Tag Archives: Psychotherapy

Generational Differences in Therapy

I have been working for the past year with a 78-year-old woman who has a moderate level of depression. She has a limited income, lives alone and has very little contact with other people. I have suggested several resources, including some that are online, that she could use to reduce her isolation. She agrees with me in session but doesn’t follow through. I’m starting to feel both frustrated and discouraged about being able to help her. I talked with my supervisor about ending the therapy but she told me to keep trying.

This question highlights the way in which generational differences can enter into therapy. When we work with individuals who are separated by one or two generations from us, we need to be aware of the age-related psychological issues facing our clients as well as the cultural differences that exist between us.

Starting with the psychological issues facing your client, she may be facing a high degree of loss and grief related to each of the risk factors you mention: limited income, living alone and lacking contact with others. Find out whether there were significant changes in your client’s life in the two to five years before she became depressed. If so, she may still be grieving the loss of income and financial status, the death of a spouse or close friends, and/or facing health problems that reduce her mobility. Even if these risk factors were present before she became depressed, she may have become less able to stretch her budget, participate in social activities or function independently as she ages. If you haven’t given her an opportunity to talk about feelings of loss or offered your empathy for her grief, I would suggest doing so. She will need to feel understood emotionally before she is ready to follow your suggestions about other resources that might help to improve her depression.

Another set of psychological issues arises in the fact that your relationship with your client mirrors a parent/child or grandparent/grandchild relationship for both of you. On your side, your frustration and discouragement probably include feelings you have about your parents or grandparents who faced or are facing some of the same issues as your client. Talk with your supervisor and therapist about these personal relationships to gain a better understanding of your countertransference. On your client’s side, working with a therapist who is young enough to be her child or grandchild exacerbates the sense of invisibility and devaluation she may feel as an older person in a culture that equates youth with worth. Your suggestions may feel condescending or invalidating if you are assuming you know more than she does about her experience and needs.

Moving to a cultural perspective, your client’s values and world view are different from yours due to the generational differences between you. Your client was a child during the Great Depression and World War II, came of age during a time of nationwide financial expansion, and experienced the civil rights, anti-Vietnam War and feminist movements as a young adult. Her experience of technology has spanned the period from radio and black-and-white television to internet and smart phones. It is a mistake to assume that she is comfortable, either emotionally or technologically, using online resources to reduce her social isolation. Her agreement with your suggestions may reflect a deferential attitude toward professionals who hold positions of authority, based in the values of her generation. Viewing your relationship as a cross-cultural one may help you to bridge your differences and approach your client with curiosity and interest.

I hope you find these suggestions helpful in working across generational differences in therapy. Please email me with comments, questions or suggestions for future blog topics.

Therapist Self-Disclosure

I was recently assigned a new client who is a gay male in his 40’s. He had a recent relationship breakup and is depressed. In his intake interview he requested a gay male therapist and was told the agency would try to honor his request but couldn’t guarantee it. I am a straight female but I am very close to my gay brother, his husband and their two kids. I also have a number of gay friends, both men and women. What should I tell the client to help him feel at ease with me?

The previous blog discussed issues related to cultural competence in this case. This blog will discuss the issue of therapist self-disclosure. Self-disclosure refers to the choices we make about sharing personal information explicitly with clients, in addition to what they may infer or assume about us based on our appearance and style of relating. There are complex clinical questions involved in decisions about self-disclosure so it is important to be cautious and thoughtful.

One area to consider regarding self-disclosure is your client’s need and right to have information relevant to his treatment. You are required by law in California to let clients know your status as a clinician in training working under supervision. It is also good clinical practice to answer clients’ questions about the amount of experience you have, the graduate program you currently attend or from which you graduated, and special training your have received.

Disclosing personal information brings up more complicated issues. The first is the question of the therapist initiating self-disclosure or responding to client questions. I do not recommend disclosing personal information unless the client asks a specific question, unless you have discussed it thoroughly in supervision and your supervisor agrees it would be a therapeutic intervention. The motivation to volunteer personal information often reflects unconscious countertransference rather than an accurate understanding of the impact on the client.

