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Hello, and welcome to another episode of the thoughtful counselor. This is Jessica Taylor and today I'm talking with Christine banks Van Allen, an adjunct instructor and doctoral student in counselor education and supervision at Kent State University. She is a Licensed Professional Clinical Counselor supervisor in Ohio, and a certified an eye movement desensitization and reprocessing. She has worked in a community mental health setting for the past six years, and specializes in trauma treatment with adolescent girls. Her scholarly interests center on the intersections between trauma, diagnosis, adolescence and social justice. Her article conceptualizing diagnosis through a social justice lens was recently published in a major issue of counseling today. Welcome, Christine.
Hey, thank you so much for having me. I'm honored to be here.
I'm so excited to get in on this discussion, I actually found your article on my own preparation to teach diagnosis in the fall. And so I was super excited to see things that were so relevant and kind of putting it in a framework that felt really accessible. So I'm talking, I'm really excited to talk about it today. Yeah, thank you. So could you first just give the audience an introduction, really about yourself? Kind of what brought you to even speaking on this perception of diagnosis and how we can really enhance how we view diagnosis as counselors?
For sure, for sure. So I am independently licensed in the state of Ohio, like you said, and I've spent about seven and a half years working in community mental health, specifically working with adolescents and adolescent girls in particular. And I remember very early on in my clinical work, finding this disconnect between how I learned about diagnosis in my graduate program and what it looks like in practice, right, where diagnosis in my program felt very straightforward, almost right, match the symptoms to the presentation, think about things like parsimony and accuracy, right? And then you have your diagnosis. But in practice, I remember seeing a lot of clients with a lot of diagnoses that didn't seem to make sense, or seemed to be repetitive or seemed to miss the core of what their their problem was, if they were coming in. And as a trauma informed person, and as a as a trauma clinician, a lot of my work is about trauma and looking for kind of what's the core of the hurt. And so I think I see a lot of trauma symptoms and people with other symptoms of depression symptoms of anxiety connected with that, but but I think with those different diagnosis, sometimes we miss the trauma piece. And so the more I worked with folks in practice and experience this disconnected in what diagnosis looks like for people, that's where my interest in talking more and learning more about diagnosis and social justice really stemmed from,
yeah, I really resonate with that, in my time in community mental health, I really felt the same thing that you just said a person would hold so many diagnoses, some of them kind of seem like they conflicted, oftentimes none of the diagnoses actually matched what I was seeing them to, and then really, when you see things from a trauma lens, a lot of these diagnosis kind of fell to the wayside. And I still see that in private practice where I might have a client coming in with a bipolar diagnosis is a pretty common one. I see. And as we start untangling through things, it's like, well, a lot of these things really seem rooted in the traumatic experience you had. And so that's interesting that you also had that parallel process. How did you start then maybe exploring more about what diagnosis was and what you started infusing into your work?
Yeah, I think a lot of it started in my in my Ph. D. program, having the opportunity to start doing some projects to dig into it, the more so really turning to the literature to understand what's the history of diagnosis, what are some of the ways that diagnosis has has been biased or have some cultural issues associated with it in terms of over under misdiagnosis among different populations? And so I think that's really where I started digging into it more. Just leaning into the literature a little bit.
Yeah, so within your own professional development, then really trying to fit figure out, okay, what is more of this history behind it? Could you speak a little bit to that, as listeners might be getting introductory knowledge into diagnosis? Or maybe that's not as much of their experience, some of the things that you noticed about diagnosis and sort of our how we understood it traditionally?
Sure, sure. And that's such a big question. So historically, the idea of classification of people and of people's distress goes way, way, far back before the DSM right, DSM started in 1952. But but people classifying other people started long before that. And typically, when that's happened before, it's not for the benefit of those being classified. Quite the opposite, it's, it's often been an experience of naming someone else's reality for them. And making generalizations or using those names as a tool of oppression in different kinds of ways. Vicki crest has done some phenomenal work in this area, talking about ethics, diagnosis, and multiculturalism. But, but she's argued that often, this idea of naming and diagnosis has been a tool use to ostracize pathologize or marginalize others and do so under this lens of scientific objectivity. So pre DSM even, you know, thinking about this idea of normal versus abnormal is very rooted in in dynamics of power. And I can share a couple examples of that, too. I would love
to ventral Yes, I'm a visual learner. So I would love that as we think about because I think sometimes when we come into diagnosis, we're coming into the sense of it helps to organize the clinical data you get, it gives access to care for people. And so that's where I thought that was interesting, that discussion that you sit with that, but also understanding more of the components of the history. So could you give some examples?
For sure, for sure. So pre DSM really going back in time a little bit, one of the early forms of classification that people used was the idea of phonology. So phonology is this old pseudoscience that developed in the 1800s. That the basically argued that you could classify people's character, their intelligence, their traits based on things like their skull shape, and their skulls size. So people with larger skulls were assumed to be more intelligent or different shapes of skulls, right, whether it's the back of your head versus forehead ratio, things like that. And so this was used to make arguments about scientific rankings between different racial groups. So basically saying that white folks were scientifically proven to be superior based on skull shape and skull five, than people of other races and black people in particular. Same thing with women, this was also seen as a tool for setting role stereotyping for women and saying what character women have depending on again, ratio of facial features, and skull shapes and size, things like that. So again, it's classifying based on something observable, but but really, the purpose of that is not for those people that are being classified and organized, right, it's, it's really a form of bias.
Yeah. And then, as far as like standards and what is better or not?
