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
Change Inc.
227 Colfax Avenue North
Suite 130
Minneapolis, MN 55405
E-mail: j3nelson@comcast.net
Cell: 612-759-8789
Office: 612-259-7384
Fax: 612-259-7185
Web: www.thechangeinc.org
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About James Nelson
James Nelson, Ph.D., LMFT, is co-president of Change Inc. — a community-based non-profit in Minneapolis, Minnesota, focusing on developing "relationships and occasions for the inevitability of change." Nelson's therapeutic attention has spanned forty years with adjudicated adolescents and their families as well as training graduate students and supervising post-graduate practitioners working towards licensure. He and his colleagues have developed a model for providing school-based relational climate assessment, intensive interventions for students at high-risk of school failure and staff development designed to remove barriers students face to school success. Nelson has been the primary developer of the Relational Diagnostic Assessment (RDA) and related Problem-Solving Solution-Focused (PSSF) treatment planning process utilized at several school-based mental health sites in the Twin Cities.
Just to be clear, “Yet we all practice in the mental health market place…” means, more plainly, “We have to put a DSM/ICD code on the insurance form, or else we don’t get paid,” isn’t that right?
Every provider of mental health services contributes to the market place and helps to make it exactly what it is. Rather than resigning ourselves to conditions contrary to the welfare of our clients, we all have to be looking constantly for any means by which we can change things.
Thank you for your work.
I think you’re spot on. We’re hoping to demonstrate a “means by which we can change things” by focusing on relational patterns related to a person’s sense of what they’d like to change as the primary emphasis not moving simply to a DSM dx. There’s, of course, a danger in messing with the monster in the first place.
A few questions for Dr Nelson, please:
(1) Working in a school context, you have a somewhat “captive” audience. To what extent do you believe that the therapist training you provide can be extrapolated usefully to other settings where client participation is less subject to external coercion?
(2) Can you demonstrate that the outcomes of your training are observable in higher student graduation and adult employment rates than seen in student peers who are not mentored/guided in the same environments?
(3) Are prescription rates for ADHD medication different in the populations treated by your professional advocates, than in student populations overall, for the environments where your people practice?
(4) Are the professionals whom you train also educated in recognizing life conditions for which therapy and counseling are not effective as management tools — e.g., where behavior or cognition is sufficiently bizarre that the client is at risk of doing violence to themselves or others?
I look forward to your further thoughts on the measurement of quantifiable outcomes in the educational program you propose.
Sincerely,
Richard, Appreciate your questions. Here are some brief responses:
(1) We are a community-based agency providing a continuum of school based services from prevention, early intervention, to formal mental health services. Students may be referred or simply walk-in. We’re not a court ordered day treatment program. So, no “coerced” here. Our intention is to create access for young people and their families.
(2) We would love to have more resources to focus on a host of outcomes. Unfortunately, covering our costs has never happened and we understand the mission part of our work. That said, we do focus on (a) the student’s perspective on improvement in either managing or solving their presenting challenge, (b) improved attendance (can’t graduate, if you’re not there), (c) improved academics (credits earned/gpa), (d) reduction in behavioral referrals. Is that sufficient? Depends on who’s asking. We also are using a single-system design to close-in pay attention to a host of variables. We’d love to have the resources to do more in this area.
(3) Our experiences, in inner-city settings, is that while many students may have the label “ADHD” given to them in elementary school by a well-meaning teacher requesting that a well-meaning parent ask their well-meaning primary doctor to diagnose and treat (through meds) suspected ADHD – nearly exclusively of boys – so that their classroom behaviors are more manageable…..most do not comply to a medication or imagine that it is, simply, an alternative to other “drugs.”….many parents with whom we’ve have worked find ADHD to be a school-problem, not a home-problem. ADHD medication unfortunately and often is about fostering compliance but introduces an external locus of control and what gets missed is working, also, on an internal locus of influence. We may have an out-of-control ADHD diagnoses with an over reliance on chemicals.
(4) Our folks are trained…we are VERY careful about consultation and supervision. While the limits of healing and therapy are not yet known, we hope to be measured and cautious with the charge and importance of our work with the lives of young people.
Of course, this venue doesn’t allow a full dialogue…I hope I’ve not made assumptions about your questions in my limited responses.
Dr. Lawhem,
From my experience using the RDA at Change Inc. I believe the short answer to your first question is “Very extrapolable.” This is because the RDA is based on 1) the common factors of therapy (i.e., regardless of treatment model), 2) identifying patterns (which all treatment systems do), which 3) raises awareness of self/other (which some define as empathy or spirituality…perhaps the greatest level of development). As Dr. Nelson alluded to, these three aims are facilitated by relational competence, which includes entering into a true dialogue with clients, meaning both the therapist and client expect to walk away from the interaction changed in some (hopefully positive) way (definition borrowed from Thich Nhat Hanh’s book The Miracle of Mindfulness).
Also based on my professional experience providing school-based mental health services, by focusing first on building relationships and providing treatment second, students who do not want to meet with us simply do not have meet with us; students are not coerced into meeting with a therapist (unless you consider highly recommending or encouraging a student to talk to someone coercion).
But if you want to consider external coercion, consider nearly every human social system ever developed and you’ll find that most all employ coercion in order to teach their members how to think and act in ways that those in power deem “best” (e.g., best practices). If anything, by developing, employing, and blogging about the RDA’s use in the public schools, Dr. Nelson is (in my opinion) attempting to ameliorate our societal predilection toward coercion, at least in the mental health field, in order to teach youth (and practitioners) that they have a wider range of thought/feeling/behavioral options than they’ve been led (coerced) into believing.