What’s a DSM?


“Chad, how did it go with your first client?”

I leaned back in my chair, contemplative. “Well, it went well, I think. She was certainly complicated.”

Kateri smiled at me. “Complicated how?”

“Complicated like complicated! Marriages, divorces, psychiatric hospitalizations, kids, child protection, drugs, suicide attempts, mental health diagnoses, and a whole lot of depression. She’s kind of a mess.”

“Well, aren’t we all?”

I laughed at that, thinking to my own immediate family’s mess of divorces, illnesses, and bouts with mental illness. And then there was me, the closeted Mormon guy with a wife and kid at home, one who had just been fired from a job after having been accused of cheating during a prestigious exam, charges I was quickly cleared of.

Kateri was lovely. She was in her mid-40s, lean and beautiful, and intensely charismatic. She had a way of addressing really serious issues that made everyone around her feel safe, and could somehow make me laugh even when she was being direct. I didn’t realize it then but some of the lessons she was teaching me early on in my career would stick with me over the following years, and would shape my therapy practice for the next 15 years to come.

I had been hired as a new therapist for a small agency in the town where I lived in north Idaho. After all of the stress of my previous job at the Department of Children and Family Services, this job sounded incredible. Previously, I’d been making about 15 dollars an hour doing impossible work that never seemed to end. This job was offering me 25 an hour for therapy services, the major drawback being that I would only be paid when I actually saw clients, and not paid when clients didn’t show up. I would also not be paid for doing any paperwork or phone calls. It was a major career shift, but it felt empowering, and my wife was supportive of the new situation. The job would work me two days per week in the home office, and two days in a remote town about an hour’s drive north. It would take several weeks to build up a full clientele, and we’d have to tap into savings for a bit before then. And as a perk for working there, I had a brilliant new clinical supervisor, who would help me in my transition for one hour per week in the coming months.

And so after the background check, applications, interviews, paperwork, and orientation process, I was up and running as a brand new therapist. I felt excited and overwhelmed after seeing my first client.

Kateri walked me through the sections of the standard mental health assessment form. It would take me over an hour to fill it out that first time, orchestrating the client had said into careful sections, like Family, Bio/Psycho/Social history, Spirituality, Health, and Trauma history. Kateri instructed me on the importance of getting notes done while everything was fresh in my mind. Writing had always come relatively easy to me, and I quickly typed up a detailed paragraph in each section, with Kateri giving me gentle hints.

With the assessment finished, I reached the diagnostic section at the bottom. “Okay, Chad, here is where you enter your multi-axial diagnostic assessment.”

I looked over at her, confused. “I’m sorry, my what?”

“Your diagnosis in the five axis format.”

“I don’t know what that is.”

She cocked her head, confused. “You don’t know what a diagnosis is?”

I laughed. “Of course I know what a diagnosis is. But I don’t know what this multi-axial thing is.”

“Chad, it’s the format for diagnostics. It’s laid out in the DSM-IV-TR.”

I looked over on the shelf at my DSM book, the diagnostic book of mental disorders the company had provided for me. “I, um, I’ve never used a DSM.”

Kateri laughed, thinking I was joking. Then she realized I wasn’t. “How is that possible?”

My cheeks flushed red, and I wasn’t sure shy. “In college, I had to choose an education track. I chose the Children and Family track, not the Therapy track, or one of the others. I never took a diagnostics course. I’ve, um, I’ve actually never opened a DSM.”

Kateri choked. “Are you fucking kidding me? You got a Masters degree in this field without ever actually opening the diagnostic book?”

My voice was small. “Yeah?”

“God!” She made eye contact. “Look, I’m not mad at you. You’re great. But I’m appalled that the college is not requiring the diagnostics course. That’s insanity. You just did a therapy session and you don’t know how to diagnose someone. God, that’s nuts.”

I felt very small as she cancelled her next appointment so that she could stay and show me how to use the DSM. Diagnostics turned out to be extremely complicated. The DSM itself was hundreds of pages long and explored dozens upon dozens of complicated diagnostics. Over the following weeks, I read the book non-stop, constantly checking the rules and consistently frightened that I would get something wrong. Kateri was patient and kind with me, bringing me up to speed on a skill set that I should have developed long before I had the job. In short order, I was seeing new clients constantly and completing mental health assessments like clockwork, even being praised for my efficiency.

I write this from the vantage point of 2017, back on experiences I had in 2005. I’ve had a long career since then. But from time to time, I reflect on my poor preparation for a job I would spend thousands of hours in over the following years. Eventually I would teach entire college courses about how to use the DSM. And I opened every class with this very story.

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