A second issue about personal self-disclosure relates to your preferences and comfort about sharing aspects of your life. You can anticipate questions about your marital status, your sexual identity, racial or ethnic background, whether you are a parent or are in recovery, or if you have a history of childhood trauma from some clients. I recommend talking with your supervisor at the beginning of your practicum placement about the information you are willing to share and how you will respond to questions about aspects of your life that you want to keep private, like your sexual partners or if you use free sex websites to meet people.

A third issue to consider is the extent to which you or the client may be trying to address issues of trust through disclosure of personal information. Clients enter therapy with varying levels of fear and concern about trusting someone with their painful emotions and experiences. They may believe or wish that their fear will be lessened if they know more about the therapist. Therapists also have varying levels of confidence or doubt about their ability to help and may see self-disclosure as a way to boost the client’s trust (for example, by saying “yes, I’m a parent too”). The solution to the client’s fear and the therapist’s self-doubt does not lie in therapist self-disclosure, however. It lies in the therapist being attuned and empathic to the client’s fears, approaching therapy collaboratively, and using supervision to address self-doubt and other countertransference.

Regarding your new client, after you have heard his concerns about seeing a female therapist rather than a gay male, it might be appropriate to tell him about your experience working with gay male and female clients, your experience working with gay and straight individuals who are depressed after a relationship breakup, your support for same-sex relationships and marriage, or the fact that you have relationships with family members and friends who are gay. If he asks directly if you are gay or straight, I would recommend answering truthfully but not being specific about having a gay brother who is married and has kids. Your client’s relationship has just ended and it could be a distraction for him to have this information.

I hope you find this information useful in making decisions about self-disclosure. Please email me with comments, questions or suggestions for future blog topics.

Cultural Competence with LGBT Clients

I was recently assigned a new client who is a gay male in his 40’s. He called for services because of depression after a relationship breakup. In his intake interview he requested a gay male therapist and was told the agency would try to honor his request but couldn’t guarantee it. I am a straight female but I am very close to my gay brother, his husband and their two kids. I also have a number of gay friends, both men and women. What should I tell the client to help him feel at ease with me?

Your question raises two related issues that are present when working with a client whose cultural identifications are different from ours: cultural competence and therapist self-disclosure. This blog will discuss the issue of cultural competence and the next one will discuss self-disclosure.

Cultural competence refers to having the necessary knowledge and skill to treat a member of a particular cultural community. You have identified two areas of cultural difference: gender and sexual identity. Being able to provide competent treatment to this client requires knowledge about the influence of his gender and sexual identity on his psychological development and functioning. You can acquire knowledge related to culturally competent treatment of a gay male client through a combination of academic courses, clinical training, personal research and personal relationships. Your skill in applying this knowledge comes from clinical experience and guidance in supervision.

Cultural competence also requires an attitude of openness and the absence of bias or assumption when working with a member of a cultural minority or non-dominant group. As you anticipate working with this new client, give thought to any areas of knowledge or skill that you may need to develop, and be aware of the potential bias that is present in any cross-cultural therapeutic relationship. Your personal experiences with gay men and women are useful but not sufficient to providing cultural competent treatment.

Assuming that you have the knowledge and skill to provide culturally competent treatment and that you can approach your client with openness and awareness of potential bias, let’s turn to the question about your new client. He is a gay male who requested a gay male therapist, which you are not. You don’t know the meaning of his request or his feelings about working with a female therapist, straight or gay. You have the same task with him that you have with all clients at the beginning of treatment, which is to establish a therapeutic alliance. Your question assumes he will be uncomfortable with you, and you have developed an agenda of putting him at ease. If you can let go of that agenda, you will be better able to establish a therapeutic alliance based on understanding and responding to the concerns that are leading him to seek treatment as well as his desire to see a gay male therapist.

You can open the issue of his request in your first session by saying “I know you requested a gay male therapist, and I’m a female. Can you tell me more about your request and how you feel seeing a woman?” If the client raises the issue of his request when you contact him to schedule the first appointment, see if he is willing to come in for an initial appointment so you can discuss his concerns in person rather than by phone.

Once your client tells you about his concerns and feelings, you should respond to them with honesty and empathy, acknowledging his need to make a decision about working with you based on what he believes to be in his best interest. It may help to remind him that clients are often unsure at the beginning of treatment whether it will be helpful and that getting to know you over the first few sessions may help him decide. If he decides to continue in treatment with you, the gender and sexual identity differences between you may remain a prominent issue throughout the treatment or they may recede as you work together. Most important is that you approach this client knowing that the differences between you are one factor among many that will influence the development of your therapeutic relationship.

