Technoscientific Knowledge Practices of Adolescent Mental Health Care Work

Abstract

This study examines the technoscientific knowledge-practices of adolescent psychotherapy. Employing an interpretive, feminist version of grounded theory, 40 interviews with psychotherapists were analyzed. Building on Science and Technology Studies and the Sociology of Health and Illness, the following research questions are asked: How are adolescent mental illnesses defined and approached within and across social worlds? How do practitioners negotiate social processes of diagnosis? In what ways does the Diagnostic and Statistical Manual (DSM) as a technology, shape the diagnostic and treatment work of mental health practitioners? In what ways does Managed Care (MC) shape adolescent mental health care?

Social worlds define psychotherapy as an art and science, resist biomedicine and embrace eclectic theoretical orientations to treatment. Psychotherapists utilize Evidence Based Practices (EBPs) in their treatment plans but critique how EBPs privilege scientific evidence over patient subjectivity, social contexts and the therapeutic relationship.

Psychotherapists challenge the cultural authority of the DSM and downplay its significance for clinical work. While the DSM is a socially-scripted technology, its significance is interpretively flexible. Psychotherapists employ work-arounds to the problems posed by biomedical and bureaucratic standardization, and participate in processes of cribbing. Cribbing signifies the collective knowledge building and translation work necessary to learn the codes that facilitate therapeutic service authorizations and minimize denials. The DSM technology and MC privilege a therapeutic focus on surface level symptoms and behaviors whereas psychotherapists focus on communication, relational and emotional issues. The assemblage of the DSM and MC creates diagnostic dissonance for psychotherapists--a conflict between their own theoretical orientations and the biomedical model. Biomedicalization processes are uneven and actively resisted.

MC governs the clinical practices of psychotherapists. For-profit MC companies have shifted care from intense psychodynamic therapy towards short-term surface level medications and behavioral programs. MC policies limit services, over-manage treatment and harm the therapeutic relationship. MC stratifies providers and patients by encouraging seasoned professionals to leave public forms of insurance. The least experienced practitioners care for those with the most intense mental illness while those with experience opt-out and treat the worried-well.