D is for Distal Contextual Affordances (ha ha, just kidding). D is for Diagnosis and DSM 5

Each quarter, as I take new classes and learn new material, I analyze and diagnose myself accordingly. I generally text a friend of mine who is a marriage and family therapist (MFT) during class. Our exchange goes something like this:

Me: OMG, I so have this.
MFT: what?
Me: I wasn’t properly attuned to as a baby. That’s why I’m so fucked up.
MFT: gawd
Me: well, it could be that or it could be that I experienced a trauma as an infant.narcissist chicken
MFT: maybe
Me: I was dropped on my head once.
MFT: well, that explains it.
Me: I know, right?
MFT: it’s just one lens, Pam. A theory.
Me: oh. Sorry for being so narcissistic.
MFT: You’re not a narcissist.
Me: borderline?
MFT: ugh.

And so it goes. Each quarter I learn new and fascinating ways to make sense of human behavior.

A few years ago, when I began working on my memoir, I asked my (by then former) psychologist if I could have access to my records. I wanted to reconstruct a timeline of events and double-check my memories. Since she had seen me through some of my darkest hours I figured I would find a good record of events that I had been too depressed and distraught to remember. And I did. But I also discovered how I had been diagnosed, and I found it all a bit unsettling to see the DSM codes next to the list of my symptoms.

If you read yesterday’s blog, Dear Reader, you know that I was depressed. So it came as no surprise when I decoded the DSM codes to find variations on that theme: major depressive disorder, recurrent episode; major depressive disorder, recurrent episode in partial remission; major depressive disorder, severe. And so on. I was fine with these diagnoses and also with the occasional Adjustment Disorder diagnosis that I found. I knew enough by then to know that when a mental health provider doesn’t know what else to use, when a client just needs to chat a bit to clear things up, they use the somewhat ambiguous 309.9 (Adjustment Disorder, Unspecified).

Diagnosing someone with an illness or disorder that appears in the DSM 5 is an art, not a hard science. This latest version of the Diagnostic and Statistical Manual is arranged quite differently from its predecessors with disorders arranged according to lifespan. So, disorders that affect children come first—neurodevelopmental disorders, followed by illnesses that appear in adolescence and early adulthood: schizophrenia and psychosis, depression, anxiety, OCD. These are followed by trauma related disorders, dissociative disorders, somatic (body disorders), feeding and eating disorders, elimination disorders, sexual dysfunctions, substance abuse issues, personality disorders, and paraphilia.

Gone are Axis I, II, III, IV, and V. Used to be that the most acute and familiar disorders—those requiring immediate attention fell under Axis I: schizophrenia, major depressive disorder, panic attacks; ongoing personality issues—narcissism, borderline personality disorder, intellectual disabilities, obsessive/compulsive disorder—fell under Axis II. Axis III was reserved for related medical conditions such as terminal cancer, which might contribute to a client’s depression. Axis IV diagnoses included life events: marriage, job loss, promotions, divorce, death of a parent or child, and Axis V is used for the Global Assessment of Functioning Scale, a 100 point questionnaire evaluating the client’s ability to function in daily life.

What we CMHC (clinical mental health counseling) students all learn early on in our clinical program is that diagnosis is a necessary evil if a mental health care provider wants to take insurance. Insurance companies will not pay if we don’t attach a diagnosis to our clients. At the same time we learn that our clients are much more than walking bundles of diagnoses.

The bottom line is that when a person presents in my office and tells me what’s going on in their life, how they are coping day-to-day, and want to pay for their sessions with insurance, I have to give them a diagnosis. One counselor I’ve talked to diagnoses everyone with PTSD. After all, she says, we have all had trauma in our lives. Others consult the DSM and match the client’s presentation with the best diagnosis.

Failure to attend to details? Difficulty sustaining attention with tasks? Often lose things? Easily distracted? Often forgetful? ADHD 314.

