The Relational Diagnostic Assessment: A Peek At An Alternative
Working primarily with inner-city adolescents and their families since the mid-1970s, my colleagues and I at Change Inc. have developed a “common factors” approach to diagnosis and treatment that draws on the foundational theories reflective of relational, contextual and systemic mental health approaches. Our work emphasizes increasing the therapist’s awareness of the therapeutic relationship and encouraging curiosity of the client’s contexts. In turn, the therapist’s awareness and curiosity invokes the awareness and curiosity of the client, helping the pair of them to identify relational patterns that then become the focus of therapeutic interventions for influencing change.
The Relational Diagnostic Assessment (RDA) and treatment planning process that we have developed is a practice-based contribution to the “diagnostic dilemmas and potential alternatives” discussion around the DSM-5.
The RDA depends upon the relational competence of the therapist, particularly their awareness and ability to be curious about a client’s social/cultural, interpersonal and intrapersonal domains. Embedded in the RDA is a Problem-Solving Solution-Focused (PSSF) process and set of questions to facilitate identification of relational patterns across ecological environments (micro, meso, macro ecologies). Because much of our work has been with urban adolescents and their families, the PSSF naturally developed from, and effectively addresses, such developmental tasks as decision-making and problem-solving.
Change Inc. is currently involved in providing student support and mental health services in the school setting in Minneapolis, Minnesota. One goal of this work is to contribute to a strong work force of effective therapists in the Twin Cities. We are utilizing licensed mental health professionals to mentor, train and supervise mental health practitioners (graduate students in the fields of Marriage and Family Therapy, Clinical Psychology and Professional Clinical Counseling as well as post graduate clinicians working towards licensure). While most mental health practitioners and professionals bring their “preferred” school of therapy with them, we intend to build on that base with an expanded focus on the vast array of relational patterns and the theoretical skills available for application in a therapeutic process. Our training task focuses on helping therapists to work relationally, as a caring adult in the life of a young person, in order to help them in the challenging transition from adolescence to young adulthood, particularly given the challenges of poverty and racism.
It’s important to note here that symptoms exhibited by adolescents, while sometimes indicating the possibility of satisfying diagnostic criteria, may simply be indicative of “typical” adolescent development. In addition to developmental issues, we have found that past and current iterations of the DSM pose significant cultural biases as well as run the risk of ignoring significant social contexts.
Yet, we all practice in the mental health market place. Thus, we are focused on creating a process that moves from awareness of contextualized relational patterns to the question of a formal DSM diagnosis. Rather than attempting to begin with a DSM diagnosis focused on DSM criteria, we privilege the relationship and the client’s identified presenting challenges as sustained by relational patterns; if appropriate, we move to hypothesizing a formal diagnosis. We believe that by focusing on relationships and relational patterns at the outset, therapists are less likely to diagnose an adolescent with an unnecessary mental health disorder, while providing important relational support for an adolescent and their family.
Needless to say, this is formative work as we create and update our training, processes and forms (e.g. RDA-informed diagnostic assessment, treatment plan, case notes) to facilitate a change in focus from a DSM-driven diagnostic and treatment planning process to a relationally and culturally attuned process that privileges client perceptions and contexts.
James Nelson, Ph.D., LMFT
227 Colfax Avenue North
Minneapolis, MN 55405