Absolutely, absolutely. A few decades later, a medical doctor from Louisiana named Samuel part right, wrote about a condition he called drip dominium. And some listeners might be familiar with this, because this has also been debunked as pseudo scientists, or pseudo science and scientific racism as well. And basically, he looked at Black people living in the American South during kind of the antebellum Civil War period, and describe to drift Romania as a pathological desire of slaves to escape from captivity. And he stated that this condition in air quotes really developed out of slave owners being too soft or treating slaves to equally and things like that. So, again, it's been debunked scientific racism is really what that is. But the idea here is that it pathologized adaptive reactions, because if people are living in horrible situations, of course, you'd have an urge to escape, right? Apologizing that adaptive reaction, and pathologizing the individuals being harmed by that system of oppression rather than just the system around them that's problematic in and of itself. So I talk about these examples to highlight the idea that classification isn't always value neutral. And the DSM as we have it today has come quite a long way from some of those examples of chronology and of drape to mania. But the roots of classification comes from this place where it's been used to objectify and other based on this value of science and scientific objectivity? Sure, and
when we think about what's the significance of understanding the history, if this isn't how we are now, why, but still being able to understand the power that we hold in diagnosing, and that's something that we do, you know, place into someone's medical chart can follow them, even if it's something that still deserves an explanation to new providers. There's a lot of power that we hold and being able to diagnose.
Yeah, absolutely. And and I think it's important to consider, right historical things feel so far away. They're so far removed from what the current practices, but it's hard to know what we're doing in the present if we don't remain mindful of the past. And in some ways, I think, and it's literally in our code of ethics that we need to be mindful of historical use of, of, of diagnosis and what that looked like in the past.
Yeah, and how it is served to control others who are more vulnerable, to shift perspectives on it, and then to validate the abuse or, you know, some of the horrible things that are done to people who are disempowered? Absolutely, yeah, absolutely. Something I thought that was really touching in your article, too, is this parable of the blind man and the elephant? And could you explain that because I thought that was sort of a very, like, handy, tangible way to talk about and conceptualizing diagnosis and the importance of perception in this process.
For sure, for sure. So the parable of the blind man is this ancient tale. And the idea is that there's a group of blind men that come together, and they hear about this animal called an elephant that's come to town, but they none of them can see the whole elephant, right. So each of them has to rely on only what they can see themselves to understand what this animal is that's in front of them. So for one person, they they touch the trunk of the elephant, and they feel that it's very just wide, it's big, it's rough feeling, kind of feeling like that. It's like a pillar of a tree trunk, almost right. So they found the tree trunk of the elephant. For another person, they reach the ear, and they find it's kind of soft, it is very big moves. And so they think, oh, that must be kind of like a fan. For someone else that lands on the elephant's trunk. And it kind of wiggles and moves, they say, Oh, this must be a snake. And so when we think about kind of these three men feeling the different parts of the elephant, each of them has a very different perception of what the whole is, and then making a guess about what the whole is based on just one part. But perhaps they're missing, what the whole thing is all together. And I think with diagnosis, we risk that sometimes when we focus too much on each individual symptom in isolation from one another, and we sometimes miss the whole roots of what someone's experiences are, what the real challenge is that that brings them into to working with us.
Yeah. Have you ever had clients kind of push back on maybe your exploration of their diagnosis, because I know at times, as I started to get more and more experienced in trauma and conceptualizing that way, I also found that some clients maybe felt protected their diagnosis, felt really confused that, you know, I've been told this my whole life. And now you're presenting this perspective. How was that for you, as you started enhancing, I guess, your understanding of diagnosis and that work with your clients?
Sure, sure. I think actually, a lot of mine has gone the opposite direction, that when I've started talking with people about the idea that maybe they don't have three different diagnoses of major depressive disorder, anxiety, you know, borderline personality disorder. But that may be this, this one trauma thing, kind of better accounts for their experiences. I've had a lot of folks be very kind of surprised by that, because they've never put the label of trauma to their experiences before. And so then it's, it's workable, right? They kind of we can work together to navigate that understand that better. So I don't know that I've had folks struggle with it or kind of latch on to the diagnoses as much. That's
what that gives me a lot of hope. And that it's something that can bring a lot of peace. And a lot of my clients will come to it. But I think at first it's this idea of I've been labeled this for so long. And so just sort of the shock now to hear that, perhaps a different perspective, like one client, I'm thinking about just years and years on medication and medication never really fit, feeling just really frustrated feeling almost like unhelpful. And so to present this alternative conceptualization, it was very, almost jare. And through time, I think it's really alleviated a lot of the shame and guilt that just I don't seem to be responding to this medication. I don't seem to be responding to this treatment course. But at first, it was just very, like shocking. And just this different view that Oh, some of my experiences have really provided the symptoms that I'm dealing with, versus my brain is just built wrong. Air quotes.