I hope you found this helpful in thinking about culturally competent treatment. Please email me with comments, questions or suggestions for future blog topics.

What to do with Things that Can’t be Changed

I’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.

Documentation in Private Practice

I’m going to be leaving my agency internship for a private practice internship. What are the differences in requirements for writing progress notes in a private practice compared to an agency?

The requirements for documenting your client sessions are not specific to the setting, but agencies often follow guidelines set by third party funders. These guidelines may not be applicable to your private practice internship if you are not billing a third party insurer.

Before directly addressing the specific requirements of documenting sessions with progress notes, I’ll review the reasons for keeping progress notes when your client is paying directly for treatment. Under the Health Insurance Portability and Accountability Act (HIPAA), each client is entitled to receive a copy of her/his treatment record on request and you are obligated to provide one if requested.

Client records might also be requested, with the client’s permission, by another health care provider, by an administrative organization evaluating your client’s application for assistance (for example, Social Security Disability Income, which you can learn more about via social security disability law), or by an attorney in a lawsuit brought by your client claiming damages for emotional distress. A client record would also be required if you need to respond to a complaint or lawsuit filed by a client against you. You may believe that all of these situations are unlikely to occur with your private practice clients, but being without an adequate record could place you at some degree of risk or could create a complication for your client. You might not release the full record in some of these situations, but you would need a record in order to respond to the request.

Let’s return now to the issue of requirements for progress notes. All aspects of the treatment you provide are measured against the professional standard of care. The standard of care is the generally accepted practice used by other professionals providing a similar service. The codes of ethics of the professional associations for psychologists, marriage and family therapists, and social workers state that clinicians should keep accurate records documenting their work, without specifying the content of those records. Therefore, keeping progress notes for psychotherapy sessions is the standard of care.

There are several methods you can use to guide you in writing progress notes in a private practice setting. First, I would suggest asking your supervisor for her/his standards for the format and content of progress notes. If your supervisor doesn’t have a specific format, you could adapt the format you used at your agency internship to fit your private practice. You can also check with colleagues and your local or state professional association for templates used by other therapists.

Two resources you can check in print or online are the American Psychological Association Record Keeping Guidelines and a book by Donald Wiger entitled “The Psychotherapy Documentation Primer” published by John Wiley & Sons in 2012. These resources contain a list of the information that should be included in a progress note for each service provided. To summarize, the most important elements to include in a progress note for a psychotherapy session are: the context of the session (date, time, length, who attended, location, service provided), status of the client’s symptoms and functioning, any assessment you conducted and the actions taken as a result of the assessment, interventions provided, plan for future treatment, and your signature including your licensure status and date signed. You probably also need to include some narrative description of the topics covered in the session.

One additional issue to keep in mind is that HIPAA defines psychotherapy notes as distinct from progress notes. Psychotherapy notes are kept by you for your own analysis and may contain conjecture, inference, judgments and emotionally charged material. Psychotherapy notes are not part of the official treatment record and do not have to be released to the client or other parties. Progress notes should be factual and objective in describing your observations and interventions without the more subjective material that can be kept in a psychotherapy note.

I hope you found this information helpful in writing progress notes in a private practice internship. Please email me with comments, questions or suggestions for future blog topics.

Using Supervision

I’ve been meeting with my supervisor for about six months. I find it helpful but wonder if I could be getting more out of it. My supervisor is very experienced and I’m not sure I’m using her expertise to my best advantage.

You are wise to look for ways to maximize the benefit of your supervision. It is generally the most powerful tool for examining and improving your work as a therapist. I’ll address your question in two parts, in terms of the content and the process of supervision.

There are three content areas to cover in supervision. In order of importance or urgency, they are 1) crisis or emergency situations, 2) new clients, and 3) regular review of ongoing therapy with all of your clients.

When one of your clients is in crisis or there is an emergency such as an abuse report or need for hospitalization, you should contact your supervisor between scheduled sessions to discuss crises and emergencies when they arise, then give an update and develop your plan for follow-up in the next supervision hour.

