July 9, 2014
Mark Forman, PhD
Before most of us have even sat with a client in psychotherapy, we have to begin to confront the question of diagnosis – whether or not the client can be said to have a specific, well-defined condition offered in the DSM-V or ICD-9/10.
Unfortunately, unlike our sister field of medicine, where much clearer tests can be created and employed, mental health diagnosis is a tricky proposition. If we pay attention to the ambiguities of the research, to critical voices in the field, as well as to our own experience working with clients, we start to see that diagnosis in psychotherapy is fraught with complexities. What are the clear lines that separate addiction from non-addiction, a depressed person from a non-depressed one, and an anxiety disorder from typical, normal anxiety? Often the answers are murky and – journalistic overstatements to the contrary – there is little on the horizon in neuroscience that is going to provide us definitive answers.
Going deeper, we may begin to see that diagnoses are created and employed within a cultural context and a certain set of conventional beliefs about the right way to live. These ideals change and morph with the times and along with our class, gender, ethnicity, age, and geography. For example, in our relatively recent history being gay or lesbian was considered a mental illness (and in some places in our culture it unfortunately still is). Or just recently some regions of our country are beginning to accept the idea that smoking marijuana does not make one socially deviant any more than having an occasional drink does. And then there is a condition like ADHD. How much of it is a true diagnostic category versus a behaviorally-defined byproduct of our constrained modern ways of living and schooling our children? What do we say to the fact that ADHD diagnoses among children are rising at rates that seem fully out-of-step with any identifiable cause? (Getahun et al., 2013)
The combined issues that relate to each diagnostic category can be dizzying. So how do we approach this? And further, what to make of it when you have an actual client sitting in front of you? As far as I can tell, to manage what might otherwise be overwhelming, many of us get stuck in an unresolvable tension. The tension is something along these lines:
- Diagnoses describe verifiable and well-defined conditions that ultimately have a biological basis, whatever the environmental contributions might be. Providing a client with a diagnosis is therefore part of being a professional and offering quality, responsible care. This view is typically much more supportive of the use of medication to treat mental health issues.
- Diagnosis is a way that cultural norms are enforced, often to control and limit the lives of individuals. Further, lacking any medical tests for mental health conditions, the idea itself of “mental illness” is really just a misguided, socially constructed metaphor. We should instead look to the subjective and spiritual lives of the individual to see what is really happening and not to any supposedly fixed diagnostic categories.
The truth, of course, is at neither of these two extremes. There is evidence and good will – as well as overstatements – on both sides. So in order to provide the best possible care, and get closer to the truth, we have to decide what is the right approach for a given client given the circumstances. We have to dance with diagnosis and all its complexities. This means that, depending on the exact issue the client is struggling with, how severe their suffering is, as well as their level of anxiety about their condition, sometimes a diagnosis is the most compassionate and effective thing to offer and sometimes it is just the opposite.
Let’s think more about this. On the positive side, a well-delivered and accurate diagnosis provides the client a container. It offers a sense of safety and structure whereas before there was bewilderment and confusion. Recognizing that they are are “depressed” can be a huge relief to people who didn’t know what they were struggling with. Or taking on the identity of an “addict” can help a lot of people get organized to begin to take steps to change whatever has reportedly become compulsive in their lives. A proper diagnosis suggests all sorts of direct pathways to change; pathways that may be harder to accept when the issues are fuzzy and undefined.
At other times, however, giving a client a diagnosis stunts the process of growth by making what is truly complex far too simple. To diagnose a person with a host of early childhood wounds, a loveless marriage, or deep existential or spiritual issues as simply “depressed” is to see the cover of the book and never to read the pages.
Knowing as a therapist how to make things simpler when the client needs that simplicity by offering a diagnosis and knowing how to stand back from labels and let things unfold in all their complexity – that is the dance of diagnosis and much of the art of being a psychotherapist.
In order to learn this, I believe we first have to know ourselves: We have to see the side of us that needs labels and finds comfort, order, and direction in them, even as they are imperfect. And we also need to see the side of us that wants freedom and needs room to self-define and not be boxed-in by our culture, age, behavior, or by other peoples’ way of judging us. When we see both sides in ourselves, then we will begin to see this same set of holistic needs in others. We will have “ears to hear.” This complex listening, seeing all sides, and then discerning the most helpful and accurate direction – that is the Integral way.