Yeah, yeah. And I can see that right, because that that idea of naming has such meaning for people. And I think that's, that's a piece that maybe we missed sometimes or maybe I missed sometimes when I when I think about diagnosis is just how powerful that is to name someone else's experiences for them. Because really, and truly in community settings and others settings as well. We're often making a diagnosis pretty early on in our work with clients. And hopefully, of course, we're navigating and reassessing as we work with folks. But to have that initial diagnosis after an assessment, or after just the first couple of sessions, that might be the whole picture, right? Or we might just be seeing one piece of that elephant that early on and missing something. But those labels, His names that people come to know about themselves are really powerful
they are and that's what I loved about the parable, you sharing that in the article, because I felt like in my community mental health setting, because we were only able to offer services to people who had smi diagnosis, I feel like it was easy to be maybe one of those blind men who only saw one area because you're looking does it meet smi criteria, so we can offer them services, thinking that, okay, and the flexibility of a private practice or another area where you can be more open, how that can completely transform that lens in which we are diagnosing,
for sure, for sure. And I think that speaks to some of just the multicultural issues surrounding diagnosis, right, that different racial groups tend to have more of different diagnoses than others in general. And in terms of class than income folks that have lower income or associate lower socioeconomic status, tend to have more diagnoses as well, in part because they're more likely to seek community based treatment where you are expected to have a diagnosis in that first session, versus other settings where there's perhaps more flexibility about when and how to use the thing.
And I think that also kind of speaks a little to managed care. I know, in my experience, it was also if this person is prescribed this medication, we have to validate that. So now here's an additional diagnosis. And now we've got for diagnosis, where in other settings, there may not be as many of those restrictions, but I definitely think managed care has played a piece in that diagnosis or like you said, even in a first initial session, having already come with an initial diagnostic impression.
Absolutely. And it's challenging, because that's kind of the reality of our practice is managed care. And it is required by managed care in most settings to to have a diagnosis on file. And so it's not an option for us to just say we're not going to do it, because ethically, we need our clients to be able to access care. And if they need a diagnosis in order to access care, then how do we refrain from that it's in our code of ethics, that we're allowed to refrain from diagnosis, if that's appropriate, and if that's indicated for someone in their case. But I think it does put us in an ethical difficulty if not giving a diagnosis. If not, it's going to make it impossible for them to access and afford care with us at the same time.
I also find that there's already a tension that as counselors, because we are so wellness, space constrained space, even diagnosis can make counselors uncomfortable of how does our role fit into this when our ideology, is this, the reality of managed care is this? Have you ever had to sit with that tension at all of being a counselor who does diagnose?
Oh, all the time? All the time? I mean, I think it's important to recognize that the way we structure diagnosis is based on a psychiatric model of care, which is very different, like you said, from our philosophy as counselors, right. Counselors are very strength based, we focus on developmental stages, we focus on social justice, those are some of our core identity pieces. And that's very different than the psychiatric establishment, where it is much more of the medical model where you need to justify treatment by specific diagnosis in that way. So absolutely. I think about that all the time that that disconnect that we walk as counselors.
Yeah. Is there anything that helps you to kind of navigate that here, ideologically? This is what I feel. But then as a practitioner, this is sort of part of the job.
I think, just a lot of reflection. Yeah, I think just a lot of reflection and over time learning not just to accept a diagnosis because it's an eye chart, but to really reassess myself, kind of think about it and try to contextualize it into the whole person, the client who, who I'm working with,
yeah, can we then can kind of veer us into stuff. So as you're talking about understanding diagnosis through social justice lens, things that maybe surprised you as we're getting into recommendations of how this could look for practitioners.
Sure, sure. So I think some of the most surprising things I've learned along the way in kind of coming to understand diagnosis and social justice is really recognizing some of the ways that diagnosis does benefit folks as well. I think from my time in community mental health, I saw a lot of the negatives, but then I see the positives now as well through a couple of different experiences. So the first of those is that in August of 2021, my son was diagnosed with autism and learning to understand and kind of adjust to that diagnosis, and seeing how that diagnosis has been helpful in allowing him to access care and necessary supports across settings. NGS has been really transformational for me and understanding the benefits of how diagnosis can serve, when it fits and when it's used appropriately. The other thing that I think has really made me recognize the benefits of diagnosis more is teaching diagnosis, which I did in fall of 2021, about two weeks after my son got his diagnosis, and just learning from students along the way, and how they frame diagnosis and the ways that with the work they've done before, that they've seen having a name really benefit clients in different ways. So I think that's been one of the biggest surprises that I've picked up along the way.
So being able to see firsthand but also these different experiences these different lived experiences from students. I'm curious what you took, is it more just like, a different perspective than you had ever seen before as far as diagnosis? Because I feel like I learned every time I teach diagnosis to from some of the richness of their experiences, because I draw a lot on clinically, what are the experiences I've seen from my clients? We may not see every diagnosis under the sun. What did you notice that you took away from teaching it?
Yeah, yeah, I think I saw a lot of folks working in different settings that already different kinds of human professional settings, and seeing the ways the diagnosis interacts there, and how that can be useful in navigating treatment and informing treatment, and things like that. I've also been amazed at students who are willing to talk openly about their, their diagnoses in settings, you know, and to share that so that the whole group can learn, you know, not just from the vignettes we talked about, or the case studies we look at, but to hear the lived experiences of their classmates with their different diagnoses as well. So I think just having those open conversations with students about what they've experienced, is really helpful as well. Yeah.
And as much as we want students to feel the most comfortable in the classroom settings. I do think sometimes that self disclosure is so important, because I think it could be easy for us to stay in this ivory tower of We are the practitioners, these are the clients in sort of separating it and constantly being reminded that it's like, we also are the clients, we are also the people impacted by this. And I feel like that really helps us to stay rooted in our counselor identity versus becoming over clinical, and you know, focusing on this cluster of symptoms, and really forgetting about the human hood that comes along with these symptoms.