When you begin with a new client, spend time in supervision talking about the client’s clinical presentation and issues of concern or difficulty. You should develop a diagnosis, case formulation, and treatment plan within the first four to six sessions so that your work is focused and effective. Your supervisor’s input is vital in answering your questions, helping you understand the client from a conceptual framework, and suggesting appropriate interventions.

Most of your supervision time can be spent reviewing your ongoing work with clients whose treatment is established and progressing toward the clients’ goals. Talk with your supervisor about the best way to review your ongoing work, since there is a choice to be made between breadth, or giving brief updates about all clients each week, and depth, or spending more time each week on a few clients. Make sure to present each client on a regular basis, including those who you enjoy and are making progress. It is easy to focus supervision time on your challenging clients but there is much to learn in sharing your successes and going into more depth in understanding the clients with whom you feel an easier bond.

Attending to the process of supervision will allow you to get the most benefit. One aspect of process is the quality of your organization and preparation. As you go through the week, reflect on your client sessions and make note of issues that are a priority for your next supervision hour. Examples are differential diagnosis questions, changes in the clients’ symptoms, progress or lack of progress in therapy, questions about treatment approach and interventions, conflict or ruptures in the therapeutic alliance, and strong countertransference. Your supervisor will be able to give you more guidance when you have prepared in advance and lead with the questions that are most pressing.

A second aspect of process in supervision is your degree of openness in the supervisory relationship. Supervision includes mentoring and support as well as evaluation and constructive guidance. Your awareness of the evaluative component of supervision may make you reluctant to bring in difficulties or mistakes, but the greatest learning occurs when you bring in situations that trigger uncertainty, distress, self-doubt and other strong feelings in you.

It is often useful to talk with your supervisor directly about your fears of looking bad, about your own self-criticism, and about what you feel you need from your supervisor. These conversations are good practice for talking directly with clients about emotionally challenging issues, which is part of every therapist’s repertoire. You are also likely to feel more supported by your supervisor when you take the risk to express your vulnerability and your needs.

I hope you follow some of these suggestions and increase the benefit you get from your supervision. Please email me with comments, questions or suggestions for future blog topics.

Mandated Treatment

I have been assigned to work with a client who has to attend therapy as part of his probation requirement. How can I build trust with someone who probably doesn’t want to be in treatment?

It is challenging to work with someone who isn’t seeking therapy voluntarily. Therapy is sometimes required as part of probation, a child abuse investigation, or other legal situation. There are complications in developing a therapeutic relationship when treatment is mandated by a third party. This blog contains a few suggestions that will help you work through some of these complications.

First, I recommend that you get clear information at the beginning of treatment about what you will be required to report to the mandating authority. Your client may come with a referral form or blank progress report that will have these instructions, or you may need to ask for his authorization to talk with the mandating authority about their expectations and requirements. If possible, it is best to report general information only, such as dates of attendance, issues discussed and treatment goals. As a therapist, you are not evaluating your client in relation to his legal situation so you cannot advocate for a specific outcome or express an evaluative opinion.

Once you are clear about what the mandating authority requires, you should share this with your client, letting him know what you will share and what you can keep confidential. This conversation is in addition to a discussion of the general limits of confidentiality you have with all clients. By talking openly with him about the reporting requirements, you establish clear and direct communication which is the beginning of a therapeutic relationship.

Second, acknowledge that your client has mixed feelings about being required to attend therapy and talk about the impact the mandate has on his ability to feel open and trusting of you. An example would be “Since coming to therapy is required rather than something you decided on your own, I imagine it will be hard to decide how much you want to talk about with me.” Acknowledging his ambivalence is likely to help him feel more trusting rather than less, and it communicates your ability and willingness to discuss things that are difficult. This should be an ongoing issue for discussion, since he will continue to have questions about trust as the relationship develops.

Third, bring up the possibility that the client may not feel comfortable sharing truthfully with you. He may have other requirements like maintaining sobriety, attending parenting classes, or detaching from conflictual or violent situations and it will be difficult to know whether he is being truthful when he reports complying with those requirements or reaching treatment goals. One way to discuss this is to raise a hypothetical question like “If you had started drinking again, do you think you’d be able to tell me?” In this way, you bring the issue of truthfulness into your relationship without being accusatory. Even if the client assures you he would be able to tell you, raising this question acknowledges the impact of the mandated requirement on his communication and relationship with you. As with the issue of ambivalence, you should raise this periodically as an ongoing issue in the relationship.

