Counselling the Already (Self?) Diagnosed Client

1. Counselling the Already (Self?) Diagnosed Client Tom Strong, PhD Karen H. Ross, MA Monica Sesma-Vazquez, PhD

2. Overview • 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

3. 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 requirements

4. Relational Map (Simplified)

5. Why the DSM-5 matters to you? It is increasingly used to administer, ration and regulate therapeutic practice

6. Dreams of algorithmic practice? [Images: Cover of Algorithmic Diagnosis of Symptoms and Signs (Collins); diagnostic algorithm for Rhinitis]

7. Why the DSM-5 matters to you? It medicalizes and internalizes what clients and you might externalise and problem solve

8. 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]

9. Therapy Culture? [Image: Cover of Therapy Culture by Frank Furedi] Eva Illouz

10. [Images: “YourDiagnosis.com,” image representing “Dr. Google,” “Online Self Diagnosis Tool”]

11. 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.”]

12. Our discursive approach • Discursive resources vs. discursive capture • Linguistic sense-making, linguistic poverty & poetic wisdom • Supplementing and braiding • Welcoming the understandings we are presented with, but not stopping there • Curiosity, preference & resource-focused • Institutional requirements?

13. Interactivity #1 (8 minutes) 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).

14. Self-diagnosed clients • Can it be a problem? • Why do people self-diagnose? • How can counsellors respond?

15. Is self-diagnosis a problem? • Accuracy/“qualification” concerns • Pharmaceutical imperialism concerns • Discursive capture concerns

16. “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?”)]

17. Client perceptions of self-diagnosis From www.wrongplanet.net

18. 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”] • Availability of information • Pragmatic advantages • Funding, programs, resources • Legitimizing suffering or vulnerability • Avoid moral or blaming discourses • Diagnoses as identity-making resources • Need to explain emergent life developments

19. Contested (self-)diagnoses • 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”

20. What qualifies as addiction? Clip from The Mindy Project (Fox)

21. Contested (self-)diagnoses • 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.

22. Contested (self-)diagnoses

23. Therapy with (self-)diagnosed clients • Modernist approach: Is the diagnosis accurate? • Consultation; referral for formal assessment • Corresponding evidence-based treatment • Discursive approach: What is the diagnosis making more or less possible? • Externalization (narrative therapy) • Supplementing the diagnostic explanation • Life beyond the diagnosis: other discursive repertoires

24. Externalization • (Self-)diagnoses may facilitate externalization • e.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 control

25. Supplementing the diagnostic discourse • What other “languages of suffering” (Brinkmann, 2013) might enrich the client’s understanding of his/her situation? • Moral • Existential • Religious • Political

26. Living beyond the diagnosis • 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)

27. Interactivity #2 • 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 responses

28. Interactivity #2 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?

29. Authorswho inform this work M. Wetherell J. Potter T. Strong H. Anderson M. White H. Garfinkel D. Tannen C. Antaki M. Foucault L. Wittgenstein

30. Families in Therapy Increasingly, families come to therapy with one or more members psychiatrically: A)Self-“Diagnosed” B) Formally diagnosed C) “Diagnosed” by another member

31. Families “self-diagnosed”: Rationale • 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. (Frances, 2013; Heritage, 1984; Illouz, 2008; Potter & Wetherell, 1987)

32. The case of the Lopez Family

33. An invitation to reflect upon: • 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?

34. Therapeutic tools: • Counsellor’sgenuine 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).

35. Interactivity 3: The Time Machine • 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.

36. Your turn to talk

37. Further reading 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.

38. To contact us Monica msesmava@ucalgary.ca Tom strongt@ucalgary.ca http://www.ucalgary.ca/strongt Karen khross@ucalgary.ca