Counsellors and the Dimensional Approach

Mental health problems or periods of lessened mental health can occur at any time to anyone. Without the right supports and interventions, they can become diagnosable mental health conditions. For some, this can be managed independently, depending on numerous factors, or it may require external supports either formally or informally. Mental illness exists parallel to mental health, where both are not ends of a spectrum, but their own overlapping spectrums (Iasiello & Van Agteren, 2020). The experience of mental illness is different for everyone and can include new behavioural patterns or a sudden increase in symptoms such as depressive or anxious emotional states and behaviours. Within this, understanding and use of a consistent definition of recovery becomes increasingly important, to guide treating professionals towards the approach they use to meet the recovery definition.

In the Australian context, there are two overarching approaches to mental health support which are the categorical and dimensional approaches. The categorical approaches explore mental health in its absence or presence (Simonsen, 2010) and dimensional contains 5 dimensions that underlie mental health support and recovery (Whitley & Drake, 2010). Specifically, counsellors are trained in using the dimensional approach as well as prevention and early intervention in mental health support (Australian Counselling Association [ACA], 2016). This paper expands on how counsellors can support the expansion of the existing mental health framework with the inclusion of a dimensional approach while simultaneously complementing what already exists in the categorical approach to mental health treatment.

Recovery is a term in the mental healthcare field that has a myriad of definitions, which often depend on the overarching theoretical approach used. Theoretical approaches to mental health care fall into two areas; either categorical, or medical and dimensional. In the traditional medical model, recovery has been defined as a lessening of severity of mental health symptoms (Davidson & Roe 2007; Whitley & Drake 2010). This definition of recovery is categorical in nature, where individuals’ recovery is from the mental health condition and defined by a return to the individuals’ homeostasis or baseline (Simonsen, 2010). In the categorical model, mental illness is either absent or present at any given time point and recovery is measured using an objective outcome, such as lower scores on an objective symptom measure (Leonhardt et al., 2017). To support separation between subsequent definitions of recovery, this will be referred to as clinical recovery. An alternative to clinical recovery is recovery from within the mental health condition, meaning that other life areas can improve even if symptoms do not resolve. This definition encompasses clinical recovery, while also highlighting the subjective experience that is the process towards recovery, or what recovery can mean within the mental health condition, which aligns with individuals’ own motivation, dignity, and autonomy (Ellison et al., 2018; Leonhardt et al., 2017). This subjective process can be explored in the presence of ongoing mental health concerns or while being vulnerable to relapse (Davidson & Roe, 2007; Leonhardt et al., 2017). Vulnerability to relapse refers to the episodic and persistent nature of many mental health conditions which can reoccur without preventative measures being used in periods of wellbeing (Solmi et al., 2023). This definition of recovery from within the mental health condition is person-centred, strengths-based, and dimensional in its approach as it allows for the individual to explore critical parts of recovery (Ellison et al., 2018). This definition aligns with the counselling lens for mental health support, as counsellors are primarily dimensional, and preventative in their approach. Additionally, recovery as defined from within a mental health condition also encompasses the categorical approach which can be a factor in the dimensional approach. In context this can include the interrelated nature of lessened symptoms and the subjective process of recovery, that can include other life domains such as improved social, physical and functional domains. The existence of both approaches working alongside each other in recovery allows for greater collaboration between the categorical and dimensional focussed professionals in the Australian mental health system.

The categorical approach significantly influences mental health care in Australia, with general practitioners (GPs), psychologists, and psychiatrists among others operating from this lens and therefore adopting the clinical definition of recovery. The categorical approach classifies mental illness within predetermined common patterns of behaviour, thought, and emotions, where a threshold needs to be met to align with a category of mental health illness (Sharpe & Greco, 2019; Xie, 2013). A practical example of this approach is found in using the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5R (APA, 2022), for diagnosis of mental illnesses or disorders. In using the DSM-5R, a client presenting with depressive type symptoms will be assessed against the noted criteria and thresholds to acquire a label of clinical depression or another variation of a depressive disorder. The diagnosis then informs the evidence-based treatments that are recommended and available to the client to begin clinical recovery. Theoretically, the benefits of the categorical approach include an ease of communication across various treating professionals due to predefined terminology and classification of mental health concerns, which also supports the preceding education of mental health professionals such as counsellors and psychologists (Carragher et al., 2015). Furthering this, communication between various practitioners is easier due to the consistent and clear terminology that extend from the individual to the governmental levels, which also supports research, funding allocations, programs and supports (Carragher et al., 2015). Historically, the categorical approach was utilised in the context of categorical decision making, such as whether to treat an individual with either medication or therapy (Kraemer et al., 2004). This perception has since changed from prioritisation of statistical significance of efficacy that focuses on a quantitative data to a priority for the qualitative experience of recovery (Le Boutillier et al., 2011).

