Understanding The Complications Of Clinical Work


Throughout my bachelor’s in clinical and counseling psychology and even more so in my graduate program for mental health counseling it seemed that the Diagnostic and Statistical Manual of Mental Disorders (DSM) was the end all and be all when it comes to diagnoses. I am now in the process of going for licensure in the Commonwealth of Virginia. I have started my 3, 400 hour residency under the licensure supervision of Anthony Lea, LPC. In our supervision meetings we have started to go back through the DSM starting with the introduction into the manual (that I never recalled reading or discussing in my graduate program).

What lesson have I pulled out from this process so far? There is a section in the very first few paragraphs that calls clinicians to remember that the DSM is not a comprehensive dictionary of disorders. In the “Use of the Manual” section  it highlights that “The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristic syndromes of signs and symptoms that point to an underlying disorder with a characteristic developmental history, biological and environmental risk factors, neuropsychological and physiological correlates, and typical clinical course.”

The key word that stood out to me was to “summarize” and prior to that “do not constitute comprehensive definitions” meaning that there is information and disorders beyond the DSM that a clinician will encounter in practice. I personally found this to be a revelation because over the course of my first year at Blackwater Outdoor Experiences we have worked with individuals who have had mental health disorder symptomatology that has not fallen directly under the diagnostic criteria of the DSM such as Nonverbal Learning Disability, and Processing Disorder. These two disorders specifically have affected a good portion of the clients I have been working with; there have been significant differences in their neuropsychological abilities that have caused them to struggle in academic, social, vocational, and familial settings. In most cases it was these neurodevelopmental or neurocognitive disorders specifically that were significant underlying factors for the development of the clients’ social anxiety, depression, low self-esteem, and substance use disorder.

Needless to say; my job just started feeling a lot more technical.

One could say that reality set in. At the same time I believe that the processes that I learned as a graduate student and now as a clinician in the field have allowed me to gain a better understanding of exactly how to parse through the information my clients present in order to help identify effectively what is the underlying struggle for them. I invite my clients on a journey with me on a therapeutic investigation to gather the clinical evidence we need to correctly identify these underlying struggles. Human behavior comes in a variety of personalities, emotions, actions, communication styles, and coping skills. The challenge as a clinician is to be able to understand that variety and recognize when an individual is dealing with a regular life stressor, trauma, or have a mental disorder.

How do you figure that out? That’s a topic for another day.

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