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진단과평가
작성자  simonshin 작성일  2016.09.03 00:56 조회수 1340 추천 0
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 신현근 박사 강의안: 진단을 하는 이유  
첨부파일 : f1_20160903005638.pdf
 

과목:  진단과 평가

주제:  Why Diagnose?

내용: 강의안

교재Williams, N. (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Ed.). New York: Guilford Press.

 

1.         Overview

1.1          The important question is, Does the careful, nonabusive application of psychodiagnostic concepts increase a client’s chances of being helped?

1.2          There are at least five interrelated advantages of the diagnostic enterprise when pursued sensitively and with adequate training: (1) its usefulness for treatment planning, (2) its implications for prognosis, (3) its contribution to protecting consumers of mental health services, (4) its value in enabling the therapist to convey empathy, and (5) its role in reducing the probability that certain easily frightened people will flee from treatment.

1.2.1     In addition, there are fringe benefits to the diagnostic process that indirectly facilitate therapy.

2.         Treatment planning

2.1          Treatment planning is the traditional rationale for diagnosis. It assumes a parallel between psychotherapy and medical treatment.

2.2          This parallel sometimes obtains in psychotherapy and sometimes does not.

2.3          Although a number of focused interventions for characterological problems have been developed over the past 15 years, the most common prescription for personality disorders is still long-term psychoanalytic therapy.

2.4          But analytic treatments, including psychoanalysis, are not uniform procedures applied inflexibly regardless of the patient’s personality.

2.5          Efforts by a therapist to be empathic do not guarantee that what a particular client will experience is empathy.

2.6          Advances in the understanding of people with psychotic disorders and borderline conditions have led to treatment approaches that are not “classical analysis” but are rooted in psychodynamic ideas. To use them, one must first recognize one’s client as recurrently struggling with psychotic and borderline states, respectively.

2.7          It is common for research purposes to define therapies as specific technical procedures. Therapists themselves, in contrast, may define what they do as offering opportunities for intimate new emotional learning in which “technique” is secondary to the healing potential of the relationship itself.

2.8          A good diagnostic formulation will inform the therapist’s choices in the crucial areas of style of relatedness, tone of interventions, and topics of initial focus.

3.         Prognostic implications

3.1          The practitioner who expects from a patient with an obsessive character the same rate of progress achievable with a person who suddenly developed an intrusive obsession is risking a painful fall.

3.2          An appreciation of differences in depth and extensivity of personality problems benefits the clinician as well as the patient.

3.3          A main theme in this book is the futility of making a diagnosis based on the manifest problem alone.

3.4          A strength of the psychoanalytic tradition is its appreciation of the differences between a stress-related symptom and a problem inhering in personality.

4.         Consumer protection

4.1          Conscientious diagnostic practices encourage ethical communication between practitioners and their potential clients, a kind of “truth in advertising.”

4.2          On the basis of a careful assessment, one can tell the patient something about what to expect and thereby avoid promising too much or giving glib misdirection.

5.         The communication of empathy

5.1          The term “empathy” has been somewhat diluted by overuse.

5.2          Still, there is no other word that connotes the “feeling with” rather than “feeling for” that constituted the original reason for distinguishingbetween empathy and sympathy (or “compassion,” “pity,” “concern,” and similar terms that imply a degree of defensive distancing from the suffering person).

5.3          “Empathy” is often misused to mean warm, accepting, sympathetic reactions to the client no matter what he or she is conveying emotionally.

5.4          I use the term throughout this book in its literal sense of the capacity to feel emotionally something like what the other person is feeling.

5.5          Affects of people in therapy can be intensely negative, and they induce in others anything but a warm response.

5.5.1     That one should try not to act on the basis of such emotional reactions is obvious even to a completely untrained person.

5.5.2     What is less obvious is that such reactions are of great value. They may becritical to making a diagnosis that allows one to find a way to address a client’s unhappiness that will be received as genuinely tuned in rather than as rote compassion, professionally dispensed regardless of the unique identity of the person in the other chair.

6.         Forestalling flights from treatment

6.1          A related issue involves keeping the skittish patient in treatment.

6.2          Many people seek out professional help and then become frightened that attachment to the therapist represents a grave danger.

6.3          Experienced interviewers may know by the end of an initial meeting whether they are dealing with someone whose character presses for flight.

6.4          It can be reassuring to hypomanic or counterdependent patients for the therapist to note how hard it may be for them to find the courage to stay in therapy.

7.         Fringe benefits

7.1          People are more comfortable when they sense that their interviewer is at ease.

7.2          A therapeutic relationship is likely to get off to a good start if the client feels the clinician’s curiosity, relative lack of anxiety, and conviction that the appropriate treatment can begin once the patient is better understood.

7.3          The diagnostic process also gives both participants something to do before the client feels safe enough to open up spontaneously without the comforting structure of being questioned.

7.4          One source of some therapists’ discomfort with diagnosis may be fear of misdiagnosis.

7.4.1     Fortunately, an initial formulation does not have to be “right” to provide many of the benefits mentioned here.

7.4.2     A diagnostic hypothesis has a way of grounding the interviewer in a focused, low-anxiety activity whether or not it turns out to be supported by later clinical evidence.

7.5          A positive side effect of diagnosis is its role in maintaining the therapist’s self-esteem.

7.5.1     Among the occupational hazards of a therapeutic career are feelings of fraudulence, worries about treatment failures, and burnout.

7.5.2     These processes are greatly accelerated by unrealistic expectations. Practitioner demoralization and emotional withdrawal have far-reaching implications both for affected clinicians and for those who have come to depend on them.

8.         Limits to the utility of diagnosis

8.1          As a person who does predominantly long-term, open-ended therapy, I find that careful assessment is most important at two points:

8.1.1     (1) at the beginning of treatment, for the reasons given above; and

8.1.2     (2) at times of crisis or stalemate, when a rethinking of the kind of dynamics I face may hold the key to effective changes in focus.

8.2          Once I have a good feel for a person, and the work is going well, I stop thinking diagnostically and simply immerse myself in the unique relationship that unfolds between me and the client.

8.2.1     If I find myself preoccupied with issues of diagnosis in an ongoing way, I suspect myself of defending against being fully present with the patient’s pain.

8.2.2     Diagnosis can, like anything else, be used as a defense against anxiety about the unknown.

8.3          When any label obscures more than it illuminates, the practitioner is better off discarding it and relying on common sense and human decency.

8.4          Diagnosis should not be applied beyond its usefulness. Ongoing willingness to reassess one’s initial diagnosis in the light of new information is part of being optimally therapeutic.

8.4.1     People are much more complex than even our most thoughtful categories admit.

8.4.2     Hence, even the most sophisticated personality assessment can become an obstacle to the therapist’s perceiving critical nuances of the patient’s unique material.

9.         Psychoanalytic diagnosis versus descriptive psychiatric diagnosis

9.1          Even more than when I wrote the first edition of this book, psychiatric descriptive diagnosis, the basis of the DSM and ICD systems, has become normative— so much so that the DSM is regularly dubbed the (“ bible” of mental health, and students are trained in it as if it possesses some self-evident epistemic status.

9.2          Although inferential/contextual/dimensional/subjectively attuned diagnosis can coexist with descriptive psychiatric diagnosis (Gabbard, 2005; PDM Task Force, 2006), the kind of assessment described in this book has become more the exception than the rule.

9.2.1     I view this state of affairs with alarm.

9.3          I expect that the overall consequences of our having deferred to a categorical, trait-based taxonomy since 1980 will persist for some time.

 
 
 
 
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