Self Diagnosed Client Tom Strong PhD Karen H Ross MA Monica Sesma Vazquez PhD DSM5 counselling amp our approach Counselling in a therapy culture Interactivity 1 Your experiences ID: 131575
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Slide1
Counselling the Already
(Self?) Diagnosed Client
Tom Strong, PhDKaren H. Ross, MAMonica Sesma-Vazquez, PhDSlide2
DSM-5, counselling & our approach
Counselling in a therapy culture? (Interactivity #1 – Your experiences)Self-diagnosing clients?(Interactivity #2 – Counselling the self-diagnosed client)Families and diagnosed children
(Interactivity #3 – Beyond discursive capture)Your critical & generative responses to the DSM
OverviewSlide3
Survey Questions about DSM Use & Evidence-Based Practice
Extent to which
you’re expected to use psychiatric discourse to meet administrative or fee payer requirements
Extent to which you’re expected to use evidence supported interventions to meet administrative or fee payer requirementsSlide4
Relational Map (Simplified)Slide5
Why the DSM-5 matters to you?
It is increasingly used to administer, ration and regulate therapeutic practiceSlide6
Dreams of algorithmic practice?
[Images: Cover of Algorithmic Diagnosis of Symptoms and Signs (Collins); diagnostic algorithm for Rhinitis]Slide7
Why the DSM-5 matters to you?
It medicalizes and internalizes what clients and you might externalise and problem solveSlide8
Why the DSM-5 might matter to you
It eclipses clients’ resources and resourcefulness[Image: Little girl standing on her sister’s back (using her as a step-stool) in order to reach a drinking fountain]Slide9
Therapy Culture?
Eva Illouz
[Image: Cover of
Therapy Culture by Frank
Furedi
]Slide10
[Images: “YourDiagnosis.com,” image representing “Dr. Google,” “Online Self Diagnosis Tool”]Slide11
Couples and families using DSM-5 diagnoses?
Individual diagnoses or relational difficulties?Family members’ diagnoses of each other
But the insurance company won’t fund family therapy unless there is a diagnosis![Image: Doctor informing a couple, “You have irritable-spouse syndrome.”]Slide12
Welcoming the understandings we are presented with, but not stopping thereCuriosity, preference & resource-focused
Institutional requirements? Discursive resources vs. discursive captureLinguistic sense-making, linguistic poverty & poetic wisdom
Supplementing and braidingOur discursive approachSlide13
In groups of 3, discuss:To what extent are you expected to use diagnoses in your work as a counsellor?
How do clients present to you in already-diagnosed terms?In what ways does this constrain your preferred ways of counselling?(We’ll return to discuss the above as a group).Interactivity #1 (8 minutes)Slide14
Can it be a problem?Why do people self-diagnose?How can counsellors respond?
Self-diagnosed clients Slide15
Accuracy/“qualification” concerns
Pharmaceutical imperialism concernsDiscursive capture concerns
Is self-diagnosis a problem?Slide16
“The mainstreaming of mental health”
[Images: Covers of The Walrus (“The New Normal: The Mainstreaming of Mental Health”), Saving Normal (A. Frances, 2013), Maclean’s (Modern Medicine: Is she a brat, or is she sick?”)]Slide17
Client perceptions of self-diagnosis
From www.wrongplanet.netSlide18
Availability of informationPragmatic advantagesFunding, programs, resources
Legitimizing suffering or vulnerabilityAvoid moral or blaming discoursesDiagnoses as identity-making resourcesNeed to explain emergent life developments
Why do people turn to diagnoses?[Image: Penguin on a date with a Polar Bear, saying “… Before we go any further you should know I’m bi-polar”]Slide19
Diagnosing Anthony Weiner: Sick or Just Plain Stupid?
“What is the difference between a disordered perv and a run-of-the-
mill dumbass anyway?”“Affluenza”
“Judge rules rich kid’s rich kid-ness makes him not liable for deadly drunk driving accident”Contested (self-)diagnosesSlide20
What qualifies as addiction?
Clip from
The Mindy Project (Fox)Slide21
Addiction and excessive behaviours
Internet, sex, shopping, food addictions?“This recognition of food as a substance-use disorder in the diagnostic manual is of extreme importance.”
“Loneliness is the unspoken diagnosis of our time.”Lonely, a memoir by Emily White, attempts to give loneliness – a state, as she puts it, of “frightening isolation” – its proper and hitherto overlooked diagnostic stature.
Contested (self-)diagnosesSlide22
Contested (self-)diagnosesSlide23
Modernist approach: Is the diagnosis accurate?
Consultation; referral for formal assessmentCorresponding evidence-based treatment
Discursive approach: What is the diagnosis making more or less possible?Externalization (narrative therapy)Supplementing the diagnostic explanationLife beyond the diagnosis: other discursive repertoires
Therapy with (self-)diagnosed clientsSlide24
(Self-)diagnoses may facilitate externalizatione.g., “I have panic disorder” – “When did Panic first begin to show up?” “What have you done to limit the role of Panic in your life?”
