I think this conflates a DSM diagnosis with a case conceptualization. A DSM diagnosis is useful for insurance purposes, communication with other professionals, and as a rough guideline for determining effective treatment approaches. But a case formulate is fluid and changes over time as more information develops. Of course not everything will be known or understood between the therapist and client in the beginning, that's why the case formulation should be continuously revisited.

If a DSM diagnosis is required for insurance companies' reimbursement, I guess it needs to be done. But I disagree with the idea that all contemporary models of psychotherapy require this diagnosis. Behavior therapies, based on learning models of behavior, establish a functional analysis of behavior, and that is absolutely unique to each individual case. Behavior therapies do not work with DSM categories. In fact, they may be totally irrelevant for intervention decisions. DSM works within an "illness paradigm", that is challenged by (some) contemporary approaches to treating behavior problems.

This is a évry good question. As a Music psychotherapist Working in psychiatry it is a Daily challenge. And yet we have good evidence! It is a World of paradoxes

Good question. To my opinion DSM and ICD indeed is useless. It does not give to the practitioner any psychotherapeutic perspective. It's only good enough for statistics. That's why there are some attempts to create new classifications that goes beyond psychiatric limitations. Take a look at "Operationalized Psychodynamic Diagnostics -2". I think it identifies diagnostic items that are good for therapeutic perspective along with DSM or ICD categories.

I use Positive Psychotherapy (after Nossrat Peseschkian) that has own diagnostic system plus ICD.

Alfred Adler's Individual Psychology focuses on the individual as a unique, indivisible unity. DSM provides insurance clerks with a cost-effective (but therapeutically irrelevant), limited catalog of symptoms,. [Is there a person behind the symptoms?] Creative, depth psychotherapy invents a unique form of treatment that matches the uniqueness of each individual. Classical Adlerian Depth Psychotherapy addresses the psychological, social, and philosophical needs of the client. The most important diagnostic tool is the discovery, unmasking, and dissolving of the hidden, unconscious, fictional final goal. This is accomplished gradually, in twelve stages of treatment. (see www.Adlerian.us/stages2.htm).

I believe that psychotherapy can be conducted with a clinical assessment of presenting symptions. Remember, practitioners should treat symptoms not diagnoses. The DSM-IV-TR provides a nomothetic approach to diagnosing, but it is the pratitioner's responsibility to take an idiographic approach with his or her patient.

Use a Bowen Family Systems Theory approach. It provides a full theoretical model for how to work with any member of a family and avoids and individual model approach that can make one individual the "patient". It does not preclude the thoughtful use of medication if the individual can function better with meds. But the "cause" is seen to be in the relationship system vs. the individual. The goals of a Bowen approach would be to work on lowering the overall anxiety of the individuals so they can begin the work of being more of a self in their system. It requires a lot of thoughtfulness on the part of the individual and a willingness to work at it over time.

This is good question, underneath which lurk issues of 'affordability' as much as anything else, and also the matter of whether high quality psychotherapy can be seen as a front-line treatment for mental health ( within private or public medical health situations alike) or whether it is, in fact, a luxury.

Individuation therapy (a Jungian term) works at depth, it is capable of very meaningful, long-term improvements in a person's capacity to live well and responsibly, and to enjoy life. But it just cannot be what we offer to everyone (even supposing everyone wanted it), because it is expensive, time-consuming and partly because of this somehow elitist, frankly.

There is a moral dimension to this discussion, because if the above sort of therapy is not universally available, it begs the question what is it that we are actually offering (in 6 sessions, or whatever, of counselling/CBT/non-depth therapy) and what are the implications of that, not only for patients, but also for the professions of counselling and of psychotherapy?

I imagine (hope!) this message might be provocative!

The question that you ask can be answered from a different conceptual standpoint, to which there are two key strands:

(i) - If we look at the use of therapies as being needs focused, rather than diagnosis focused, we can then seek to address/mediate those needs with a therapeutic approach that is tailored to the client. This may be a needs-led decision to follow a course of psychotherapy i.e., one that can be evidenced to promote effective outcomes for the client in terms of identified therapeutic goals.

(ii) - The daily practice of many effective practitioners often involves the use of therapeutic approaches that are based on a combination of evidence-based practice and practice based evidence. Reflective practice of this kind has quite frequently been identified as playing a key role in improving the quality of decisions made, actions taken and outcomes achieved by practitioners.

An outcome that may be especially important in the current ethical and financial climate, is the opportunity to identify a therapeutic approach that both reflects what the practitioner has found to be particularly effective and is seen by the client as being sensitive to his/her cultural/personal viewpoints and treatment aspirations.

I definitely find this question provocative, given the current lack of funding for longer term psychotherapy, beyond the "six sessions" typically granted by EAPs or psychiatric facilities utilizing short term or primarily intellectual level interventions. I attempt to balance my belief in what can work with what the client or patient believes he or she needs. However, most days I have to admit that I experience a dilemma in relation to what I believe is needed and how much time the client and I would need to achieve the needed goals. EAP companies in Ontario often pressure therapists to, in my opinion, to manipulate clients to believe that they can achieve necessary goals within the allotted number of sessions. Moreover, they often expect the therapist / counsellor not to inform the client of the total number of sessions available.

I also think that many of the short term approaches over and undershoot the client's developmental capacity which can leave them feeling falsely confident that they are doing fine because they have ' the right tools' or falsely ashamed for having failed in the eyes of others once again.

I attempt, for one example, to assess each person's capacity for reflective functioning, (as co-determined more or less),as a rough guide to determine whether they can benefit from timely interpretations rather than mainly responses experienced as empathic, implicitly or explicitly, and essentially supportive. H. Bacal's specificity theory has been useful in this regard but at best the client's gain through increased awareness and relational experiential gain, through a small number of sessions, may be minimal yet significant. Of more concern is the possibility that the balance of needs and my attunement to those needs nonetheless leaves the client with an expectation that may not be met by me or anyone else in the system, if they cannot afford further therapy. I am aware of a number of EAPs and institutional programs that consider that returns for more brief treatments is a reasonable approach. I don't see a meaningful and adequate solution on the horizon for those with even average incomes.

I see three clear strands emerging here (1) Client needs (2) Context (3) Ethical Dilemmas.

I work from the premise that it is the quality and integrity of the relationship that counts in meeting client needs. If I stay client focused, from a reflexive stance then I can engage with best practice. I work in contexts where sessions are limited through funding, time or space. Ethically I would not want to mis-lead a client as to what actually is availabe and would not work for any agency that woulld suggest I lie though omission or commission.