Monday, January 30, 2012

Abnormal Discussion Week 2: If People are not Labels, then People are not People

The theme of my night: People are not people. People = a label. Gotta love it. So people ARE labels, then?

I love this course material. PSY 424. I'm actually enjoying the material. Almost as much as I enjoy ethnic and feminist literature (I said ALMOST, don't get carried away...). The discussion posts made by most students in this on line course are, as you might imagine, much shorter and less...well, less...

Anyhow, I plan to post my discussion posts on my blog when I think they are worthy of being read by someone other than me.


Question Posed: Many people argue for a “people first” approach to clinical labeling, recommending, for example, the phrase “ a person with schizophrenia” rather than “a schizophrenic.” Why might this approach to labeling be preferable?

Simply put, it would be inaccurate, unnecessary and insensitive to use a label that describes one aspect of an entire person in order to characterize the entire person. While most of us know that a person is not her or his disorder, a person is not her or his sexual orientation, a person is not her or his physical condition; it is difficult for the majority of us to define what makes a person a person. We spend a great deal of time, as humans, trying to understand and develop our individual personalities. We are constantly bombarded with messages in the media that encourage us to define ourselves in terms of one of our preferences: what music we like, what coffee we drink, what kind of e-reader we use. The media banks (CHA-CHING!) on our desire to Be Somebody - to identify with something, to associate ourselves with something larger than ourselves. If we feel a sense of belonging and community in something (in a group, for instance), then we are likely to feel a certain degree of pride in the label attached to that community. If we feel isolated and alone in something (in a long-time struggle with a family member, for instance), the we are likely to feel a certain degree of shame in the labels and meanings attached to that struggle. In that regard, the degree of isolation and sense of belonging largely determine our perceptions and feelings about any given label. But, whether we shun or embrace a label, people are still not labels.

Even the term "people" is just a linguistic device created to for the purposes of communication and identification. Though it's hard to definitively say why or how, there does seem to be some human drive that propels us to create language in order to interact and communicate with others in the world. Speaking of language and labels, I was captivated and intrigued by Halgin and Whitbourne's description of the Diagnostic and Statistical Manual of Mental Disorders as a "common language."  Though I doubt the authors considered the linguistic connotations and connections and interpretations that can be made in connection to the organization and delineation of disorders, their reference to a common language is a perfectly fitting and far-reaching descriptor. I appreciate the way in which the authors frame the language of disorder as a "common language" because it evokes the simplistic yet profound idea that we all espouse in some form or another: to engage in a common language. We seek, in our work environments, in our romantic relationships, in our home life, to create and relate a common understanding. We seek, and it is very natural and beneficial to do so, community and communion and communality. A common language can free us to be ourselves, but it can also confine us. It benefits us to identify with and feel part of a community. However, if we become so identified with and infiltrated into one community, or into the foundational language that creates that community, we may lose sight of ourselves as individuals within that community. We may even become so accustomed to the body of language that we cannot see or think beyond it.

Language is both the creation of community and the creator of community. Before spoken and non-spoken language, there existed a non-verbal, non-human realm communication. The movement and interaction of the elements is a very synchronous and cyclical form of communication. Non-human elements in the world interact and come together in various ways. Water is absorbed into the air and comes back down to earth in order to water the land that harnesses the seed from which something, in direct sun or in partial shadow, grows to feed a hungry land creature that puts something back into the soil to replace what it has taken. We could look at human communication the same way, were it not for the great many languages that have allowed us to define and redefine and deconstruct our natural place in and relationship with the world as well as the language of living. I very much see the common language of the DSM as having dual-roles as both explicator and creationist. I think the authors of "Abnormal Psychology: Clinical Perspectives on Psychological Disorders" provide an excellent framework in Chapter 2 for understanding the purposeful yet limited and limiting nature of the DSM. It, like any language guide, provides its disciples and speakers (from varying backgrounds and at varying levels of fluency) with a evolving framework and instructive guide. It, like language, is a way of looking at something - it's a world view in and of itself because it creates a world view. As with any world view, there will always be limitations and contradictions with which its visionaries must contend.