Yeah, that's a beautiful way of putting it, it keeps it real, and keeps us mindful of what that is. And honestly, that's what our clients need us to do is to always be thinking about it and thinking about who's the person, it's not just the diagnosis, it's who is the person experiencing these different forms of distress?
Yeah, because many of our sights, it might describe people as the diagnosis, here's another x diagnosis, versus how we can really be challenged and know who's the person behind it. So let's go into some of these recommendations. What are things that you've noticed that have been useful into integrating social justice into diagnosing?
Sure. So one of the things I think about a lot is our multicultural and social justice competencies. And I think we've offered a nice framework for how we can approach thinking about diagnosis from a social justice lens, at each different level of, of that model. And so the social justice competencies are divided into kind of four sets of attitudes and beliefs, knowledge, skills, and action. And so what I write about in the article is kind of breaking down each of those themes and offering different recommendations that might be helpful to consider in each of those, those different domains. So with attitudes and beliefs, this is really helping counselors just be aware of our own belief systems, our understandings kind of what we bring with us into the space. And so this is kind of the internal work that we're doing as professionals and as people to be more mindful of social justice just in our general practice. So the first recommendation I offer here is the idea of contextualizing diagnosis. So diagnosis does not exist in a vacuum, right? That when the DSM talks about a diagnosis, it makes it it reads kind of like it's just this isolated symptom cluster that exists within this person, and it just is what it is right? But the reality is that every symptom, every diagnosis exists, with within a context around that that person and in many cases, the level of disability, perhaps that comes from a diagnosis is really more about the environment than the individual. So in contextualize the diagnosis, I think about kind of questioning what's the socio cultural, what's the linguistic what's the cultural context that someone exists with? Then, and how does that help us understand the specific type of distress that they're experiencing? Other questions I would think about considering here would be, if I was working with a client who was a different race than the client in front of me, or a different gender than the person in front of me? Would I still diagnose them the same way? Or would I see the same thing? Why or why not? Right? So really just asking some of those contextualized questions. Another recommendation I think about here is doing the Harvard implicit bias test. They're not a perfect tool by any means. But what they help us to do is kind of recognize those areas of implicit bias, we might carry those kinds of snap decision biases that we each may hold internally about different socio cultural groups, to help us be mindful of what those implicit biases might be. So that then we can be mindful of those in our practice to make sure we don't let those interact in in the work that we're doing with folks.
And can I ask how do you think you worked through maybe, because I feel like it's a very common thing that when we have our biases, when we reflect, we can have defensiveness come up sometimes, because we think, you know, I'm a good person, I want to do good. Of course, I'm not bias. How did you navigate this sort of like checking yourself and reflecting but not finding yourself getting caught up in the defensiveness part versus be open to really learning what some of these biases might be?
Sure, sure. So my example of that is I was a Women's Studies major in college, right? So I see myself as a feminist in general. And the first time I took the implicit biases, tests, I took the the gender when and I remember, it reflected that I was pretty, I had some pretty strong gendered biases. And I was very confused, like, how could that be? If I'm a feminist? Like, how can I carry this? And so I think it really just took time to kind of just slow down, you know, really take our time that these implicit things happen pretty immediately. And we just have to slow down a bit, decide what to do what not to do with them, and keep moving forward, I think and the same thing, and just thinking through them and sitting with them is recognizing it takes them some time.
Yeah. And also this idea of like, if it's uncomfortable, that's where we, I mean, we teach students like do discomfort comes growth. So if it makes you uncomfortable, I love what you just said, like maybe slow it down even more, kind of like checking what is the parts that make me uncomfortable? And sometimes having those labels of like, oh, that that is more traditional than I would think or, you know, I didn't realize I stood here that just gives us data. And the same way that we teach clients don't don't evaluate all the data you get, just notice it. And maybe some of that mindfulness can kind of help with the defensiveness that I know, I might go to when I'm really checking myself and thinking like, no, like, I am discomfortable. Let's check these other things. Because some of it can be more insidious and subtle than we realize.
Yeah, yeah, absolutely. And like you said, kind of recognizing that I don't grow by not learning new things about myself, right. But it really is we have to encounter and sit with those things in order to move forward.
Now for my ego, I definitely sometimes I'm like, But do I and then it's just checking if I'm only surrounded by Yes, people or things that are affirming what I'm doing, how might I ever grow and evolve? And the whole point of this thing of life, to my opinion, is to evolve as a person. So sometimes it takes a little mental gymnastics. Yeah, for sure. Sorry. Okay. So what were you doing with recommendations?
Yeah, yeah. Another recommendation with respect to the attitudes and beliefs is just reflecting on clients strengths. And I think of counselors were probably pretty strong in this area is is thinking about the strengths. So diagnosis, and the language of diagnosis tends to be pretty deficit based talking about symptoms, problems, challenges, things like that.
On functioning, there's always this like, effects on.
Yeah, absolutely, absolutely. But it's a really kind of questioning that and flipping it into a strength based lens. So instead of focusing just on what are all the problems, the challenge is really consciously thinking through what are the strengths that someone brings, what are the abilities? What are the ways that they're astounding, of what we have with what they're bringing to the session as well, that makes
me think of when I have clients who come in maybe from different racial backgrounds, and they are very, very cautious that they're going to come off as like aggressive, were in a strengths based approach, more of the sense of you have good experience with boundary setting, you understand things like assertiveness and being able to just re label that although society or maybe certain forces of power have labeled something too much. That really it also can be seen as like a survival mechanism that has kept you safe up until this point, or kept you protected.
