A Return to the Relationship: Counseling Beyond Symptoms

Hello, and welcome to the second episode of the Theory of Change podcast, a podcast for counselors. On today's episode, we sit down with Dr. James Hansen. Dr. Hansen is a professor of counseling at Oakland University. His scholarship focuses on philosophical and theoretical issues in counseling and critical analysis of contemporary mental health culture. Without any further hesitation, I'd like to welcome Dr. James Hansen. Alright, welcome to this episode of the Theory of Change podcast. With us today, we're sitting down with Dr. James Hansen. Welcome Dr. Hansen. Thank you. I'm happy to be here. Before we get started, can we just take a minute to introduce the listeners to you and what your area of scholarship is? Yes, I'm a professor at Oakland University, which is about an hour north of Detroit, Michigan. And my interests in scholarship are philosophical and theoretical concepts in counseling. So I'm interested in what I've called mental health culture, and I have a strong interest in humanism. Excellent. I really like that you started the introduction with talking about humanism, because I think humanism is one of the most identifiable characteristics of your work. If we could take a minute to maybe provide a definition of humanism and what got you interested in that philosophy? Yeah, but I could give you a kind of a long explanation for that one, but that sounds good. Do you want the long answer? Yeah, sure. I was trained in graduate school in psychoanalysis. And it might as well have been a psychoanalytic institute where I went to graduate school. I really had extremely limited exposure to any of other kinds of ways of thinking about people. And then I got a job at Oakland University, and humanism was the predominant orientation. And once I got there, I became very interested in humanism, and I took it from there. In terms of a definition, my favorite way of characterizing humanism is probably the way Larry Davidson does it. The central value of it being irreducibility, meaning that human experience cannot be reduced to baser elements. So, you know, experiences, for example, like love, envy, greed, aesthetic awe, can't be reduced to neurotransmitters or social processes. They have to be taken in and of themselves. And I think this value animates humanism throughout the centuries, including the psychological humanism that emerged in the mid-20th century. I think that's a good way to put it, too, because oftentimes when we talk with our clients, we deal in those types of dynamics. We often don't deal with things that are measurable or, in fact, some things that may be unique onto this client. So, for instance, if somebody is describing the situation where they're in love or a situation where they're in distress, but there are certain aspects of that that's uniquely onto them and unlike any other measurements of that same principle ever taken. Yeah, I completely agree with that, but that's a very humanistic take what you just said on the counseling process. The trend these days is toward reduction, primarily toward reduction to symptoms, so clients are increasingly characterized according to their symptom constellations. But humanism prefers to think of clients as irreducible, and their experiences are the important thing. Yeah, and I think that's an interesting problem that we're often confronted with when we're relating to other people. I think something that comes to my mind while we sit here and talk about this is not that long ago. I was able to see a full solar eclipse, and in that moment, I had just a whole number of unique experiences, but then after that, I did my best to describe to other people exactly what it was like. It was very challenging to convey just that moment and how I was experiencing it, but we can only just get a little bit close. And the only way that I could do it is by comparing it to other things that way, someone else to sort of understand what it was like to sit there and watch the moon fully overtake the sun. And I think the same thing happens when we sit down with our counselors that are somebody sitting there talking about the distress or the amount of issues that they're having that bring them to the counseling office or wherever they're getting services, and that there's sort of this inevitable problem that we need to reduce their experiences in order for counselors to fully understand it. Yes, I think that's a very good example. You had the experience of the eclipse, and that experience could be described in terms of your neuroanatomy, or it could be described in terms of atoms, or it could be described in terms of sociological phenomena about how you were raised in a culture that was taught to appreciate that. But all that from the humanist point of view would miss the point because it would reduce the experience to something else. There's something important about keeping the experience pristine from the humanist point of view. I think the value of what we're talking about today has a lot to do with the ways that counselors come to understand their clients, especially when you're meeting somebody for the first time and you sort of want to understand what brought you here. Typically, what people tend to offer counselors are narratives or other ways of explaining the issues that they're experiencing, and so I think this is where humanism and the act of irreducibility comes in, is by being able to take that person's experience as exactly that their experience. I agree. And trying to show that you appreciate their experience, and that you get their experience. And I think you can never, of course, exactly experience what someone else is, experiences. But people greatly appreciate you trying to get there. Absolutely. That's relationship forming, that's bonding, and we know that the relationship is the factor that's