Use caution around positioning clients as agentic with relation to matters that are out of their controlExternalizationSlide25
What other “languages of suffering” (Brinkmann, 2013) might enrich the client’s understanding of his/her situation?
MoralExistentialReligiousPolitical
Supplementing the diagnostic discourseSlide26
Discursive repertoires supply not only language and knowledge, but practices.When is the client “performing” from alternative repertoires that contradict or ignore the diagnosis? (cf. exceptions or unique outcomes)
Living beyond the diagnosisSlide27
In groups of 3, read the self-descriptions on the distributed handouts (each is different).Options:
Role-play (counsellor, client, and observer)Discuss possible counselling responsesInteractivity #2Slide28
To consider …What might the diagnosis be accomplishing for this client?How is the diagnosis organizing his or her identity/self-understandings, behaviours, etc.?
What tensions or dilemmas might surround this diagnosis, either for the client, for the counsellor, or others in the client’s life?What approaches or strategies might you draw upon in working with this client?How do you imagine the client might respond?Interactivity #2Slide29
Authors
who inform this work
M.
Wetherell
J. Potter
T. Strong
H. Garfinkel
D. Tannen
C. Antaki
M. White
H. Anderson
M. Foucault
L. WittgensteinSlide30
Increasingly, families come to therapy with one
or more members psychiatrically: A) Self-“Diagnosed” B) Formally diagnosed
C) “Diagnosed” by another memberFamilies in TherapySlide31
Families have concerns and they
make sense of them using diagnostic discourses.Families appropriate & incorporate psychiatric understandings.
Families use language of “mental illness” to relate to each other.Diagnostic discourses
organize families in patterned behaviour.Families’ descriptions
capture
what is happening with the child,
prescribing
and
constituting
present and future
actions
.
Families “self-diagnosed”: Rationale
(Frances, 2013; Heritage, 1984; Illouz, 2008; Potter & Wetherell, 1987)Slide32
The case of the Lopez FamilySlide33
How do family members respond to each other once the psychiatric diagnosis is given?
How do family members use these discourses and organize through them?How do psychiatric understandings build new interactions and responses?How do counsellors respond to these understandings, actions, patterns, and interactions?
An invitation to reflect upon:Slide34
Counsellor’s
genuine curiosity about the “diagnosis,” accepting local knowledge and avoiding criticism, judgment, and correcting with the “right condition”. Instead, exploring concepts and meanings. Counsellor’s use of tentativity (Anderson, 1997).
Counsellor exploring the story of “diagnosis”: timeline, local definitions, conversations about it, unique outcomes (White, 2007)
Counsellor identifying patterns: who talks about the diagnosis, in what manner, where, with whom, about what, how families organize around diagnosis, preferred interactions, specific actions. Talk about exceptions in the patterns
(White &
Epston
, 1990)
.
Counsellor exploring how the diagnosed members DO (perform) the diagnosis: performance of the problematic and family responses. Discuss
alternative stories and doings
.
Counsellor exploring different understandings and helping to construct
alternative stories
(White, 2007; White &
Epston
, 1990)
.
Therapeutic tools:Slide35
Think briefly of a family who has arrived asking for your help with a diagnosis during the last year.
How have you worked with them?If you had a time travel machine, and went back to them … would you do something different? What would you do to invite new interactions?Please share your ideas with the group.
Interactivity 3:
The Time MachineSlide36
Your turn to talk Slide37
Anderson, H. (1997). Conversation, language and possibilities: A postmodern approach to therapy.
New York, NY: Basic Books.Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. New York, NY: Harpers Collins Publishers.
Furedi, F. (2004). Therapy culture. New York, NY: Routledge. Heritage, J. (1984). Garfinkel and Ethnomethodology. New York, NY: Polity Press.
Illouz, E. (2008). Saving the modern soul. Therapy, emotions, and the culture of self-help.
Berkeley, CA: University of California Press.
Potter, J., &
Wetherell
, M. (1987).
Discourse and Social Psychology: Beyond attitudes and
behaviour
. London, UK: Sage.
Strong, T. (2014). Brief therapy and the DSM-5: 13 possible conversational tensions.
Journal of Brief Therapy
.
Strong, T.,
Gaete
Silva, J.,
Sametband
, I, French, J., &
Eeson
, J. (2012). Counsellors respond to the DSM-IV-TR.
Canadian Journal of Counselling and Psychotherapy, 46
(2), 85-106
White, M. (2007).
Maps of narrative practice.
New York: Norton.
White, M. &
Epston
, D. (1990).
Narrative means to therapeutic ends.
New York: Norton.
Further readingSlide38
To contact
us
Monica
msesmava@ucalgary.ca
Tom
strongt@ucalgary.ca
http
://www.ucalgary.ca/strongt
Karen
khross@ucalgary.ca