Dr Giles, we agree on the potentially harmful effects of labelling. I realise that labelling does not NECESSARILY mean that the dr will treat his patient poorly. However, we both know the theory and research on labelling, which suggests that it is at best possible, and at worst likely that he or she will do so, so why take the risk? What's wrong with sticking to a careful formulation?
re: Marsha Linehan's work; as I said, I deeply respect this work. I was differentiating behavioural outcomes (reduced suicide attempts is, of course, major clinical change) and measures of psychopathology (BDI, suicidal ideation, hopelessness and the like). I'm not sure about what the MOST important changes would be.
A meta-analysis of CBT for deliberate self harm is due to come out soon (by keith hawton and colleagues); there are several promising studies due out in long term and severe psychological difficulties ("personality disorders"); Kate Davidson's is, I believe, out now.
I'm not suggesting that your inmates do not fulfil criteria for DSM IV personality disorder; I'm suggesting that it is not always a helpful way of describing these people.
Multiple hypotheses and formulations......yes, yes, yes.
My suggestion is that we treat DSM IV axis 2 with deep skepticism, and our patients with deep respect. Which I think you do, reading your posts.
Jim: the impression that you proceeded with symptomatic treatment comes from when you said "Ideally, I would prefer to develop a shared understanding of Gary and his problems and then intervene. If interventions are based on a shared understanding, they are more likely to be on target and Gary is more likely to follow through on them in real life. The reason I tried a quick intervention was two-fold. First, Gary was asking for some quick symptom relief to help him cope while we worked towards a better understanding of his problems. This seemed like a legitimate request and a number of my previous clients had found progressive relaxation to be helpful, so it seemed appropriate to give it a try. Second, I was assuming that if the relaxation exercises did not work, Gary and I could take a look at what went wrong and discover additional clues which would help us in developing our shared understanding."
I presume that you did more than that by your comments.
I share your belief that the criticism of personality diagnoses applies to other diagnoses. DSM is a set of operational criteria for identifying "archetypes". You know and I know that the patients who fall either side of the divide between OCD and GAD are more similar to each other than, for example, and OCD washer and an OCD checker. Reliable research diagnostic criteria allow research in groups of people who show a particular characteristic very strongly, which then can allow some generalisation to others with broadly similar characteristics. This works fine in axis 1, where cognitive-behavioural characteristics of reliably composed groups are established. Axis 2 is another thing altogether, with the criteria being unreliable (sometimes very unreliable) and no data on the characteristic cognitive-behavioral processes. Treatment outcome data tells us next to nothing about processes which might lead us to devise briefer and more effective treatments.
I would dearly like to know more about Gary's assessment; you know, dissection of a recent incident, identification of key beliefs in that incident, evidence for those beliefs, factors which you hypothesis may maintain those beliefs, that kind of thing. Later, the experiences, attitudes and critical incidents which may have led to his particular beliefs and reactions at the present moment. But not his axis 2 diagnosis; I should be able to work that out from the description.