From Hoarding To Foraging for Memories: Moving Beyond the DSM

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OVERVIEW

The American Counseling Association, the worlds largest counseling organization, opposes some revisions to the main diagnostic tool used in mental health. According to Rebecca Daniel-Burke, staff liaison on the ACA DSM task force, “in general, counselors are against pathologizing or ‘medicalizing’ clients with diagnoses as we prefer to view clients from a strength-based approach and avoid the stigma that is often associated with mental health diagnoses.” (Bass, November 28, 2011).

In support of this strength-based approach, an educational session, conducted by Drs Sally Gelardin and Nader Shabahangi, joined by Marilyn Harryman, NCC, DCC,  is scheduled for Sunday, March 25, 8:45 am to 10:15 am.  We challenge the mainstream understanding of aging as decline and/or disease and the focus on diagnoses of illnesses, represented by the DSM Code.  Instead, we focus on a more expansive, humanistic, and creative vision and approach through the use of metaphors.

The three main subjects addressed in this paper are the following:  (a) Define and demystify the DSM code; (b) Examine positive ways counselors can reframe diagnoses through metaphors; (c) Provide a toolbox of life-affirming wellness activities that counselors can use with clients to move beyond medical diagnoses.

Who and/or what defines an individual? Is it simply illness diagnoses?

Individuals over 80 are the fastest growing population.  How do we relate to our elders – note each sign of decay? failing eyesight or hearing? slower pace? each memory slip? every time the phone is left off the hook? In our youth-oriented culture, it is difficult to find anything to look forward to as we age. Once an individual has been diagnosed by the medical profession, is that the whole person, or does that individual have other “evolving” abilities?

Labels are for jars, not people.

Labeling through medical diagnoses continues throughout our lives, but most of us start to notice it more as we pass 50. For example, over 8% of the U.S. population (children and adults) have diabetes. Over 25% of U.S. citizens over 65 have diabetes. Adults with diabetes have heart disease death rates 2 to 4 times as much as those without diabetes, plus develop other serious health challenges.

In some cases,  a diagnosed illness can be reversed – the individual can be “cured”.  In other cases, the diagnosis many remain throughout the rest of one’s life, but the symptoms can be moderated. Sometimes, a person who has been diagnosed with an illness, as well as those with whom the diagnosed individual is in contact,  can lead a fuller, more rewarding life than before becoming aware of the diagnosis.

EXPLORATION AND GOALS

To challenge the mainstream understanding of aging as decline and disease, we ask questions, such as the following: What really gives us joy and celebrates our existence? How can we experience endings as new beginnings, losses as opportunities for new gains? What are the opportunities to create our lives as we age? How do we cultivate what is latent and wants to come to the fore? How do we care for others and for ourselves as we age, taking into consideration and moving beyond medical diagnosis?

Goal 1: Define and Demystify the DSM Code

In the United States, a medical diagnosis is used to explain why an individual’s behavior deviates from the norm.  Individuals are labeled by the diagnosis.  Here are some examples: compulsive hoarder, paraplegic, Aspergers, diabetes, Alzheimers.

In this workshop, we shall rephrase how we view individuals with different abilities.  For example, a compulsive hoarder may become an individual in her later years who forages for memories in creative ways.   The quality of our lives depends upon how we perceive ourselves and how others perceive us.  If we can approach each individual as unique, with his/her own set of strengths and challenges, then we can move beyond labeling to more constructive ways of perceiving others and viewing ourselves.

The expanding number of DSM categories demonstrate an increasing focus on disease by psychiatrists and pharmeceutical companies (Cosgrove, Krimsky, Vijayaraghavan, Schneider).   There is a big war currently going on regarding how many criteria a person needs to be diagnosed as having Asperger syndrome and whether Asperger’s should be consolidated with Autism Spectrum Disorder or Pervaisive Developmental Disorder. Dementia of the Alzheimer’s Type, has eight sub-classifications (http://psychcentral.com/disorders/dsmcodes.htm). There is more to people than diagnoses of illnesses!

Goal 2: Examine Ways We Can Reframe Diagnoses through Metaphors

Norman Amundson, who experienced a heart attack in May, 2011, realized retrospectively that he had not been practicing what he was preaching. He re-read his early writings on metaphors and created metaphor cards to move us beyond the stories that we tell ourselves and the diagnoses with which we have been labeled. “We [counselors] can enrich our speech and practice through the use of metaphors, raise people’s spirits, and point to new futures  (Amundson, 2010). A metaphor is a figure of speech in which two unrelated ideas are used together in such a way that the meaning of one of the ideas is superimposed and lends definition to the other.

One of the most difficult tasks for most older (and many younger)  individuals is to let go of material possessions, downsize, and adjust to a new environment.  When the need to collect gets out of control, leading to a chaotic physical environment  or even taking things that one does not own, the medical profession diagnoses individuals who demonstrate these characteristics as “compulsive hoarders.”  Compulsive hoarding is one of 365 mental disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. Hoarding is the excessive acquisition and inability or unwillingness to discard large quantities of objects that would seemingly qualify as useless or without value..  When Mahatma Gandhi died, he had five things: glasses, bowl, diary, prayer book spoon, and loincloth. The average person had 20 to 30,000 items. Who is hoarding? Shabahangi notes, “We do the diagnosis because we are diagnosing ourselves. We are scared of psychosis because we see that in another that is wrong.  We are scared of being different or wrong. We need to go beyond diagnoses, to see our selves as other than  labels.”