most strongly associated with counseling outcomes. So humanism has a lot of great insights that many of which have been lost in contemporary mental health counsel. And I think it's interesting the ways that you talk about humanistic insight being lost. I think one of the things that has me most interested in your work is the idea of the message and malady dichotomy when it comes to understanding client issues. Could we take a moment just to introduce listeners to this principle and ways that that could actually benefit the conversation of furthering humanism in today's society? Yes. Yes, I'd be happy to talk about that. I recently wrote a paper, that's what you're referring to. Absolutely. A message versus malady in counseling. And just to tell you about the evolution of my thinking in terms of that paper, I start off with the idea that counseling, what unifies it really, is suffering, and our attempts to alleviate it. About people suffering, there would have been no counseling, and counseling is an arrangement where a sufferer sees someone who holds out the promise to alleviate the suffering somewhat through talk. That basically describes for me the counseling situation. So then it becomes real important to understand how have we thought about suffering over the years. This is not an issue that's discussed much in the social science literature, but of course different theories have ideas about how suffering is conceptualized. Psychoanalysis, suffering is due to unconscious conflict, cognitive behavior therapy, suffering is due to your wrong ideas about the world, et cetera. But I was kind of curious to see if there were any meta ideas about suffering that caught across theories. And that's what the paper was about. And I think I've identified too, and I call them meaning versus malady. And to tell you a little bit about that, there's these two ways that caught across many theories to consider suffering. One is that, and I've called this meaning, that suffering is trying to send a message. That there's a message behind the suffering. And that means that the goal of the counselor, or talk therapist, is to detect the message, to hear it. There's another idea about suffering, and that's that suffering is a sickness, what I call and if you consider the ability to do it, you can see that the ability to do it is a very important thing. or suffering that way, it's just sickness. The goal is just to get rid of it. And these ideas hear the message versus get rid of it have been present since Freud began the profession in the late 1800s. There's even different ones present in Freudian theories, message and melody are both present in there. So to give you an example, let's say someone's experiencing sadness and in crying spells, and they no longer wish to engage in the pleasurable activities they used to enjoy. One way to conceptualize that person is there's something wrong, something off, ill, sick, how deficient, and to get the person out of that state through therapeutic means, maybe CBT or something like that, CBT which is very much a malady theory. So this version of the depression is malady that I've just described. However, there's another version that the depression is trying to tell you something, that the person suffering is sending a message and what kind of message could this be? Well, something internal, like the person is really angry underneath it all. And the depression serves as a way to protect the person from experiencing it, right? And the depression is just a message about the anger. Another one could be the person is, say, unhappy in their work, and not quite realizing it, and the depression is a message about that. So if you just got rid of the depression and those circumstances treated as a malady, the person might just have the same job that they're, you know, didn't quite realize they were unhappy in, and the person might just be CBTing themselves, telling themselves they're really happy and going through this existence, where if you hear the message, that holds out promise that, you know, maybe the person could wrestle with the fact that they didn't like their job or that they're really angry underneath it all. So these message versus malady, as I've called them, perspectives have switched on and off throughout the history of the profession over the last century and even within certain theories. And there's not one that's superior to the other. Sometimes pain is just pain and you want to help the person get rid of it. Other times pain is trying to tell you something, and that's an inside that's really been lost in contemporary mental health culture. I do think it's an interesting point to connect it to culture, because I think we see suffering in terms of the way that we've defined it here, change culturally depending on what era and what part of the world we're in. I mean, I do think about even Sardartha, who sort of takes suffering as being a constant and saying, as long as we accept the fact that we will encounter suffering, when we encounter suffering, it won't really have this nuance to it that it needs to get taken away or that we need to get rid of it, that we need to sort of face it head on as a fact of life. And I see a lot of ways that what we're talking about too has sort of translated into contemporary mental health culture. It reminds me even of Gabor Matei, who talks about people who suffer with addictions, and his main question is, instead of asking why the addiction asks why the pain. And I think that there's something about that idea that seems to be a little bit hidden in mental health culture today, and that our primary focus is to quickly identify what's bothering this person and help them get rid of it, or else we're not really doing our job as counselors. I agree, that is the attitude today. And it reflects a wider cultural attitude about suffering. If you're suffering