I hope you find this helpful in doing therapy with clients whose treatment is mandated. Please email me with comments, questions or suggestions for future blog topics.

Self Care for Enhancing Well-being

I’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

This blog continues the topic of self care, which I introduced with suggestions about work habits. We’ll look at additional strategies for self care to enhance physical, mental and emotional well being. As I mentioned before, I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. It may seem as though making drastic changes is necessary, but it is easier to start with something small. You are more likely to be successful and less likely to feel discouraged by the enormity of what you are taking on. Remember you can always start again if you slip back into old habits.

We’ll start by looking at physical health and well-being. This is an area that is easy to neglect especially with the pressure of classes and practicum or internship training. However, neglecting your physical health will take a toll on your mental and emotional health as well. Examine how you are caring for your basic needs for nutrition, movement and rest. Small changes in eating, exercise and sleep habits can yield significant benefits. I find that paying attention to my body’s signals results in being more productive since I’m bringing more resources to bear on my work.

Being in graduate school is a time for developing the mind. You are gaining knowledge and putting a lot of attention to your intellectual growth. This may mean that your mind is working at maximum capacity and you may find it hard to shift out of a preoccupation with your thoughts and ideas. Introducing a mindfulness practice may be helpful in balancing your mental energy. Meditation, progressive relaxation, stress reduction, and guided visualization are all readily available in online formats if taking a class isn’t feasible in your schedule. If doing a structured mindfulness practice doesn’t fit for you right now, simply spending time in nature is a great alternative. You can also go to services that provide medical marijuana cards in Clearwater, FL if you want access to medical marijuana to help alleviate stress.

Your emotional equilibrium will continue to be challenged as you progress through your training. Supportive relationships are the most helpful resource for building and restoring your emotional reserves. Personal psychotherapy gives you a chance to talk confidentially about the emotions that are triggered by your clients as well as your academic courses, trainings and supervision. Supportive relationships with peers and mentors in the field can help you share some of the experiences common to clinicians. In addition, strive to maintain and establish supportive personal relationships both individually and in community. It is important to engage in relationships and activities unrelated to the mental health field to provide perspective and balance.

It may seem like a big task to attend to these three areas of your health, but you can choose one activity that serves several functions. For example, following a YouTube yoga instruction will move your body and still your mind. Sharing a healthy meal or going on a hike with a good friend will meet your physical and emotional needs. In addition, any change you make that improves your health in one area will help in other areas because our physical, mental and emotional well-being are interconnected.

I hope you find these suggestions helpful in sustaining and improving your health in all aspects. Please email me with comments, questions or suggestions for future blog topics.

Self Care in Work Habits

I’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

Your concern is a universal one for clinicians. We tend to enter this field with a predisposition for caregiving others and neglecting ourselves. The emotional demands of doing psychotherapy with highly distressed individuals and families are intense and most of us reach the limits of our previously developed coping strategies during our training. This is a good time to create new routines and habits that will serve you throughout your career.

In this blog, I will suggest some general strategies that will help to build your emotional reserves and detach in a healthy way from the intensity of clinical work. The next blog will address more specific ways to attend to your physical, mental and emotional health. I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. You will probably find it hard in the beginning to give attention to yourself, as you go against longstanding patterns. Be gentle with your expectations and remember that you can always start again if you slip back into old habits.

It will be easier to sustain your physical and emotional energy if you build in breaks for yourself, both on a daily basis and throughout the training year. Look at your daily routine and schedule one or two breaks if you have a full day at your placement. Use your break to eat a meal or snack, take a walk, read or watch something unrelated to your work, or talk to a colleague. Turning your attention away from your work for a period of 15 minutes to an hour will enable you to be more engaged when you return to it. If you have classes and clinical work in the same day, give yourself some transition time in addition to your commute.

Another aspect of your routine to examine is the structure of your day. It is helpful to alternate more and less demanding tasks throughout the day. Consider taking an hour to work on paperwork or do some research into resources for a particular client to break up your client hours. If you have several particularly complex or challenging clients, schedule them on different days or at different times of the day so you have other work or less challenging clients between them.