Let’s see how we can incorporate metaphors to help people who hoard live safer, more enjoyable lives. Consider replacing the DSM phrase “compulsive hoarders” with the metaphor “foraging for memories.” We can develop ways to help our clients forage for memories, such as creating aprons with numerous pockets and giving such a client a little metaphoric gift, symbolizing love, from a pocket. Residents can design and wear their own aprons to collect little trinkets.  The give and take is a multi-sensory interaction, so much needed by those who may be in need of human contact (foraging for love).

Goal 3: Provide a Toolbox of Life-affirming Wellness Activities that Can Be Used with Clients To Move beyond Medical Diagnoses


To move beyond the DSM, we focus on wellness. The term “wellness” is used frequently, but do we really know what it means both in our own lives and in the lives of others? Being “well” used to refer merely to the absence of illness. Wellness today refers to a state of well-being, even if we have a diagnosed “illness.”  According to Best-Martini, wellness includes our physical, social, cognitive, emotional and spiritual health.  She notes that everybody can participate in and benefit from a focus on wellness, including young and old, physically and emotionally fit, or physically and emotionally challenged individuals. The “Wellness Tree of Life” (Best-Martini, 2007) is a metaphor that can be transformed into an activity and applied by elderly care providers and individuals in transition.

Another wellness metaphor Best-Martini created is the “Iceberg Model.”  She says, “Illness and health are only the tip of an iceberg. To understand their causes, you must look below the surface.” The Iceberg Model places “State of Health”  at the tip of the iceberg and the most visible. But under the water’s surface are the Lifestyle / Behavioral Level- Cultural / Psychological / Motivational Level and the Spiritual/Being/ Meaning Realm.

To determine our state of health, we need to look at all of these aspects of our lifestyle and decide what needs to be changed, altered or added. There will always be areas that we cannot change, such as a pre-existing genetic disorder, but we can manage our lives in a more balanced way and with more awareness by focusing on wellness. According to Best-Martini, we need to practice what we preach, to be aware of and understand the concepts and consequences of our own lifestyles, and also to role model wellness. Best-Martini, who is an occupational therapist and exercise teacher,  says, “With regular exercise, participants will experience  better circulation, improve sleep patterns which improve coping skills, feel more energetic, feel more positive, have a better appetite and improve digestion and create positive social interactions.”

Initial Questions To Ask

  1. In what areas of wellness (physical, social, cognitive, emotional and spiritual health)  are you strong?
  2. What areas of your life can you improve?
  3. What is one metaphor that can help you improve the quality of your life? For example, “foraging for memories apron” to replace the DSM diagnosis of “compulsive hoarding.”
  4. How might you apply this metaphor to improve one wellness area in your life? Consider the following: (a) your strengths (b) behavior that you want to change, ( c) your goal, (d) action/s you will take to meet your goal.  Keep it simple!

*If you need help in identifying those areas in which you are strong, or which you could improve, here is a toolbox of wellness surveys and life-affirming wellness activities that counselors can use with clients to move beyond medical diagnoses.

SUMMARY

In this post, the authors rephrased how we can view individuals with different abilities.  The DSM code was defined and discussed. The authors examined positive ways counselors can reframe diagnoses through metaphors, such as replacing the compulsive hoarding diagnosis with the metaphor “foraging for memories.” Several wellness surveys and a toolbox of life-affirming wellness activities were provided to help clients to move beyond medical diagnoses. The view that each individual is unique, with his/her own set of strengths and challenges inspires us to move beyond labeling to more constructive ways of perceiving others and viewing ourselves.

Additional Resources

BIOS

Dr. Sally Gelardin’s mission is to bring together people and ideas in creative ways that emphasize mind/body/spirit wellness. She earned a doctorate in International and Multicultural Education, two Masters degrees in education and counseling, and is a Qualified Activity Coordinator, per OBRA Federal Guidelines & California Title 22. Gelardin is author of three books, including Career and Caregiving: Empowering the Shadow Workforce of Family Caregivers. She has conducted over 150 live and recorded interviews with industry experts, over 50 of which are devoted to aging and later life issues. In her current position as media specialist for AgeSong Elder Communities, she spreads the AgeSong philosophy of lifelong learning and aging as growth. Contact:  415.312.4294, sallyg@agesong.com, www.agesong.com, www.agesongtoday.com.

Dr. Nader Robert Shabahangi is a licensed psychotherapist, businessman, author,  publisher, and advocate for marginalized groups of society.  He has led anticipatory bereavements groups for Coming Home Hospice; founded the Pacific Institute to train psychotherapists in a multicultural, humanistic approach to counseling  and to provide affordable therapy services to the many diverse groups in San Francisco; and developed an innovative Gerontological Wellness Program to provide emotional and mental health care services for the elderly. In 1995, he started AgeSong to develop and operate assisted living communities. nader@agesong.com, www.agesong.com and www.pacificinstitute.org.

Marilyn Harryman, M.S., GCDF, DCC, is Counselor Educator/Supervisor, University of LaVerne; former Counseling Services Coordinator and Secondary School Counselor, Oakland Schools; co-author, High School Success Guide – a tool to help students plan and make informed choices; and producer/host of “CCC Live!” “The Counselor Community Connection”, KDOL TV 27. She is a counselor association representative to the Pupil Services Coalition for legislative issues; a Distance Credentialed Counselor; a Global Career Development Facilitator; and a Career Counselor with the  Bay Area Career Center, San Francisco. Contact: Marilynhar@aol.com, www.bayareacareercenter.com.

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