Absolutely, absolutely reframing survival mechanisms that I talked about that all the time with clients because that's so important, right? And I try not to do too much of the language of resilience because sometimes that can be a little bit off putting like I wouldn't have to be resilient if society was more just but absolutely but but really for You think these are the survival techniques, these are the things that kept you safe. And so in our work together, we're going to try to allow you to feel safe enough in the present that you don't have to lean on these quite so much. But But recognizing the value to, to what's kept them safe in the past, I've really
seen that helped to start neutralizing that sense of shame of why they've done the things that they've done to get to this point, and understanding or that if these were survival instincts, if anything that might bring a little sense of pride that you have survived, I understand these strategies may no longer serve you. And that's the work that we can do together. But that's pride of how you survived in a situation that was likely very unfair.
Yeah, yeah, absolutely. So two more recommendations. So we talked about attitudes and beliefs. So the next group is knowledge based skills. So these are kind of specific techniques and skills that that counselors can be educated on and kind of learn about, the first one of these is just know your population. So in different settings, everyone works in in with different specific populations, right. In my community mental health setting, we had a lot of folks coming in with low socioeconomic status. In general, I worked with adolescent girls a lot. So that would have been my population, I have colleagues that focus on on working with trans folks, and we all have our population. So basically, the idea of this is just know your population. If we're going to be doing diagnosis and assessing someone from a different cultural group, then then perhaps where we're from, we really need to understand what the culture is that they're coming from, so that we're not miss naming or miss labeling, things that they're experiencing, based on having a different worldview, right. So just being really mindful of that, sure. Or
not spending so much time in session of them having to teach you about their culture, versus things that you can do on your own that feels like you've got a little bit more understandings of those in group dynamics.
Yeah, absolutely. Absolutely. It's fine for us to ask some questions, but they shouldn't be teaching us their culture, right, we need to do our homework on that, before we're doing diagnosis. I think connected to that, is the idea of educating clients about their diagnosis. I've seen so many clients come in where I see their medical chart, and they have like four diagnoses. And they don't know what they are, they don't know that they've ever received a diagnosis, much less know what it means to them. So really, I think taking the time to, to talk about what diagnosis is, what their diagnoses mean, for them and kind of having some dialogue about that. What I see, especially working with adolescents is if we don't take the time to really break down that diagnosis for someone, they'll find it somewhere else often in therapy Tic Tac Toe scary place, sometimes.
I have had many, many that come in, I think I have this now. And I'm like, Okay, let's talk about what you've used that has led to this.
Exactly, exactly. And then we just break the DSM out in session and go through the criteria together and talk about it.
It is I don't know what trends you're saying. But I've got a lot of narcissists and ADHD and ADD that seems to be the the keywords that a lot of my folks are hearing right now.
Yes, yes. For sure. For sure. Because Because tick tock told them
yes, yes. So take the time to break down what a diagnosis is the purpose that can serve advantages and disadvantages, things that maybe really align with their lived experience. And then maybe even some psychoeducation of it is pretty common. I've seen like providing statistics sometimes can really help a client to feel normalized or validated about their experience. Yeah, absolutely. Absolutely. The more the more knowledge, if we're giving if we're adding a name to them, if we're talking with them about adding a name or a label for what they're experiencing, we need to make sure it fits for them. Right, and that they know what that what that represents from our our position.
Along with that, I think it's important that we educate the allied professionals that we work with, because counselors don't work in isolation. In general, counselors work within complex systems of care with other folks who may or may not be trained in diagnosis. So I'm thinking here about working with perhaps case managers or working with legal services or children's services professionals, or even school personnel as well, depending on honor setting, and most of these folks aren't well trained to diagnosis. And so when we're using our diagnostic language, they may not be understanding what that means, or it carries some biases about that as well themselves. So I think as as counselors, it's also our responsibility not just to educate ourselves, to educate our clients, but to make sure we're offering that information to the allied professionals that we work with. So they understand what the diagnosis means and why we're using it in the way that we are. Sure. And
then also maybe holding a little bit of accountability to some of our professionals that when they say things that it's clear that biases, they're just sort of like asking them well, what do you mean by that? I really like testing some of the language used around some of our clients and their diagnoses.
Yeah, absolutely, absolutely. And I think connected to that, too, is the idea that diagnoses have real world implications for people. And so it's important that we get this right when we're when we're doing this. I've seen clients end up in in rough spots later on because of diagnoses they had when they were young person. I'm thinking specifically here about someone I worked with a while ago, who had had a diagnosis of major depressive disorder and generalized anxiety disorder in their adolescence, and then was interested in joining the military after they graduated from high school and found out they were going to be unable to for several years, because of the diagnoses they had had as an adolescent.
And so nothing I ever learned in graduate school, not until I went into private practicing adults and started seeing these adults, I had never heard of something like that really affecting even your chance at military service, a childhood diagnosis.
Absolutely, absolutely. And then the flip side is that for some folks, that's really helpful to have a diagnosis that gives you access to care and the support services you need. So I've worked with college students who've never received the diagnosis and are struggling, you know, in college, because they really need some support, but they need to get this diagnosis a little bit later in life to access with the burdens that they need. And so I think we need to be really mindful that these implications are both for ourselves, and how we diagnose and also to educate clients. So they really understand kind of what that might mean for them in the future. Yes, I
think that's crucial that information and the power that we hold with it.