In "The Dream of a Common Language," Adrienne Rich provides a poetic language for and about women by speaking in the language of women. Rich's collection of poems, separated into three sections, is, indeed, a "whole new poetry." The creation of a language arises when their is a need for such a language. The need exists because one of more members of a group, often a silenced and invisible majority or an oppressed minority group, desire to articulate their experiences in order to preserve their experiences and create a sense of community among themselves. More than anything, though, the language of the group is created in order to reach out to those outside the community in order to seek understanding and compassion from outsiders and oppressors in the hope that such an understanding will create change. The DSM was first developed in 1952 by the American Psychiatric Association. As in the case of Rich's poetic language, and the way it spoke to and about lesbians and marginalized/outsider women, the American Psychiatric Association sought to create a common language to speak to and about psychological disorders. It sought in its earliest form, on a very elemental level, to challenge misconceptions about mental health and unhealth as well as to create a communal resource and framework for, in which ratings and criteria and definitions could be used to connect insiders to one another and outsiders to insiders. It served and still serves as a tool to dispel stereotypes and stigmas that leave individuals with mental illness feeling isolated. It serves as a common language among mental health professionals as well as a way tool for those who have experienced mental illness to understand themselves and feel connected to the common language. And, for those outside of the mental health profession, it provides an informative framework into which the common language can be accessed, processed and comprehended. On the other side of that common language is the unfortunate fact that there will always be someone or something left out of that language. While language seeks to make outsiders insiders, it inevitably excludes and, therefore, creates outsidership. If there is a community to be in, there is also a community to be marginalized from.

Besides the limiting and dualistic nature of language itself, a common language always is vulnerable to misinterpretation and misuse. That is to say, sometimes we let the power of language go to our heads. Sometimes we forget that language is just language, becoming so caught up in the story of one common language that we lose our ability to interpret and experience the world in new ways, with new languages and new stories. That is my fear for the DMS and for the field of Clinical Psychology itself. The authors, however, do a wonderful job of calming my fears in their very comprehensive and sensitive presentation of the language. Halgin and Whitbourne offer us a very human-oriented and human-based approach to the subject of Abnormal Psychology, by providing us with the essentials of the common language while at the same time staying case (or individual) focused. They don't force us into a common language of dualistic labels; they, rather, apply the common language unobtrusively and without pretense into real life situations. I certainly have my own concerns about the ability of the powers that be in the mental health industry to influence and dictate our perception of mental health through their construction of a common language (with financial pressures from insurance companies to over-diagnose and overuse the label of disorder in order to suit the medical-model that allows the field of mental health to be a financial industry).

Anything that becomes part of what Minnie-Bruce Pratt calls "The Money Machine" is susceptible to becoming so caught up in the financial side of things that it loses its authenticity and effectiveness. Still, if the DSM is handled with care and thoughtfulness, as it was by the authors, I feel it can be a helpful common language. It all depends on the context and the individual situation - which is what the "people first" (and relationship-oriented) approach to clinical labeling is all about. I am curious about the theoretical background of the authors, since their style and approach appeals so much to me. I very much appreciate how attuned they are to the dimensionality of the individual. It's hard to read this chapter, even in light of the differing views that are presented, and not feel at ease about any fears you have about the dehumanization of the mental health diagnostic approach.


Consider the reasons why treatment is not always successful. How do the client’s insight, judgement, motivation, and ability to change affect treatment success? How do the clinician’s education, modality, competence, and theoretical orientation affect treatment success?

