Transcript here - Persona Counselling

Madness has a lot to teach us and
it has existed long before
counselling,
so let’s be humble about it.
The categorisation
of mental illness
has always been
“psychiatric” in nature
and essentially
medical in its
approach
The need/desire for a
classification of mental
disorders has been
evident throughout the
history of medicine
In Ancient Greece, the first
classification system for
mental illnesses, including
mania, melancholia,
paranoia, phobias and
Scythian disease
(transvestism).
•Due to an imbalance in
the 4 humours
10th Century
An elaborate
classification of
mental disorders was
developed
17th Century
Thomas Sydenham
developed the concept of a
syndrome, -individual
behaviours that had long
been recognized came to
be grouped together. This
group of associated
symptoms having a
common course, which
would later influence
psychiatric classification 18th and 19th centuries
saw the development of the
scientific concepts of
psychopathology (literally
referring to diseases of the
mind)
The term "psychiatry"
("Psychiatrie") was coined in
1808, from the Greek "ψυχή"
(psychē: "soul or mind") and
"ιατρός" (iatros: "healer or
doctor").
Early 20th century schemes in
Europe and the United States
reflected a brain disease (or
degeneration) model that had
emerged during the 19th century,
as well as some ideas from Freud's
psychoanalytic theories
drapetomania
Spanning the turn of the century,
German psychiatrist Emil Kraepelin
advanced a new system. He grouped
together a number of existing
diagnoses that appeared to all have a
deteriorating course over time —
under another existing term
"dementia praecox" ( later renamed
schizophrenia).
Mental disorders were first
included in the sixth revision
of the International
Classification of Diseases
(ICD-6) in 1949.
Three years later, in 1952,
the American Psychiatric
Association created its own
classification system, DSM
The categorisation
of mental illness
has always been
“psychiatric” in nature
and essentially
medical in its
approach
The Diagnostic and Statistical Manual
of Mental Disorders
[DSM]
Published by
The American Psychiatric Association
The International Classification of Diseases
[ICD]
Published by
The World Health Organisation
• In 1917, the American Medico-Psychological
Association, formulated a plan that was
adopted by the Bureau of the Census for
gathering uniform statistics across mental
hospitals
• In 1921, the American Medico-Psychological
Association changed its name to the
Committee on Statistics of the American
DSM-I (1952)
Psychiatric Association.
DSM-II (1968)
•
DSM-III (1980)
DSM-III-R (1987)
DSM-IVand
(1994)
in 1952 the first edition of Diagnostic
DSM-IV-TR
(2000)
Statistical Manual: Mental Disorders
(DSM-I).
DSM-5 (2013)
DSM
• DSM contains criteria for the diagnosis of nearly 300
different mental disorders from schizophrenia,
personality disorders and depression to acute medical
conditions such as brain injury. The earlier versions were
used to collect data for the census and hospitals, which is
why it’s called a statistical manual.
• Many mental health professionals use the manual to
determine and communicate a patient’s diagnosis after
an evaluation; hospitals, clinics, and insurance companies
in the US are generally require a DSM diagnosis for all
patients treated. The DSM can be used clinically in this
way, and also to categorize patients using diagnostic
criteria for research purposes. Studies done on specific
disorders often recruit patients whose symptoms match
the criteria listed in the DSM for that disorder.
International
Classification of
Diseases (ICD)
The first international classification edition, known as the International List of
Causes of Death, was adopted by the International Statistical Institute in 1893.
The World Health Organization (WHO) was entrusted with the ICD at its
creation in 1948 and published the 6th version, ICD-6 , which, for the first
time, included a section for mental disorders.
ICD 10 has all diseases, is published by WHO and is worldwide
CD-10 was endorsed in May 1990 by the Forty-third World Health Assembly.
The 11th version, ICD-11, is now being prepared. The development phase will
continue for three years and ICD-11 will be finalized in 2017.