Heart palpitations? Sweating? Trembling and/or shaking? Shortness of breath? Nausea? Choking feelings? Fear of losing control? Fear of dying? Panic Disorder 300.01

Marked distress? Significant impairment in social, occupational or other areas but doesn’t meet the criteria for another mental disorder? Adjustment Disorder 309

When I left the psychologist and started seeing the counselor, I stopped feeling like a hopelessly troubled person and more like a person with some troubles that could be resolved. Instead of being treated for my “mental illness,” I was treated like a person and we looked together at why I might be feeling depressed or anxious or sad or worried. I began to see that my inability to come off my meds for depression had more to do with the fact that in my case, I had been treating the symptoms, but not the root of the issue.

Over time, I came to understand that my behaviors, moods, and thought patterns had more to do with how I had learned, over the course of the last few decades, to deal with the world. Starting in infancy we all learn how to get our needs met. Some of us learn to trust that we will be taken care of, that our needs are important, that our voices are valued. Others not so much.

There are many lenses through which to evaluate human behavior: family systems, attachment theory, behaviorism, post-modernism, Jungian. There are many schools of thought on how to best help people: cognitive behavior therapy, exposure therapy, psychoanalysis, narrative therapy, play therapy, art therapy, drama therapy.

There are a multitude of diagnoses I could apply to my future clients, but my clients deserve more than a label and to be compared against a checklist of criteria.

I must to remember Carl Rogers and not ask, ”How can I treat, or cure, or change this person?” But instead,“How can I provide a relationship which this person may use for [her] own personal growth?”

Lesbian Shame, Attachment Theory, and Identity Integration. (Or, I am so f*ing tired of this sh*t)

peanuts attachment
I love that Peppermint Patty is the securely attached one in this graphic

I’m currently working on a group project for my Counseling Sexual Minorities class. We are looking at Attachment Theory as it applies to LGBTQ people and the clinical implications for counseling this population. For my part, and to help the cause along, I decided to take a look at the relationship between attachment styles (secure, fearful/avoidant, dismissive, and preoccupied), identity integration and lesbian shame.

Attachment theory suggests that how well our primary caregivers met our needs as infants and children determines how we relate in relationships later in life. (For a more complete discussion, check out this site).

cass_2
Cass Identity Integration Model

The Cass Identity Model is one of the primary ways of evaluating how well gays and lesbians have integrated their sexual orientation into their lives. It has six stages, beginning with Identity Confusion (am I a lesbian?) and ending with Identity Synthesis (I am a lesbian and I am out in all areas of my life). (For a more complete discussion on the Cass Model, click here).

The Internalized Shame Scale is an assessment tool used to rate individual’s levels of internalized shame.

Turns out there is a correlation between a lesbian’s attachment style and the amount of shame she experiences. The two studies I looked at gathered data on about 500 lesbians and discovered that those lesbians with a secure attachment style had lower levels of shame (as measured on the Internalized Shame Scale) than those lesbians with other attachment styles (fearful, dismissive, and preoccupied).

The first study (published in 2003) looked at 380 women who self-identified as lesbians and as a level 4, 5, or 6 on the Cass Identity Integration Model. The results aren’t really that surprising. What’s surprising is that overall, lesbians scored 49.8 on the shame scale where 50 is a clinically significant result (i.e. pathological). As a comparison, heterosexual women average a score of 33.

attachment cartoonIt’s important to note that most infants and children who escape childhood with a secure attachment style tend to remain securely attached in other relationships as their lives go on. Not so with LGBTQ children. Even those who begin life securely attached run a high risk of shifting attachment styles later in life due to particularly severe breaks in important relationships: rejection by their family when they come out, for example. Rejection by peers, teachers, clergy, friends.

One paper I read for my presentation reported that 43% of LGBTQ youth experience some form of physical violence. In addition, a significant number get kicked out of their homes when they come out to their families. LGBTQ people are barraged daily with messages that it’s not okay to be LGBTQ. I just have to open my laptop and scan the headlines on any given morning to read that politicians want to strip me of my rights, that “christians” want to round us up and put us in camps, that self-appointed guardians of morality want to outlaw me, and that people like me are threatened with death just for being who we are.

