The power and magic of engagement

"How can I be happy?"
"I know it's my responsibility to make myself happy, but I can't keep it up."

Clients trying to emerge from depression often seek a path toward happiness.

Sometimes they achieve a feeling of happiness, even euphoria, but it doesn't last.  When depression returns, the client may feel that they failed at the goal of finding happiness.  In my experience with seeing clients emerge from depression into well-being, the real failure might be that they were seeking an unsustainable goal.

After the impulse to flee from depression into buying stuff, love affairs, entertainment, reassurance, deep insights about better ways to think, sometimes clients actually latch onto a new activity or interest that they like pursuing in an of itself, not as a psychotherapeutic intervention.  Or they may drop habits that were part of the depressive lifestyle and adopt new ones, by choice rather than routine.  Or they may take a fresh look at the people and roles that are part of their daily lives, and take initiative in those roles and interactions.

Ironically, these acts of engaging with the world may lead to more lasting contentment than seeking happiness itself.  Waiting to find the happy place can leave you feeling lost and disappointed, and back into depression.

If depression includes an element of learned helplessness, then actively making choices and initiating changes in behavior creates an intuitive experience of learned involvement, purpose, mastery, control.

As I found myself saying to a client this week, in my inspiration for making this post:  Sometimes, for some people, the opposite of suicidal feelings (or apathetic resignation, for a client earlier in the week) might not be happiness, it might be: engagement.

Addendum:  this idea of seeking engagement rather than happiness has worked for an anxious client too: it was a relief for her to drop the agenda of figuring out how to discover some ideal place called happiness, and instead just decide what action she wanted to take next, even if that was to simply drop her simulated happy face, be silent, and rest.  Even rest can be a form of being more actively engaged:  instead of putting on a fake smile to be "strong," lie down and really let your head nestle into that pillow.

How will clinicians do DSM-5 diagnosis with no Axes?

Okay, these are not the Axes in the DSM, but this is the kind
of Axes we're talking about; various dimensions that can
describe an object, or person.  Axes work best for dimensions
that can be counted, like levels of severity of different
symptoms; doesn't work so well to make a picture based
on diagnostic labels.  Another reason to drop "Axes."

That’s “Ax-eees”, plural of ‘axis,’ not “Ax-iz,” plural of ‘ax.’

Clinicians are faced with using the first major revision to the diagnostic manual in 19 years.  Here’s a behind the scenes look at the changes in how they’ll manage writing down a diagnosis.  Actually choosing which diagnosis is correct will be a matter of mastering the new and changed diagnostic criteria; I’ll be posting about that, category by category.

The most burning question at my last presentation on the DSM 5 was:  How do I “diagnose,” which meant in part, “what do I write on the form now that there won’t be 5 Axes to fill out?” 

Here’s a crosswalk from the old process to the new process: 

Until summer 2014 (or later, depending on when agency paperwork is updated) “Diagnosing” used to mean filling in information in five “Axes” on a form:

Axis I:  Clinical disorders and other conditions (“V” codes) that are a focus of clinical attention

            à  The primary and secondary conditions being treated by the person filling out the form, and other diagnoses also present but not as much the focus of treatment

Axis II:  Presence of personality disorder or cognitive disability/”mental retardation”

à Conditions that might not necessarily be the subject of treatment, but that affect how treatment proceeds.

Axis III:  Medical Conditions

à Especially those which may affect mental health problems and treatment

Axis IV:  Psychosocial Stressors

            à A list of conditions outside the individual which affect mental health problems and treatment

Axis V:  Global Assessment of Functioning (GAF)

            à  a number from 1-100 (0 used only if there is no information) describing the impact of the mental health condition on the person’s ability to successfully manage the tasks of everyday life.   This number was used as a comparison point to show progress in treatment. 

BUT THE FIVE AXES ARE GONE!  WHAT DO WE DO NOW?

Basic answer:  Just list the diagnosis you’re focusing on, and others that might be important to mention.

When I say “basic” I don’t mean “easy”; you do have to use the revised manual and find out what’s a match for your clients; more guidance on that for a variety of different conditions in upcoming posts. 

First, we have some Axes to mourn.  

Where will we put that important information that was in the Axes?

Axis I:  mental health diagnosis will still be there.  There will be some more writing here than in the  past:  The codes will not be enough to clarify all the “specifiers” that must be written our verbally, such as the course, severity, and associated features that can go along with a condition.  More about specifiers soon.