something's wrong and you need to stop suffering, is sort of the wider cultural attitude, which has made its appearance in mental health thinking too. So even now that bereavement is pathologized, if you're suffering after someone dies, you can have a mental health disorder. And everything in the DSM is a form of suffering, and the general strategy is if you have it, you should get rid of it. There's not the insight anymore that maybe your suffering has meaning and should be opened up instead of shut down. And that's not the insight in the wider culture either. I mean in the '70s and '80s even, if you were suffering or struggling with something, there was a common sense cultural notion that that might lead to a greater conclusion about your life and the way you live it. That's not really the case now. Suffering is seen as something's wrong with you, and it needs to stop. And again, there's room for both perspectives, but if you look across the history of mental health, they swing pretty wildly from one to the other, and when one is dominant, the other is really suppressed. And since really 1980 with the introduction of the DSM-3, we've been living in a malady culture. And I think that's a good thing to point to is the historical progress that we've taken as a profession, because I think about the people that are being trained today and the way that they might go on to train counselors in the future. And the historical passage of these ideas is something very significant in terms of how counselors conceive their job in terms of even diagnosing clients and treating clients. That's absolutely true. We operate in a professional culture, what I've called mental health culture, with its own values, morals, rituals, traditions that were taught, and we as participants in that culture are indoctrinated to believe it. But it is just a culture, and we have an ethical obligation, I think, to critically examine what our culture is telling us to do and whether it's good for our clients. Because there's been many errors throughout mental health, where you did not want, in retrospect, to do what the culture told you to do. And have we escaped that? Are we beyond history? No. We're still in that history. And there'll be many things today that we look back in 2034 years and say, how could we have ever done that? How could we have ever thought that way? And it's good to critically think about those things ahead of time, what they might be. And, you know, one of my candidates is the idea that everybody who suffers is sick and suffering is always bad. Yeah, and I think we even look back at things historically today and still have that thought of, like, how could I have thought that this was true? Even when we look back at, like, how we used to think that the sun revolved around the earth. And it seemed at the time to be the best case because standing from Earth, you could totally witness the sun going around. And there's nothing to tell us otherwise until we learn more and change their minds. So I think one of the things that I want to get to and not really move over too quickly is the process of indoctrination. What are some of the characteristics of today's mental health culture that you think allows the discrepancy between these two ideas to go unknow this largely? Well, culture in some ways is like gravity or air. It's all around you influencing everything you do, but it's completely invisible. So, you know, to reframe what you're saying, what are those invisible factors that are indoctrinating us? Absolutely. And one of the biggest, I think, or some of the biggest, are the DSM and are drive toward, especially in counseling and professional advancement. And professional advancement means being more esteemed in this culture and the culture is very biological and symptom based. But that's actually the opposite of what we should be doing as counselors to help our clients. So there's this disconnect and in fact, this negative correlation between what we have to do to help our clients and what we have to do to advance the profession in the public eye. To advance the profession in the public eye, we have to become increasingly technical, show that we're more knowledgeable, we have to, you know, wear white lab coats or something and then, you know, be more like medicine and the closer we get and talk about neuroscience and, you know, the closer we get to sounding like medical doctors, the more respected we become in the culture because that's a cultural value. But the closer we get to that, the further away we get from the deeply relational type of profession we should have. So that's sort of my beginning take on your question. Yeah, and I think the next part that I would think would be best to explore is the idea of symptom based understandings of clients. So we brought up the idea of the DSM being one of the central pieces of the counseling profession. In your perspective, what are some of the limitations to the DSM and maybe what are some pieces of guidance we might offer counselors who are seeking to more responsibly make use of this tool? Yes, I think the only way to responsibly make use of it is to get paid. I think it's completely useless for counselors and other talk therapists. So I take a pretty firm position on this and I think it might be helpful if I was to discuss the history of the DSM and how it contributes to the mental health culture to make my statement clearer. Is that okay? Yeah, absolutely. Okay, so I mean the DSM has been around since the mid century and it was never really taken seriously by a psychiatrist or anyone else in my 12 until 1980 and in order to understand why you have to really understand what the profession of psychiatry was experiencing in the 70s that led up to the 1980 DSM 3 and in the 1970s the psychiatric profession was in a crisis and they were in a crisis for several reasons. One, there