An international survey of psychiatrists in 66 countries comparing use of the
ICD-10 and DSM-IV found the former was more often used for clinical
diagnosis while the latter was more valued for research.[
•
The ICD is produced by a global health agency with a constitutional public
health mission, while the DSM is produced by a single national professional
association.
•
WHO's primary focus for the mental and behavioural disorders classification
is to help countries to reduce the disease burden of mental disorders. ICD's
development is global, multidisciplinary and multilingual;
the primary constituency of the DSM is U.S. psychiatrists.
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The ICD is approved by the World Health Assembly, composed of the health
ministers of all 193 WHO member countries;
the DSM is approved by the assembly of the American Psychiatric
Association,
The ICD is distributed as broadly as possible at a very low cost, with
substantial discounts to low-income countries, and available free on the
Internet;
the DSM generates a very substantial portion of the American Psychiatric
Association's revenue, not only from sales of the book itself, but also from
related products and copyright permissions for books and scientific articles.
Why diagnostic categorisation
• Autism is a disorder that's identified solely by behaviour there's no blood test, DNA screening or secret tattoo that
tells you whether someone is autistic. So in order for a
diagnosis of autism to have any meaning, everyone needs
to agree on just what those behaviours are. It would be
impossible to provide support, distribute funding or
conduct research if we didn’t have a consistent
understanding of what autism looks like.
• The different sets of diagnostic criteria were developed to
provide this common language for identifying and
describing autism. Put simply, they're a checklist of the
behaviours that must be present before someone can
officially be considered autistic.
Independent experts also say that it is hard to see how the world of mental health could function
without diagnosis. "We know that, for many people affected by a mental health problem, receiving a
diagnosis enabled by diagnostic documents like the DSM-5 can be extremely helpful," said Paul Farmer,
chief executive of the mental health charity Mind. "A diagnosis can provide people with appropriate
treatments, and could give the person access to other support and services, including benefits.“
The diagnostic categories are termed "disorders" and yet, despite not being validated by biological criteria
as most medical diseases are, are framed as medical diseases identified by medical diagnoses.
However, there is no evidence that these experiences are best understood as illnesses with biological
causes. On the contrary, there is now overwhelming evidence that people break down as a result of a
complex mix of social and psychological circumstances – bereavement and loss, poverty and
discrimination, trauma and abuse
Since the 1980s, psychologist Paula Caplan has had concerns about psychiatric diagnosis which is
unregulated, so doctors aren’t required to spend much time understanding patients situations or to seek
another doctor’s opinion. The criteria for allocating psychiatric labels are contained in the DSM, which
can "lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is
causing the patient’s suffering". So, according to Caplan, getting a psychiatric diagnosis and label often
hinders recovery.[50]
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Psychiatrist Joel Paris points out that psychiatrists like to diagnose conditions they can treat, and
gives examples of what he sees as prescribing patterns paralleling diagnostic trends, for example
an increase in bipolar diagnosis once lithium came into use. He notes that there was a time when
every patient seemed to have "latent schizophrenia" and another time when everything in
psychiatry seemed to be "masked depression", and he fears that the boundaries of the bipolar
spectrum concept, including in application to children, are similarly expanding
•
Critics claim that the American Psychiatric Association's increasingly voluminous manual will see
millions of people unnecessarily categorised as having psychiatric disorders. For example, shyness
in children, temper tantrums and depression following the death of a loved one could become
medical problems, treatable with drugs. So could internet addiction.
•
Jon Ronson, only half-joked in a recent TED talk: "Is it possible that the psychiatric profession has
a strong desire to label things that are essential human behaviour as a disorder?"
•
"In essence, instead of asking 'What is wrong with you?', we need to ask 'What has happened
to you?'," Johnstone said. "Once we know that, we can draw on psychological evidence to
show how life events and the sense that people make of them have led to the current
difficulties.“
•
Prescriptions of antidepressants increased nearly 30% in England between 2008 and 2011,
the latest available data.