Despite the prevalence of the categorical approach, it has inherent limitations that can have significant implications on the recovery and wellbeing of individuals. Many critics of the categorical approach highlight the significant comorbidity between the symptomology of disorders which occurs more often than by chance (Carragher et al., 2015). This comorbidity makes it difficult in the categorical approach to confidently diagnose the presence or absence of a specific mental health condition. In addition, the categorical approach is limited in its often rigid or reductionist in its view of mental health conditions, where they are confined to strict lists of symptoms and thresholds (Carragher et al., 2015). A further limitation is in the application of the categorical approach where prevention and early intervention is underused due to the present or absent mentality to mental health conditions (Salicru, 2020). An example of the categorical approach in Australian mental health support is the co-creation of a Mental Health Care Plan (MHCP) between an individual and their GP. To be able to access a MHCP, which is a referral for a mental health clinician such as a psychologist, a diagnosis of a mental health condition must be made (Services Australia, 2024). There are two large limitations of this process: the recommended assessment tools are not diagnostic and are paired with a limited ability of GPs to diagnose mental health conditions. The assessment tools typically utilised in a MHCP include the Mini-Mental State Examination and an outcome measurement tool including the Depression, Anxiety, Stress Scale (DASS21), Kessler Psychological Distress Scale (K10), Patient Health Questionnaire (PHQ-9), Short Form Health Survey (SF12) and the General Anxiety Disorder (GAD-7) (Services Australia, 2024). Generally, these tools are not diagnostic in nature, but rather screening tools that can indicate towards an area of concern, meaning while symptoms may be present from this objective measure, a final assessment is done at the GP’s discretion. An example of this in practise is utilising the Mini-Mental State Examination screening for dementia by measuring cognitive abilities (Nagaratnam et al., 2022) or the DASS-21 providing screening for Depression and Anxiety (Henry & Crawford, 2005). Each of these tools allow for the understanding of the presence of symptoms and an idea of their severity, however they do not ensure all thresholds are measured to confirm a diagnosis. In the MHCP protocol, the screening tool outcomes lead to a diagnosis with the addition of the GP’s own understanding of the condition. Therefore, if an individual does not meet the criteria for a diagnosis, despite the flaws in assessment, they are declined a MHCP to access mental health support. This reiterates the categorical approach’s standpoint of viewing mental health conditions as either present or absent, rather than a spectrum of symptoms. Mental health conditions have been frequently misdiagnosed (Hui et al., 2018; Stahnke 2021) leading to inappropriate treatments and referrals. These can have a detrimental impact on the individual as they may continue with a treatment that is inappropriate or discontinue support due to the effect of a misaligned treatment. Alternatively, individuals may not receive a diagnosis either by masking behaviours (Bishop & Rinn, 2020), or unaware that their behaviours, thoughts, or emotions are not within the typical spectrum (Bertilsdotter Rosqvist et al., 2023). The use of the categorical approach can lead to individuals who do not meet the threshold for diagnosis of a mental health condition being unsupported which could lead to symptoms increasing to diagnostic levels.

There are many dimensional approaches to mental health and recovery; the most appropriate for the current Australian system is proposed by Whitley and Drake (2010). This dimensional approach encompasses functional, existential, social, physical and the clinical or categorical areas towards recovery (Davis et al., 2013; Khoury, 2020; Whitley & Drake, 2010). To support readability, the categorical segment of this framework will be referred to as clinical to distinguish from the overarching categorical approach, as its factors include symptoms, medical care, medication and therapy. Within the model, functional factors include employment, housing and education; physical factors include exercise, diet and addiction; social factors include community, family and peers and existential includes factors relating to agency and self-efficacy, empowerment and can include religion and spirituality (Agrest et al., 2021; Whitley & Drake, 2010). This model begins to provide solutions to the limitations of the categorical model, as it allows for person-centred care. It focuses on recovery from within and from the condition, and wellbeing within a patient’s own subjective experience and presentation (Fossati, 2011; Khoury, 2020). The dimensions allow for the expansion of the spectrum of symptoms, which eliminates the reductionist limitation (Carragher et al., 2015) and allows for preventative care for individuals who require support but do not meet the clinical threshold to meet diagnostic criteria. Inherent in this model is collaboration between formal and informal supports towards recovery and wellbeing, which aligns with a collaborative care model (Muntingh et al., 2016). In essence, the model is a framework for communication between treating professionals for a more holistic treatment plan and network for the client (Muntingh et al., 2016). The overlapping nature of areas in the dimensional approach (Agest et al., 20 allows the client to begin their journey at a dimension or dimensions that feel accessible to them, either from access to resources or within their perspective of their current capacity. The use of the dimensional approach has been demonstrated to reduce stigma, allow for holistic and comprehensive support from additional support services, both formal and informal, as well as measurable recovery outcomes for the client (Khoury, 2020; Salicru, 2020; Winsper et al., 2020).