was a strong anti-sekiatry movement. It started by people like Thomas Zaz in the early 60s that he gained a lot of momentum and resulted in artistic expressions like one through over the cook business. They were trade psychiatrists as just barbaric sadistic jailers and so that was obviously very bad for the PR of psychiatry. Also the homosexuality vote in 1973 while you know we remember that is a great you know event that it was stricken from the DSM. At the time people thought well wait a second how can you just vote on diagnoses? You can't vote on diabetes it's there whether we vote on it or not right? How is it that you have a diagnostic system where you can vote stuff in and out that doesn't make any sense and you know so that was bad for the PR. Another was the Rosenhand study where Rosenhand and his graduate students faked mental health conditions to get into a psychiatric hospital to get in psychiatric hospitals and then acted completely normally and none were detected as fakers. So all that was horrible PR for the psychiatric profession in the 1970s and added to that organized psychiatry was split between old school psychoanalysts and new style biological psychiatrists so they couldn't get on the same page about anything much less these kind of massive problems that were having. So the solution that was eventually decided upon was to reinvigorate the old DSM that no one paid attention to and that would hopefully stand as a symbol that the psychiatric profession was an honorable medical profession not just a bunch of people making it up as they went along. So in essence the DSM might be the instrument in which the profession of psychiatry has been validated amongst other critics. Well that's what they were hoping for and to some extent it worked and they appointed Robert Spitzer with that task to develop the DSM and Spitzer had to decide one of his first things to decide was what should be the grounding ideology of this new symptom guide right what the DSM it was psychoanalysis the earlier days and that certainly wouldn't appeal to everyone and it wasn't a success at all and that now that there were many schools of thought in the 70s you know you had to have one that cut across all of them and what he did his choice was very faithful and it determined mental health culture from that point on he selected what is called descriptive psychiatry as the basis of the DSM. Descriptive psychiatry was a movement started in the late 1800s by Emil Krapelen a German psychiatrist who essentially said that you know at this time we don't know why the asylum residents behave as they do we don't know what their conditions are we have no idea how to treat them he said you know let's face this time in history honestly all we can do is describe people according to their symptoms so let's just talk about symptoms let's talk about people is having different clusters of them and then we can follow these clusters see which ones tend to group together and look at the course of these symptom clusters at least that way we'd all be talking about the same thing now Krapelenian descriptive psychiatry was essentially eclipsed by psychoanalysis which took off at the same time but there was a group that hung on to this vision and spitzer happened to be affiliated with the group and he decided to adopt this nearly hundred-year-old ideology as the backbone of the DSM so the DSM just became a list of symptoms and his early thinking was that in this way anyone no matter what their theoretical orientation can talk about patients because you know everyone can presumably agree on symptoms and this symptom-based guide was introduced in 1980 and it took off like a rocket and it took off so much because it's so radically favored biological psychiatry which was rapidly ascending because biological psychiatrists have chemical compounds to reduce symptoms and so that was something that was almost designed for them and managed care companies were just giddy with the light that they now had a way of denying payment if the symptoms were gone or reduced they no longer had to pay whereas before that you know the psychoanalysts they would describe their patients in such abstract ways the insurance companies couldn't figure out ways to die of payment but now they had something concrete so what happened is that we came into a symptom-based culture and psychology counseling and social work as they've done for years followed the money and prestige of psychiatry and started talking this way themselves just about about symptoms and what I like to- sorry to interrupt but what I like about what you're mentioning too is that there's almost an intersection with a business perspective in terms of how to keep clients being treated and when we talk about psychoanalysis historically those go on for a very long period of time and now based on symptoms we have a more defined cap to the scope of one's treatment yeah absolutely I mean and if you look at mental health culture generally or probably most cultures it comes down to power and money so and that's certainly the case in mental health it really doesn't come down to scientific advancement too much I mean some but it comes down to the culture shifting and changing and talking different ways because of the power and money in those ways but the old insights like that if you want to help someone and talk to them you ought to try to get in touch with what they're experiencing is should be a very basic insight that's rapidly been lost in a larger culture that message insight is I've talked about it so going further from this history of the DSM and talking about ways that counselors have little to no use of that what are some of the pieces of guidance that you would offer somebody who has to operate in both worlds right somebody that does have to use the DSM in order to successfully complete treatment and get paid for