•
A recent article in the online edition of the British Medical Journal suggested "that only one
in seven people actually benefits" from antidepressants and claimed that three-quarters of
the experts who wrote the definitions of mental illness had links to drug companies.
•
the British Psychological Society released a statement claiming that there is no scientific
validity to diagnostic labels such as schizophrenia and bipolar disorder.
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IN THE NEW MANUAL, DSM-5:
■ Disruptive mood dysregulation disorder, or DMDD, for those diagnosed with abnormally severe and
frequent temper tantrums.
■ Binge-eating disorder. For those who eat to excess 12 times in three months.
■ Hoarding disorder, defined as "persistent difficulty discarding or parting with possessions, regardless of
actual value".
■ Oppositional defiant disorder, described by one critic as a condition afflicting children who say "no" to
their parents more than a certain number of times.
OUT OF THE MANUAL
The term "gender identity disorder", for children and adults who strongly believe they were born the
wrong gender, is being replaced with "gender dysphoria" to remove the stigma attached to the word
"disorder". Experts liken the switch to the removal of homosexuality as a disorder in the 1973 edition.
Division of Clinical Psychology Position Statement Final Version
May 2013
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Core Issue 1: Concepts and models
• Interpretation presented as objective fact: Psychiatric diagnosis is often presented as an objective statement of
fact, but is, in essence, a clinical judgement based on observation and interpretation of behaviour and self-report,
and thus subject to variation and bias
•
• Limitations in validity and reliability: As a consequence of the above, numerous critiques testify to the resulting
problems in reliability and validity, and the issues have surfaced once again in the process of developing DSM 5
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• Restrictions in clinical utility and functions: The above limitations diminish the utility of functional diagnoses for
purposes such as determining interventions, developing treatment guidelines, commissioning services, and
carrying out research based on these categories.
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• Biological emphasis: The dominance of a physical disease model minimises psychosocial causal factors in
people’s distress, experience and behaviour while over-emphasising biological interventions such as medication
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• Decontextualisation: Psychiatric diagnosis obscures the links between people’s experiences, distress and
behaviour and their social, cultural, familial and personal historical contexts.
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• Ethnocentric bias: Psychiatric diagnosis is embedded in a Western worldview. As such, there is evidence that it is
discriminatory to a diverse range of groups and neglectful of areas such as ethnicity, sexuality, gender, class,
spirituality and culture
Impact on service users
•
Some service users report that diagnosis is useful in putting a name to their distress and assisting
them in the understanding and management of their difficulties, whereas for others the experience is
of negativity and harm. Some of the key concerns include:
•
• Discrimination: Research has demonstrated discrimination due to negative social attitudes towards
those with a psychiatric diagnosis. This can create and compound social exclusion
•
• Stigmatisation and negative impact on identity: The language of disorder and deficit can negatively
shape a person’s outlook on life, and their identity and self-esteem
•
• Marginalising knowledge from lived experience: Service users often emphasise the primary
significance of practical, material, interpersonal and social aspects of their experiences, which only
constitute subsidiary or ‘trigger’ factors in the current
system of classification
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• Decision-making: Decisions about how to classify a person’s behaviour and experience are often
imposed as an objective fact, rather than shared in a transparent and open manner. For example
service users’ disagreement with their diagnosis can lead to being labelled as lacking insight, without
acknowledgement of the limitations of the current system
•
• Disempowerment: The current classification systems position service users as necessarily
dependent on expert advice and treatment, which may have the effect of discouraging them from
making active choices about their recovery and the best means of achieving it. Many recovery
narratives include a rejection of diagnoses
•
• As noted above, diagnosis can lead to an over-reliance on medication, while underplaying the
impact of its physical and psychological effects
•
in 2007 nearly one person in four (23.0 per cent) in England had at least
one psychiatric disorder and 7.2 per cent had two or more disorders
•
in 2007 5.6 per cent of people aged 16 and over reported having ever
attempted suicide but were not successful
the proportion of women (aged 16-74) reporting suicidal thoughts in the
previous year increased from 4.2 per cent in 2000 to 5.5 per cent in 2007
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people aged over 75 common mental disorders (CMD) were higher in
women than men (12.2 per cent of women compared to 6.3 per cent of
men)
the largest increase in rate of CMD between 1993 and 2007 was observed
in women aged 45-64, among whom the rate rose by about a fifth
the survey demonstrated a strong association between the presence of a
disorder and a low adjusted household income.