Theoretically, the dimensional approach to mental health care provides many benefits and potential solutions to the limitations of the current categorical approach. The next step is to apply this approach to counselling with session and treatment planning. The application of this approach is simultaneously simple yet complex and has not been evaluated within the counselling setting. There is evidence to suggest the efficacy of the dimensional approach within supported employment (Cabassa et al., 2013; Whitley et al., 2012). However, this evidence is limited due to only exploring the functional dimension and specifically the employment factor and has not been exploring using the overarching model. Theoretically in the counselling context, counsellors can build an individuals’ capacity within any of the five dimensions, greater capacity can foster greater self-awareness and understanding that supports engagement within the dimension and provide prevention or early intervention strategies to support growth. For example, understanding how executive dysfunctions can impact meaningful and paid employment for an individual allows for the exploration of the strengths and barriers to engagement. Building capacity in any of these areas would have a flow on effect to further engagement with other professionals that are able to help growth in this area. For example, in the instance of executive dysfunction, a practitioner would support making the referral to an employment agency and attending the session. In a counselling session, the dimensional approach adopts a person-centred practise, where the client directs the dimension that they would like to explore. This is flexible and can change at any point for a myriad of reasons such as the client shifting focus, or a change in life circumstances that adjusts priorities. Usually, this focus is the dimension that is in alignment with the presenting concern of the client, such as interpersonal issues being a focus on the social aspect of their recovery. Due to the inter-related element of each dimension, subjective and objective improvement in one dimension is expected to flow into the other dimensions. For example, minimising the barriers to engage with the functional dimension, specifically obtaining meaningful employment, would have flow on effects to the existential dimension in an increase in agency and self-efficacy (Bradley & Roberts 2004). Therefore, overarching treatment planning would begin in initial referral, with co-directed adjustments occurring throughout the duration of the counselling treatment, where treatment would align with the noted dimensional area and any interrelated dimensions. The specific approach in session is open to an eclectic response, or within any trained modality. For example, an individual seeking to improve and explore the social dimension may utilise the Dialectical Behavioural Therapies interpersonal module (Accardo, 2020) within their treatment plan, or exploration of Cognitive Behavioural Therapy to improve social skills to engage with the factors of this dimension (Laugeson & Park, 2014). Overarchingly, this supports a subjective process towards recovery that is person centred and supports and explores the individual understanding of recovery.

The application of the dimensional approach appears inherent in the practice of many counsellors who are either trained in or adopt a person-centred approach or work within the dimensional framework. However, there are inherent limitations to its implementation in the Australian mental health landscape. Some of these include a lack of understanding of dimensional-related terminology due to the dominant categorical approach, and the concern for maintaining a balance between the subjective and objective measures that are required on an individual, educational, research and discipline level. The balance between these types of evidence is required to ensure that clinicians, clients, and other supporting professionals use harmonious terminology, and that this translates into equitable care for the individual. These limitations are answered in the dimensional approach due to the addition of the clinical dimension, and therefore can be assessed alongside the other aspects to support communication between each practitioner. This allows for familiar terminology of the categorical approach to be used alongside new or specific language of the other dimensions that help an individual’s recovery. Previously, a limitation of adopting the dimensional approach was the lack of objectivity in the subjective process towards recovery. While the subjective is unique factor in the counselling approach, objective and quantifiable measures are important for communication between treating professionals and funding for programs and treatment (Carragher et al., 2015). Validated and reliable measures have been developed that are able to objectively measure progress in each of these dimensions. For example, within the existential dimension the subfactor of self-efficacy has scales such as the Self-Efficacy survey that has demonstrated strong reliability and validity (Panc et al., 2012). Therefore, these measures can be utilised in session with clients to check in periodically, while also ensuring that the language and terminology are applicable to other disciplines.

In conclusion, expanding the current mental health approach to encompass the dimensional approach and use the professionals who primarily operate from this lens can have great implications for individual recovery. Expanding, this would require revision of the current definition of recovery to be recovery within the condition rather than from and occurring in a spectrum. This would support individuals with ongoing mental health conditions, and those that do not meet the diagnostic criteria for further treatment. The dimensional approach as proposed by Whitley & Drake (2010) provides an easily implemented model. It also does not disregard the current approach and terminology inherent in the categorical approach, but rather builds upon and expands our understanding of mental health treatment. The limitations of the dimensional approach include a lack of objective data, however the answer to this limitation is already in the current mental health system. Each of our current measures of mental health outcomes can be explored in the alignment of the dimensions noted. This supports the application of the dimensional approach in counselling sessions that honours person-centred care and the subjective process of recovery.

Counsellors and the Dimensional Approach: The Important Addition to Recovery in the Australian Mental Health Landscape