their treatment but then also has to be amongst others that rely on the DSM for the basis of those treatments so what about those people who want to engage that message or meaning aspect of what we're talking about but they're in a very malady based setting yes and I'm in that situation so I can tell you the way I deal with it I think everyone has to come to their own ethical conclusions about what to do when they're surrounded by you know this guide that talks about symptoms alone and everyone's sick and you're a counselor and really shouldn't be thinking that what I do and what I advocate that people consider is a strictly separationist point of view which is that the DSM and the symptom based treatment planning are like filling out a giant bill and when the door closes that that's a completely different goal you have there which is to help the client and if you when you have that goal, you cannot think. in terms of the filling up the bill, DSM symptom goals. So I really don't think it does any good to think of a person who's sad as having major depressive disorder. Because think about the different experiences people have, or diagnose with that. Some people have been depressed for decades. Others, it's been a very recent thing. Some, it's an inner sense of emptiness that's been bothering them for years. Other, it's guilt that is really eating away at them. Others, it's some kind of trauma. Others, it's something they're mourning. Yet when you summarize people by symptoms, all of that gets just blended over and you talk about them in the exact same way. This is the reason that medical doctors don't have stomach pain disorder, right? Because that's a symptom. And you would never say that the person has stomach pain disorder if they want to see a doctor and you gave them a stomach pain reliever and they were cured, right? Because if someone's having stomach pain, it could mean they're nauseous, they are stressed, they have stomach cancer, right? It could mean anything. So you would never describe someone just by their symptoms. But yet, that's the way mental health works and we have to think about that very critically in whether it's helpful. - Yeah, I like, we're going with this too because it reminds me a lot of some of the patterns I see with novice counselors, especially regarding what to share with their clients about their diagnosis. There's often this incompatibility between the relationship and disclosing to somebody, a diagnosis, especially significant diagnosis. So for example, in supervision, I often get counselors saying that I don't wanna let this person know that I feel they have major depressive disorder or that that's the diagnosis I'm using because I don't, almost as though they're breaking bad news to them, like Sarah to tell you, but you have major depression disorder. And so I think that even counselors today feel that difference in meaning versus malady when it comes to their everyday interactions with clients and trying to blend the two worlds of diagnosis and the counseling relationship. - Yes, and again, I'm not a blender, I'm a separationist. So I typically say things like, in order for your insurance to pay for this, they require that I summarize your symptoms with a label. That the best summary in that system I can come up with is what's called major depressive disorder. I want to let you know, though, that I don't think of you that way, as a collection of symptoms, I'm very interested in getting to know you. But if you want this to be paid for by a third party, they make this demand, and this is how I'd fulfill it. - Yeah, what a great sentiment. I do think that it also can help clients to going back to the way that we're talking about mental health culture being the air we breathe, or the water that we're all swimming in. Oftentimes you'll find clients come to counseling having diagnosed themselves already. And it is the work of the counselor to put that frame of reference into place that way the client themselves can join the counselor. - Yes, and sometimes that's success, and sometimes it's not, because the culture is very strong. And just to say here that I think there's some justification in psychiatry using some of those labels, because psychiatry does have medicines that do alleviate certain symptoms. I'm certainly not anti-medicine. I realize that it has its place, and people with severe symptoms or problems, that might be the best option for them. - Absolutely, so I completely understand that. But if we're talking about what's useful in our profession, I can't think of a use for a relational profession to describe people just according to their symptoms. It's not, if we help, because of our relationship, and we know that we do, then just reducing someone to their external symptoms can't be helpful. Any more than if you're trying to make a new friend or something, and you just make observations about the way they're behaving. And so I'm trying to get to know them. It's really ridiculous. So it's something we use for billing in our profession, and that's where I think it should stop. The only exception would be, I think it's good for us to be able to identify, severe symptoms, let's say someone's hallucinating. We ought to know that that's not ordinary, and we can refer that person maybe to a good psychiatrist. But that's the only use I can see for this guy for our profession. - And I think what's sort of latent in this conversation here are deeper issues of what we should consider to be normal. Oftentimes we talk about culture as having pieces that are used as the yardstick to measure other pieces. And so when we're talking about mental health culture, often there's this idea of what it means to be normal as it is depicted in the DSM, and that it puts counters in a position to only view their clients as to how much they either match or deviate from these definitions of