Sure, we’re gaining rights, but we also face a backlash from those who believe we are less than human, less than deserving of equal rights. The Kim Davis’s, Antonin Scailias, Michelle Bachmans, Ann Coulters, Ted Cruzs, Marco Rubios of this world. We have the right to marry, for now. But how long will that last? Will a change in our country’s administration threaten my rights again? Will I ever be able to relax or must I remain vigilant?

The second study, published a year later looked at 100 lesbians who scored a 6 on the Cass scale and who had also spent at least three years in therapy. What this study showed was that these lesbians scored 43 on the shame scale and 58% were securely attached, compared to 49% in the previous study.

What are the clinical implications of reduced lesbian shame, more secure attachment styles, and higher rates of identity integration? Therapy may work to repair attachment by providing a new secure base, resulting in reduced internalized shame. This is good news.

Why am I interested? Funny you should ask. One of the amazing (and awful) aspects of this graduate program I am in, is that I am constantly analyzing myself, challenging my assumptions about myself and monitoring the way I am in the world. I can’t think of a single class I’ve taken that didn’t shove me right up into the shit, from the initial Family of Origin Issues class, where we looked at intergenerational patterns and all the ways we have unfinished business with the people in our lives to Human Development: Gender in which my mind was blown regarding the social constructs of gender roles and the false dichotomy of binary genders (i.e. boy/girl, male/female).

Every class has taught me something about myself: Ethics, Psychopathology, Psychodiagnostics, Group Therapy, and so it has been with this class, Counseling Sexual Minorities. I signed up for the class with a level of excitement and anticipation I’d not had for other classes because we were finally in my wheelhouse. I thought I knew a thing or two about this topic, at least from the client side of the couch. I wasn’t prepared.

In general, the class has been less than stellar, but even still, I wasn’t prepared for how digging into all the ways in which LGBTQ folks are discriminated against would impact me. I figured that I’ve been out of the closet for the past 40 years and had dealt with my internalized homophobia and had come to terms with my sexual orientation, but what I have realized so far this quarter is just how exhausted I am, how much I shut out on a daily basis in order to protect myself, and that there’s a simmering rage just below the surface that is eating away at me.

The other day I ran across a story on some county clerk in Texas who likened her fight against same sex marriage to the fight against Nazi Germany. Really? And the rhetoric amongst the GOP candidates who want to roll back what few legal protections LGBTQ folks have terrifies me. One candidate whose name shall not grace this blog has stated he would nominate Supreme Court justices who would repeal same sex marriage.

And that’s the thing that just kills me a little inside all the time—other people think they have a right to determine what is best for me simply based on whom I love. Everyone has an opinion and sometimes even a vote about what rights I should have. Just this morning there’s a story on the front page of my local paper about a debate in Charlotte, NC on LGBT protections. A debate. About my rights as a human.

As I grew up, instinctively knowing that there was something different about me, I tried hard to keep that difference under wraps, to not let my true self out for fear of rejection. But eventually the need to be true to myself overruled cultural mandates to fit in. Being authentic, regardless of sexual orientation, can be challenging for many of us, but I would posit that most people don’t spend most of their time with this level of anxiety.

As I came out over the years (coming out happens over and over and over again, by the way, not just once), comingout_rainbow doorrelationships fell away. Some repaired, others did not. I remember writing to a friend from my high school days when I adopted my oldest daughter. My friend wrote back that I was an abomination, that my daughter deserved better, that I was going to hell.

Eventually, I learned to be more discriminating, oftentimes pushing people away and shutting others out who may not have rejected me. Better to protect my heart than to have it shattered over and over again. Even now when I know better, when I am pretty certain that the folks around me are open and accepting, I still armor myself against betrayal, though occasionally I let down my guard and show up as completely out, completely me, defenseless, and vulnerable because I feel safe, because the environment seems to exude acceptance and warrant trust. Sometimes I’m right. Sometimes I am very wrong.

I am tired. I want to lay down my shame. I want to live in a world where I am not afraid, where no one cares who I sleep with, where no one is threatened by my relationships, where no one wants to strip me of my dignity, humanity, my rights. I want to live in a world where no one gets to vote on my right to marry, work, buy a house, use a restroom, adopt children. I want to live in a world where who I am is not up for debate.