There are many things that might affect the success or failure of a treatment. Modality certainly would affect the types of treatments, as well as the goals for (and criteria for the success or failure) treatment. In a group therapy setting, the goal might be more centered on improving the functioning of the family unit as a whole; whereas in individual psychotherapy the goal would likely be more centered on improving the functioning of the individual (however - an improvement in individual functioning always leads to an improvement in interpersonal or communal functioning). It's hard to say how, exactly, the personal and theoretical orientation of the client and clinician affect treatment success. That's like trying to pin down the cause or root of a phenomenon. We can say everything affects everything, so yes, of course, insight, judgement, motivation, education, competence and theory would all affect one another and engage in an interaction that would affect the overall clinical process. Defining treatment success is just as difficult. We would have to have a very strong theoretical background, as well as a deeper knowledge of each of these qualities of the clinician and client in order to really say how the set of circumstances and characteristics come together to form a working relationship that results in treatment success or failure. It's also very difficult to define success or failure. Even a small step in the direction of mental health (of functionality) or a step away from isolation might be considered a success.

As we discuss this topic, I think it will helpful for each of us to think about how we might define success in a psychotherapeutic setting. I can't say anything about how any other client or clinician might define success. It's even hard for me to say how I would define success because I don't have the first-hand experience and I have never though about this subject before. I'm glad to be considering it, though. I have never, formally, been a clinician; however I have been a client. When I came out of the closet as a teen, my parents arranged for me to see therapists (it was my mother's desire that I should guided, through therapy, out of my defiant state of lesbianism). I saw a few clinicians at that time. I only considered one of those clinicians successful. But I still have trouble defining what made his approach successful in my eyes. I believe it was mostly a manner of his gentle-nature and theoretical orientation. I cannot actually define or point to definitively his theoretical orientation, I can only say that I felt accepted. I did not feel any pressure to tell him the lies I was telling everyone else. When I told him that I believed the love between the person in my past and I was mutual, and filled him in on why I felt/thought that way, he did not react with hysteria. He did not diminish nor negate my feelings. He honored my autonomy and even validated my feelings and experiences (not just by listening but by showing empathy and, dare I say, compassionate love).

To this day, I think about this man (he is a pastor and is near retirement) and wish that I could have continued seeking out his acceptance and moral guidance throughout my life. That was the closest thing to acceptance, in a counseling situation, that I experienced during that emotionally profound time in my life. I actually think it was his motivation-less mindset that made our work together successful. He did not seem to go into it with an agenda. Perhaps after he evaluated me, he felt that the best treatment plan was to provide me with a safe place of listening and true acceptance. I was, at the time, experiencing a great deal of unacceptance in some of the major realms of my life. Given that, I think he thought what he could best provide was a place of acceptance. Listening and acceptance and story-sharing and validation WITHOUT an intention to change or alter anything may have been his treatment plan. Isn't it ironic. His lack of seeking, his lack of a plan to change me was actually the thing that most affected (and perhaps even changed) me. What I needed more than anything, at that time, was a person I could trust and confine in and feel safe with. I did not have to worry that he was going to report the teacher I loved or tell my mother what she wanted to hear or request that I not label myself as a lesbian "just yet." Just knowing he was in the world, with the impression he made on me, made me a stronger, healthier person who felt she wasn't completely alone (who felt a great deal of relief knowing that someone out there, even just one single person, could understand and honor my love and perhaps even believe me).

He did just what I needed: he made me feel sane and acceptable. I felt sane and acceptable on some level, but my mother was forcing another message down into my psyche - that I was crazy, deranged, sick, evil. I don't know whether or not he felt he was successful with me, especially given that we had to stop meeting fairly early on because my parents could no longer afford it. I only know that I perceive myself as having benefit from it. I would like nothing more than to someday be able to provide that acceptance and validation for someone like myself who is isolated by their own intelligence and open-mindedness. Sometimes people just need support when they are in a place of isolation (when they find that they cannot relate easily to the majority of other around them, for whatever reason). My personal account as a client of counseling raises an interesting set of questions about the mutuality and/or separateness of client/clinician perception: Can a clinician feel she has been successful if her client does not feel it has been successful (in other words, can the perception of success by anything other than mutual? Is it still success?).

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