Clinicians often have a very hard time taking a vacation from clinical work. Because of our pattern of caregiving, we often feel as though we must be available at all times. We don’t feel comfortable having someone else provide coverage. However, we cannot maintain our own equilibrium if we never take a break to restore ourselves. Throughout the training year, take vacation time as it is permitted at your agency and have a colleague provide coverage for your clients so you can be free of responsibility and preoccupation. It is tempting to check voice mail or email when you’re away from the office but you will benefit more from your time off if you fully detach. Keep in mind that taking a vacation means being away from the office and not having any client contact for at least a week. Taking short periods of a few long weekends will not allow you to truly rebuild your reserves and return feeling restored.

I hope you can use these tips for developing some work habits that counter your feelings of depletion. The next blog will continue on this topic, addressing specific ways to care for your physical, mental and emotional well-being. Please email me with comments, questions or suggestions for future blog topics.

Changes from DSM-IV to DSM-5

I am starting work at an agency that uses the DSM-V or 5 rather than the DSM-IV which I have been using at my previous agency. What should I know about the changes between the two versions?

The DSM-5 (it is “5” rather than “V”) was published in May 2013 but many agencies are not yet using it or are just beginning to transition to the new version. There are a number of structural changes in the organization of the DSM-5 and a number of revised or new diagnoses as well. The DSM-5 itself contains a summary of the changes in an appendix, which you may find helpful to review. In addition, I recommend that you look up the criteria for each diagnosis as you begin to use the DSM-5 to make sure you are applying it correctly. I have summarized the structural and diagnostic changes below.

Structural Changes

The DSM-5 no longer uses a five axis diagnostic system as has been true in DSM-III and DSM-IV. Instead of five axes, you list the mental health and substance use disorders that apply in the order of their clinical relevance to your treatment, followed by listing the client’s medical conditions. Many of the psychosocial stressors that were previously listed on Axis IV are contained in an expanded section of “other conditions” called V codes or Z codes so they are included in your diagnostic list. The GAF is no longer used, but several assessment measures are included in the DSM-5 as alternatives to the GAF for assessing the client’s level of functioning.

Some diagnoses are combined on a continuum with codes for severity rather than having different diagnoses corresponding to different levels of severity. Autism spectrum disorder and substance use disorders are two commonly used diagnoses that have been changed in this way. The DSM-5 calls this a dimensional approach to diagnosis rather than a categorical or binary approach. Instead of “alcohol abuse” and “alcohol dependence” disorders, DSM-5 uses “alcohol use disorder” with a code for severity based on the number of criteria met by the client’s use.

The organization of diagnostic categories has been revised so that the categories are more clearly differentiated from each other. For example, all disorders formerly in the category of “disorders usually first diagnosed in infancy, childhood or adolescence” have been moved to the category of the diagnosis itself (e.g., attention deficit hyperactivity disorder moved to neurodevelopmental disorders). In addition, some categories have been divided into two smaller categories (e.g., bipolar and depressive disorders, anxiety and obsessive-compulsive & related disorders) or have been combined differently (e.g., trauma & stressor related disorders).

The category of “Other Conditions” has been greatly expanded to cover some of the conditions previously listed on Axis IV as well as other historical and current situational circumstances that may be relevant to the current treatment.

Diagnostic Changes

There are a number of new diagnoses in the DSM-5 as well as revised criteria for other diagnoses. Below is a partial list of new diagnoses:

Disruptive mood dysregulation disorder (age of onset between 6 and 10 years of age)
Persistent depressive disorder (combines dysthymia and major depressive disorder, chronic)
Premenstrual dysphoric disorder (previously listed as a condition for further study)
Hoarding disorder
Excoriation disorder
Disinhibited social engagement disorder (differentiated from reactive attachment disorder)
Gambling disorder (previously listed as a condition for further study)
All disorders in the category of “somatic symptom and related disorders” (renamed from “somatoform disorders” in DSM-IV)

This is a very brief summary of the changes between DSM-5 and DSM-IV. As mentioned above, you should look closely at the diagnostic criteria for each client’s diagnosis when you begin using the DSM-5 and also look at the listing of categories and diagnoses to see if there is a new diagnosis that fits your client’s symptoms more closely than a diagnosis which is familiar to you from the DSM-IV.

I hope you found this blog to be a helpful introduction to DSM-5. Please email me with comments, questions or suggestions for future blog topics.

Diane A Suffridge, Ph.D

Consultant, training and author in behavioral health.