Yeah, for sure, for sure. And I think that power piece is so important to, to really sit with because they, we don't necessarily think of it as a power just in our everyday offices. So many counselors were strength focused, we tried to be collaborative and limit this power differential. But this is a real world way that we do carry power over our clients and our ability to name and to diagnose what's going on for them.
Well, that's I think this conversations are so important, because I feel like the power that we hold is very palatable for a lot of people going into the field that they are very social justice focused, they don't want to hold the power in the room. And I commend that greatly. But the reality is just with managed care, we do hold that power. So I think it's like So being aware of it and being very mindful and how you yield that power. But nevertheless, sitting in the seat that we get to as therapists, that is a powerful role.
Yeah, for sure, for sure. So some of the skills, then that I think we can use to take these attitudes and beliefs and the knowledge and kind of point that forward would be to use the Cultural Formulation Interview, which appears in the DSM, this is a helpful tool. And it's not super long, it's 16 items, but it's included as part of the assessment process to make sure we're really thinking about culture and different cultural factors, when we're engaging in diagnosis when we're doing our assessments. And this would be good just standard assessment practice for folks to make sure that we're really getting that full picture of, of someone as we're, as we're working with them. Narrative approaches are also super, super helpful to use an understanding diagnosis because the idea is not on an internal pathology, which a diagnosis can feel like, but it's about kind of the story of what happened, what's the what is the problem that we're trying to help them work through, but not necessarily internal to themselves. So it can be a really good approach to understanding diagnosis to working with this problem without it feeling like it's becoming a part of their identity, necessarily, sort of a
way to emotionally distance from it will still gaining their perspective.
Yes, yes, absolutely. Absolutely. And then other, I think skills that are important are just really being mindful of cultural norms. In the assessment process. Often, you know, this kind of talk therapy approach that that we learned much of the time tends to be a very western centric view of interacting with others, between kind of the one on one setting expectations of eye contact, personal space. So really making sure we check in with people before we start assessment, to make sure that they feel comfortable and they feel heard and seen in the space that that we're, we're in as we're talking with them.
Yeah, I think all those things are really important as well as being aware of what's going on globally within these different cultures. And honestly, we can't know everything about every piece of news, but I've seen it be so powerful that if I check in with a client on something that I feel is like affected their community, really lets them feel seen really makes them feel that I'm attune to sort of what their lived experience is like and I find it being really powerful versus times that I might want to bury my head in the sand. Act like the news doesn't exist. I miss some major components that could be affecting our clients, affecting their community. Yeah, affecting the mood and behavior in which I witnessed them in therapy. So I think also just being sort of aware of what is the news that doesn't just affect you as a clinician, but also your clients and their lived experiences or their experiences of safety and power?
Yeah, absolutely. And I think that even ties back to the idea of where does the pathology lie, or for many folks, I think the DSM model tends to be very internal, right, and that it focuses on this pathology exists within the individual. And the reality is, that's not always true for folks, it's often someone who's struggling, because the society is not well designed for them, and the world that they exist within. I think of this with autism a lot. And the idea of autism as a diagnosis versus autism as a disability versus autism as a form of neurodivergent. See, where if we think about it in in terms of everyone's brain is different. Everyone kind of perceives the world differently, acts differently in different ways. The world is not well designed for folks with autism, necessarily. And so they're the level of disability that someone with autism experiences is sometimes more a matter of what the societal treatment of them is, than it actually is, like, how they are internally.
How like the design is of our world versus our actual clients or these individuals and their experiences.
Yeah, exactly, exactly.
Yeah, I use that a lot. I work primarily with women, but I use it a lot with some of my college women who just feel that they can't do it. Right. They're not enough. And so it brings a lot of symptoms of depression, anxiety, and it's like, are you not enough? Or is the system sort of designed in that way for many different agendas to make you feel not enough? Whether the beauty industry, social media, governmental, like whatever it is? Is it a design that way, and your symptoms are just a product of this design versus inadequacy? And you?
Right, right, that's exactly it is is really kind of balancing like, how much of this is the context versus what's actually internal? And I think so much it actually is about the context and the struggles and the distress that comes from living in this context, versus something internally wrong or something inside the person.
So then not to do is you've given us some skills? Are there things on that other sides and to how we can build our skill? Or what to avoid in our skill building?
For sure, for sure. I think some of the things not to do would be diagnosed in isolation, necessarily,
based on observation of symptoms, or, you know, reports of a cluster of symptoms.
Yep, exactly, exactly, we really should be leaning on kind of the whole picture of what someone is saying. And if possible, getting some some collateral information from other people in the system as well. Or from other if we're working in an agency setting where we have different treatment team members, making sure we're working together with with the different people in the treatment team to understand the diagnosis, I think I'd rather not to do is just accepting any of the diagnoses in the chart. Like I've said, I've seen so many cases where there's just a bunch of diagnoses, and they contradict each other, they don't make sense. And we don't need to accept those. In fact, our ethical responsibility says that we need to assess for ourselves and understand what's happening. And so I think that's an important piece and don't just accept a diagnosis just because it's what's been seen before.
And I feel like that's different than my training. My training was always like, defer to what the MD says, So sure, you can have your ideas, but we're going to defer to the prescriber, where I've been able to learn now with a little bit more confidence and experience. Sure, we can have it documented with the prescriber saying, but I also can very accurately document what my initial impressions are what I'm actually observing them to so at least it provides all the data for any future clinicians versus just feeling like I must defer to the medical professional.