Axis II:  Personality Disorders and Intellectual Disabilities (moving on from the old term “mental retardation”) are just listed like any other diagnosis, though it’s still likely in many settings that there is some other condition that is the primary focus of treatment.

Axis III:  Medical conditions are sometimes the direct cause of the mental health symptoms and should be listed separately as a medical diagnosis, and then listed as part of the diagnosis, as the example on p. 181 of the DSM-5:  244.9 hypothyroidism; 293.83 Depressive Disorder due to hypothyroidism.

Axis IV: Psychosocial stressors are included in the expanded list of V codes, “Other Conditions that may be a Focus of Clinical Attention.”

Axis V:  GAF rating scores for the client as a whole are gone, but we are increasingly rating severity as part of the diagnostic process.  For many diagnoses there are guidelines for rating severity of symptoms and/or severity of the impact on functioning. 

What has changed most in the process of writing down a diagnosis:  The loss of the Axes.  Separating this kind of information into five Axes has been… given the Ax. 

Coming up:  how to search for the right diagnosis,

How to correctly diagnose using the criteria for the brand new diagnoses found in the DSM-5

Important changes to the criteria for existing diagnoses,

Preventing overdiagnosis and misdiagnosis,

Changes in thinking about some diagnoses reflected in the new categories and chapters.   For example, OCD and PTSD are moved out of the category of Anxiety Disorders, but Selective Mutism is moved IN to the category of Anxiety Disorders,

And more, including responses to questions about the DSM or some of the other realms of Mental Health Knowledge. 

That controversial diagnostic manual DSM-5

It has been popular in the blogosphere to critique the criteria for diagnosing mental health disorders.  Some writers criticize the whole diagnostic establishment of the American Psychiatric Association, claiming that this is an effort to push drugs and stigmatize people.  Other critics* are focused on the newest version of the APA's diagnostic manual, the DSM-5.
    I'd like to take a different approach to talking about the new diagnostic manual.  It's here.  It's what we will be using.  Let's talk about how to prevent stigma rather than saying that the manual has the power to create it.  Let's talk about how to prevent overdiagnosis and thus overmedicating rather than saying it will automatically happen. And when we get into specific controversies, let's look at the facts and details rather than just echo slogans from yet another blogger who hasn't read it.   I will address some of the main controversies head on (as I did in a post already, exerpted from material on several DSM controversies that I've written for an upcoming edition of a textbook on mental health disorders).
    I welcome comments on my take on these controversies, but we all would benefit more if you comment with a DSM-5 open in front of you rather than echoing what you've heard about what's inside its 900+ pages.  Over the summer and early fall of 2013, after teaching a college course about mental health diagnosis,  I've paged through the entire manual side by side with the previous edition of the manual, in preparation for training people about mental health diagnosis in general and for specific diagnoses.  So, we can disagree in our predictions about the impact of the new criteria, but I will make sure we base our discussion on some agreement about what the manual actually says.  I'm stunned that after 11 solid months of researching the DSM, it is very hard to find comments on the internet based on actual information rather than speculation and echoes.  So I'm putting this together myself.  I want to simply lay out the facts and get mental health clinicians back to work helping clients rather than alarming them, and getting clients and patients back work trusting clinicians (psychiatrists, clinical social workers, and other psychotherapeutic professionals) rather than fearing them and the scary blue books.

*I find it interesting that the two main critics of the new version, Allen Frances and Robert Spitzer, were the coordinators of the publication of the previous versions of the manual and began their criticisms, years before the manual were produced, based on the new DSM task force being too secretive, even though subsequent criticism of the criteria, starting years before the manual was published, were based on proposed versions made available for public comment.  Is this a case sour grapes that they weren't in charge any more? That's speculation on my part, and they know the internal politics of the process much, much better than I do. But some of the alarming pronouncements by Frances and others about the Bereavement Exclusion and DMDD and other diagnostic topics are just simply wrong, or at least disconnected with the facts except the distorted, selected, neglectful version of the facts that fit a preconceived notion.
 
      Controversy generates viewership.  I wouldn't mind readership (though I have no books to sell nor any other benefit I can think of), but I'd rather generate knowledge and agreement than alarm and controversy.  If you're interested in the same, keep visiting; I'll be hitting the major controversies and then going diagnosis by diagnosis to talk about what's new in the first change in diagnostic criteria since 1994, affecting nearly every diagnosis you'll encounter.  I hope this will be helpful.