Pros & Cons of Diagnosis
PROS
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Can help individual to make sense of what is
happening
Can help the family to anticipate (in cases of
history of disease) occurrence
Diagnosis may bring access to certain
supports within the system - medical,
personal, financial.
Diagnosis process as a safety device for
professionals and community in some cases.
For some patients there can be a safety in
abdicating personal responsibility.
Creates common language . Can make
communication easier between professionals
CONS
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It could be frightening for patient to be
‘labelled’
It could influence patient to "fit in" to
diagnosis and then this becomes a selffulfilling prophecy
It can shape other’s perception of the
individual [label not person]
Diagnosis could be inaccurate/wrong
Diagnosis infers a treatment regime:
- side effects and inflexibility
Stigma of Mental Health devaluing of
individual by society and by him/herself.
Could be used as a form of social control.
Gender, cross-culture, education, social
culture and disability issues
Social /Financial discrimination
…along comes counselling
USA
Counseling developed in the late
1890s and was interdisciplinary
most counseling was in the form of
advice or information.
Most of the pioneers identified
themselves as teachers and social
reformers/advocates. They focused
on teaching children and young
adults about themselves, others,
and the world of work.
The word counseling appeared in
the professional literature in 1931.
A first theory of counseling was
formulated by E. G. Williamson and
his colleagues at the University of
Minnesota.
• UK
The first counselling services to
develop in the UK were offered by
voluntary-sector organisations - the
Marriage Guidance Council (now
known as Relate) brought counselling
services to the UK around the
beginning of the second World War to
support families and help keep
marriages together and this Londonbased initiative spawned a network of
similar initiatives post-war
Evolving out of marriage guidance,
and inspired in part by the ideas of
Rogers
the term “counselling” began to be
used in the 1950s to describe the
work done by trained volunteers who
provided those in distress with
“someone to turn to”
…..and it develops
USA
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school counseling, still known as
guidance in the 1930s, became
more of a national phenomenon.
Furthermore, the government
established the U.S. Employment
Service in the 1930s. And this
agency published the first edition
of
the
Dictionary
of
Occupational Titles (DOT) in
1939.
Carl Rogers in 1942 publishes
Counseling and Psychotherapy,
which challenged the counselorcentered approach of Williamson
as well as major tenets of
Freudian psychoanalysis..
UK
• Over the ensuing decades,
counselling was taken up by
other
voluntary-sector
organisations as a way of
drawing on the capacity of
volunteers to respond to the
needs of people affected by a
wide range of issues including
alcohol
problems,
bereavement, mental health
problems, domestic abuse,
drug
problems,
serious
illnesses, and many others
…and it begins to change
USA
UK
With the advent of World War II, the
U.S. government needed counselors and
psychologists to help select and train
specialists for the military and industry
Rogers ideas were taken up by British
voluntary-sector organisations from the
1950s onwards to endorse the logic of
counselling as a practice in which
counsellors are positioned as their
clients’ peers, rather than as expert
professionals
Rogers’ ideas also provided a robust
rationale for insisting that counselling
training was best served by the practicebased development and refinement of
existing relationship skills, rather than by
the extensive “book learning” or
academic study associated with training
for
professional
occupations.
Consequently, there were no academic
pre-requisites for counselling training,
and adults who had left school without
any qualifications trained alongside
university graduates. Training was
offered free at the point of delivery in
return for a commitment to volunteer
for a few hours each week.