Yeah, absolutely. Absolutely. And I think that's so common, it's that power again, right, who in the treatment team has the most power? And I think our counselor, our clients need us to step up and take some of that power to when we see something different. That's that's worth conceptualizing and understanding.
Yes, I feeling confident in that, that we see our clients for much more extended periods of time, then psychiatrists or other medical providers can to the nature of their schedules and managed care. So feeling empowered that we can have those discussions?
Yeah, absolutely. Absolutely. And then I think another may scratch that. I don't know what I was gonna say.
So it's mostly get the full context. Try not to feel so limited by order of symptoms or list of symptoms, try not to feel intimidated that maybe another provider has seen these things, and really trying to like dig in. And also I always tell my supervisees and students diagnosis is something that can be fluid. So because on this first day you saw this or you thought you saw this, as time unfolds, and you get more data, it's completely appropriate for your conceptualization to shift and then the diagnosis as well.
Absolutely. Absolutely, I think the other piece as a not to do would be don't underestimate the impact of trauma. Again, being a trauma therapist I, trauma is everywhere, right? So many so many clients bring different types of trauma, whether it's developmental family trauma, whether it's larger societal trauma responses to adverse circumstances that occur in the world, it's pervasive. And so I think for many people, when we really look at trauma, the symptoms of trauma can look like a lot of different things. For some folks, it's going to look like depression. For some folks, it looks a lot like anxiety. For others, it looks a lot like ADHD. And so really, kind of being open and mindful of that, and never underestimated kind of what that impact of trauma might be on what they present with in the present. Sure,
do you think some of your EMDR training has helped inform that because I have found for me that, when I've had so many hundreds, 1000s of hours, I don't know, at this point of therapy, and with EMDR, when we like boil it down to some of those like basic components, it always seems to be rooted in things of like power security, like helplessness, has your entire practice at all informs maybe how your diagnosis is or that trauma perspective?
Oh, absolutely, absolutely. EMDR training changed my entire life professionally. Such a fan girl. But absolutely, it very much does, because it breaks through the symptoms, the cognitions, the beliefs, right, that that we see with all the symptoms and recognizes that there's often a route that connects all of these. So it's not just perhaps a negative belief, or an isolated behavior that's occurring, there's something connecting it all together in a really meaningful way. And knowing we can do that and really address the root of the problem, rather than maybe the branches of symptoms coming out of the tree, the better able able we are to help people. I really think that
because it's it once you hit that root, and you understand symptoms more as the way that the body is expressing its pain, or its incongruence or whatever is going on within the environment, then therapy can still be effective, obviously focusing on symptoms. But when you get to that route, it's almost like this domino effect that then you just see it, you can use that metaphor of a tree, you just see it start extending to the branches, you really see the healing start extending into other areas outside of just the symptomology. And so I feel like getting trained in a trauma modality can be really helpful when it comes to diagnosis, because you see some of those major core issues that keep popping up just the side effects. Are the symptoms look different? The the actual manifestations of it can really vary.
Yes, absolutely. It's all a coherent picture. So instead of having three or four disparate looking diagnoses, it's really one condition, perhaps one diagnosis that has just symptoms across several different groups.
And I do feel to if anyone is interested in sort of like being able to practice this more, getting more of that trauma understanding helps you to really understand and see it as those survival techniques, like we talked about, which I just felt like helped open up this whole different branch of compassion and patience for me as a clinician, that if we're going deeper, like this is going to take time, this is going to be trial and error, this is going to be challenging, versus if I just stay in that two inches deep of water of just doing symptom management, then I found myself it was easier to get frustrated of okay, well, we did this thought log we practice this thing, this behavioral thing. Why is the change not happening? And it's like, okay, because I was staying two inches deep. And so we're really the core is
absolutely, absolutely. And I think clients feel that too. Right? Kind of that stuckness and that frustration then that this isn't working, what's wrong with me that I'm treatment resistant, or whatever beliefs they start to carry? So yeah, the more deep we can help them go the the more we can help them feel that that empowerment as well.
Sure. So things then that helped you to practice a more social justice approach to diagnosis, any recommendations you have that maybe listeners can take after this discussion, especially if they want to understand more of these components of diagnosis or expand how they view diagnosis. Obviously, your article in counseling today, the May issue I think, could be really helpful because you use a case study that I think can really illustrate what this can look like in practice.
Sure, sure. I think some other works that have been really helpful and informative for me as I think about this. Again, I mentioned they love Vicki Chris's work around diagnosis and and multiculturalism and ethics. She does some really some really great work in that area.
We just had her on the podcast not too long ago. She's just been on an episode here. So definitely go back and look that since Christine has named her doctor a few times that Vicki Chris has done a lot in our field.
Yeah, she's amazing. Another person. So Krista Malad, and colleagues wrote an article just in 2023 about the idea of decolonizing diagnosis. And so I think that's really interesting work as well and not just looking at kind of how to make DSM diagnosis more socially just but really like decolonizing it Um, the entire practice of diagnosis. So I think there's some really cool work that's, that's happening in that area as well. And then IV and IV have written about a theory called developmental counseling and therapy theory. And the idea of, of that is really similar to what we're talking about as well, this idea of maybe a diagnosis is just one part of how we frame experiences, but really kind of approaching the whole process of diagnosis and conceptualization through kind of a liberation psychology type approach to naming. So those are all really cool pieces that inform how I think about it, and then that might be useful for listeners to think about as well. That'd be
great. And we'll definitely link to those in the show notes. I'm curious, as you talked about teaching diagnosis, anything to these, like new baby practitioners who already feel so anxious about diagnosing, if I'm thinking about my supervisees, they oftentimes have 45 minutes to do a whole psychosocial assessment and a treatment and plan and a diagnosis, is there any sort of guidance or thing that you might say, to help encourage them because now we're adding this extra layer of oh, by the way, also, at this piece of the whole person trying to get all these, you know, pieces that might, that might come together to form again, this cluster of symptoms that you notice, but to really understand and conceptualize? You might need to take some time any guidance that you have?
