Impulse Control, and Conduct Disorders
• Substance Related and Addictive Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilic Disorders
• Other Mental Disorders