After the war, the U.S. government
further promoted counseling through
counselor training institutes
In addition, the VeteransAdministration
(VA) funded the training of counselors
and psychologists by granting stipends
for students engaged in graduate study.
The VA also “rewrote specifications for
vocational counselors and coined the
term ‘counseling psychologist’”
Counseling psychology, as a profession,
began to move further away from its
historical alliance with vocational
guidance.
USA
1950’s the decade produced at least
five major events that dramatically
changed the history of counseling:
1. The establishment of the
American Personnel and Guidance
Association (APGA);
2. The charting of the American
School Counselor Association
(ASCA);
3. The establishment of Division 17
(Society of Counseling Psychology)
within the American Psychological
Association (APA);
4. The passage of the National
Defense Education Act (NDEA); and
5. The introduction of new
guidance and counseling theories
UK
Thus, in contrast to most
professional-client interactions, in
which clients are assumed to
occupy lowlier positions than those
from whom they seek help, the
origins of counselling are bound up
with a commitment to foster
egalitarian, non-hierarchical
relationships between practitioners
and clients, for which, at least at
the time, professional status was
considered antithetical.
During the 1970s, as more and
more voluntary-sector
organisations began to take up the
idea of counselling, new networks
developed that forged links
amongst those using similar
approaches in different settings.
One expression of this was the
creation of the Standing Council for
the Advancement of Counselling in
1971, which became the British
Association for Counselling (BAC) in
1976,
USA
Professionalism within the APGA
and the continued professional
movement within
• Division 17 of the APA also
increased during the 1960s. In
1961, APGA published a “sound
• code of ethics for counselors”
(Nugent, 1981, p. 28). Also during
the 1960s, Loughary, Stripling,
• and Fitzgerald (1965) edited an
APGA report that summarized
role definitions and training
• standards
• for school counselors. Division
17, which had further clarified
the definition of a counseling
• psychologist at the 1964
Greyston Conference, began in
1969 to publish a professional
• journal, The Counseling
Psychologist, with Gilbert Wrenn
as its first editor.
UK
1971 Foster Report was a first
attempt to turn “psychotherapy”
into regulated profession
1981 a private member’s bill tried
to create a statutory regulation for
counselling and psychotherapy
2007 in the White Paper “Trust
Assurance and Safety” the UK
government proposed that
counselling and psychotherapy be
regulated by the Health professions
Council [HPC] A loud voice within
the profession objected to being
regulated under this particular body
because of the alignment to a
medical model and prevented this.
USA
State Licensure begins in the mid1970s but has only been completed
across the USA in the past 8 years
so that all states now legally
regulate counselors
in 1992 counseling became a
primary
mental health profession, for the
first time in the health care human
This recognition put Counseling on
par with other mental health
specialties such as psychology,
social work, and psychiatry.
By the beginning of the 21st
century, it was estimated that there
were approximately
100,000 counselorsin the United
States
UK
The development of IAPT is another
attempt to regulate the profession
started in 2007 and now well
developed with the support of
BACP. It has been led by NICE
recommendations about effective
ineterventions
2011 the DoH paper Enabling
Excelence: autonomy and
accountability for health workers
evidences a move away from
statutory regulation and a move
towards enhanced voluntary
registers and BACP and other
organisations are now moving
towards the creation of a quality
assured voluntary register (under
the Professional Standards
Authority)
CONCLUSION AND REFLECTIONS
Mental Health has fallen within the remit of medicine for centuries and
doctors diagnose
Counselling is very much a new-comer into this arena and emerges from a
different culture
As society becomes better informed and new models of research gain
credibility, other mental health professions see the grave limitations of
diagnostic categories in the treatment of people
Our clients often clothe themselves with diagnostic labels or they present with
a range of symptoms which are commonly understood to fall into a diagnostic
category
As counsellors we know very little about diagnosis and sometimes there lurks
a danger of dismissing this with a form of inverted snobbery.
It is relevant to know something about “diagnosis” and this may also be
relevant to how we work with our clients and what expectations are
appropriate