being normal. - Well, absolutely. And unlike medicine, there's no stable bar of what normal means in mental health. In medicine, if you have a temperature of 104, it doesn't matter what culture you're in, it doesn't matter if it was 500 years ago or 500 years in the future, you're very sick. And the reason we know that person is very sick, and we have to know nothing else about them, is because the normal human body temperature is about 98 degrees, and 104 is a deviation from that a significant deviation. So abnormal by definition means a significant deviation from normal, right? So in order to know what abnormal means or whether someone's sick, you have to know what normal means first. Now, the problem with mental health is that normal keeps changing according to the time, the era, the culture, what it means to be normal. And there's no 98 degree equivalent in mental health, right? Homosexuality was considered abnormal from most of human history, and that was reflected in how organized psychiatry thought about it, right? And then when the culture started to change, thankfully, the thinking of organized psychiatry change. That's not diagnostic, that's cultural commentary. - That's what you was saying, that's cultural commentary. - And going back to this piece of cultural commentary, I do like the way that we talk about counselors as being a relationship-based profession and inherent in those relationships is the task of understanding somebody's subjective experience. Now, when we look at medicine and we look at other ways of measuring individuals, there are some that believe that one's experience can be measured simply in synapses or simply by the ways that they respond to certain external stimuli. So sort of bringing back the idea of counseling being a relationship-based endeavor. What are some of the benefits to a more materialist way of looking at human subjectivity? So for example, my telling you about my experience of the eclipse could simply be broken down into specific synapses and specific areas of my brain versus this idea that one could never really fully understand my subjective experience. - I think that let's start with what we know. And what we know from over four decades of counseling outcome research is that the relationship and the quality of it is the within treatment variable that's most highly associated with counseling outcomes. Techniques in latest meta-analysis account for less than 1%. So which is a startling figure to people who might not have been familiar with this. But the relationship is the most important part, okay. So if you start with that assumption, then how do you build relationships? Is the sort of next question? Because we ought to be very concerned about that, okay? And do you build and maintain relationships by thinking about the other person in material ways, right? When I give my wife a Valentine's Day card, do I say this part of my brain is firing, right? No, I say I love you or something like that, right? We don't build relationships in material ways. We build them by trying to get to know and show that we're understanding or at least getting closer to understanding the inner experience of other people, right? If we just simply think about what we do, we want in relationships, it's for someone to get us and the more they get us, the closer we feel. So, you know, if you're asking about what is the role of material reductionism, what is the role for understanding people according to their neurons or something in counseling? And I can't see a role for it, right? I don't see one at all. You know, counseling is about one person building a relationship with another by talking. And unless these movements tell me something novel to say a new way to put words together that makes for those connections, I can't find much use for them. Yeah, and I think this is a really great way to come back around to this idea of humanism and non-reductive points of view. That out there, there are several different camps of thinkers or schools of thought that would promote a reduction of an individual that you're meeting with to symptoms and to simple synapses. And so kind of pulling us back out of this, would you have any books or readings that you would recommend for students who might want to learn more about this? Or if someone is sort of new to these ideas, what are some other ways that they can deepen their understanding of what we've talked about today? Well, some of what we've talked about today is representing my favorite book in the field. And I think it's the best book has ever been written in the field. I recommend it to everyone, which is Jerome Frank's persuasion in healing. And that's a book I've drawn from over the years and have very heavily and has been a founding book in terms of my thinking. So that would be a prime choice. You know, Mark Scholl and Scott McGow and I have added a book on humanistic perspectives and contemporary counseling. And I think that's not a bad choice for a book about how humanism applies to contemporary issues. Roger's seminal paper is one I make all my students. The necessary and sufficient conditions for therapeutic personality change. My vote for the best paper ever written in mental health. And decades later, it's still going strong. Yeah. And he was decades ahead of his time. Absolutely. So those would be my go-to's probably in terms of things that have influenced me in terms of, you know, humanism and how to think about therapy. I think that's a really great way to conclude our conversation today. I do want to mention that there's a lot more on this conversation that we've just barely touched. And so for those looking to understand more, there's still much yet to uncover. But I want to thank you for being on the Theory of Change podcast today and my hope is that you continue to keep up the good work. Oh, well thank you very much. I've enjoyed