Yeah, I think part of it would be kind of giving them almost the permission that they don't need to have the answer right away, you know, that that in many settings, that's going to be your expectation that you need to to kind of have a diagnosis, but kind of helping them understand that you can have kind of a Not Otherwise Specified Or an unspecified diagnosis initially, and then refine as you go. And then for the clients benefit is that you don't necessarily need to have the full, you know, the final answer within that first 45 minutes session. So it's okay to really slow down collect that collateral information before feeling like you have to know the answer. Because as counselors, we often don't need to have the answer. Right? We can we can take away, for sure, for sure. So I think not being afraid to do that. I think using the Cultural Formulation, interview, really making that standard practice for folks to make sure you're assessing the impact with culture and understanding the whole person as you're conceptualizing. And I think asking students or having students ask themselves, like, what else could this be? And really trying to broaden that scope a little bit to understand like, what else could this be? Is this representing something that's occurring within their system? Is this something within the family like, what else could this be besides just what my initial impression is diagnostically? Yes,
I've also found it helpful. One, I've started giving each of my clients the ACES questionnaire to as part of their intake paperwork, that I'm already acknowledging that very difficult or adverse childhood experiences can be implemented to our work, it might be something that's an influence, and I only see adults, but I found it to be so helpful in helping me to be very strategic in my questioning, for me to already be listening out to some of those trauma components, even if a client doesn't endorse coming to therapy for trauma. So I found that really helpful, and in conceptualizing clients to what is my perception, but also what would their caregivers say? What would maybe their boss say? What would society say? I feel like going through those different perspectives also helps me to see like, Am I just doing this in a vacuum of therapy and only in isolation of symptoms? Or what are these different other systems and their view of what my client's challenges right now, that's helped me to be able to take a step back a little bit to just make sure I'm trying to be as holistic as possible.
Yeah, that's a really cool approach to having them think or having yourself think through what would each different person thing or have them think about that?
How would the site think about this? How would the insurance company think about it, they feel like then you can land into a place that you feel really empowered with, but it feels like okay, I've definitely viewed these different perceptions, what maybe their child would think to, and so I've heard that at least going through that process has helped me not to just get to focus on symptomology, especially, like I said, if we know our population, sometimes that's only the lens. So immediately, I hit Oh, trauma, okay, this is trauma. And I might even ignore some of the other things that actually are not trauma related. So I try to go through that line of questioning every time just to make sure that the blind spots are limited, though, of course, there might still be some that unfold. Yeah,
Is there anything else that I didn't ask you about that you would think is important for listeners to take as far as being able to diagnose them as holistically as possible?
Um, I think just really being mindful of that idea of power. Right? Just really being mindful of what that that power that we hold means and making sure we use that power for good. You know, there's no way to be totally powerless. When we think about diagnosis. We can be very collaborative, we can invite our clients to have pretty frank discussions with us about diagnosis under diagnostic thinking and what we're seeing. But but we do still carry about power, there's no way to avoid that. So I think just really being super mindful of, of what that means. And what that looks like, in the session is helpful. I think the other piece maybe is the idea that diagnoses change over time. So diagnoses change within our clients over time. So someone who presents with one diagnoses may it may shift over time and become something different, but the nature of diagnoses as they appear in the DSM shifts over time as well. That's a very example when PTSD was first included in DSM three it was it was listed under the anxiety disorders, and was later moved into the trauma disorders to represent that it's not just a fear response, there's also anger responses and dissociative responses and a whole host of things that are are different than the anxiety disorders. But really keeping kind of abreast of what's happening in the DSM and how diagnoses and the definitions of them shifts over time, because they do they all shift a little bit between editions of the DSM.
I think so. And I think when people have the challenge of the power, because I again, especially clients who maybe are much more humanistic, and they feel really in touch with that sense of holding the power in the room, playing that out that if a client became high risk, or suicidal, who's the person who has the power to hospitalize them or not, who's the person who has the power to involuntarily hotspot like we do, even if we hope to never, ever use it, we ultimately do that power of diagnosis, you may not think anything of it when you see that client, but in five or 10 years when they're applying for life insurance or the military, like you said, or to adopt a child. Those are things that as much as we don't want to hold the power, we just in our professional roles do have it. So like you said, just being really, really mindful, documenting what led to this impression. And then also understanding you can have that evolve. This could be an initial diagnostic impression and then evolve over time, not just this black or white art. You've got depression. We're treating you for this. And that's all that's documented. Yeah, absolutely. Absolutely. Yeah. Well, I thank you so much for first writing this article. And I really hope that listeners will go to counseling today, to be able to read it. I thought your example really brought things to light. Like I said, I'm a visual learner, but I thank you for kind of expanding on this today. So that way people have a digestible way to really re think how they're diagnosing and maybe some avenues they can use to deepen what that looks like all for the betterment of the clients.
Yeah, thank you so much for having me. I've appreciated it.
Let's Thanks Christine. And then thanks ions here has been another episode of the thoughtful counselor.
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