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Therapeutic Reflections: On Diagnosing People

Psychotherapy has something clunky and something incredibly elegant about it. Clunky because the tools used to diagnose and treat people are mainly our own mind and body. But this is also elegant because one has to use oneself as an instrument in order to feel, think, connect, and resonate with the person in front of you. Let me explain.


The common analogy in therapy textbooks is that of several explorers observing an elephant in the mist. One person touching the trunk, another inspecting the feet, another the tail, the ears. All don’t see the full elephant, but have some insight into some of the parts of this elephant essence. One explorer describes the elephant as being trunk-like with; the other touches the ears and describes it being like a fan; the other notices a thin tail, etc. But the people cannot agree and all claim to have a true representation of what the elephant is, and are blind to the whole.^1

Observation and Interpretation

In very simple terms you can say there are things you see (observe) and what you make of them (your interpretation). If I see a blue pen I can describe its colour, shape and measurements. This is something we can all agree on based on observation (some might call this intersubjectivity). What the blue pen means to me (e.g. a gift of my grandma or a bully once poked me with that pen) adds to my interpretation of the pen. This distinction is crucial in psychotherapy, where the observed behaviors and expressed thoughts of clients must be interpreted with care, avoiding the pitfalls of oversimplification. Our interpretations, grounded in empathy and understanding, strive to capture the nuances of the human experience, but are by definition incomplete. Diagnosing a person is a subset of combining both observation and interpretation.

Understanding vs Labelling

Words and labels help us make sense of the world - but they are not the world. As beautifully put by Korzybski (1933): “A map is not the territory it represents, but, if correct, it has a similar structure to the territory, which accounts for its usefulness. […] If we reflect upon our languages, we find that at best they must be considered only as maps. A word is not the object it represents.”^2.

Diagnosis serves as a classification, an often necessary step for crafting a treatment plan. Yet, it's vital to remember that a diagnosis is a label – a tool for communication that, while useful, can be scientifically imperfect and culturally biased.

When, for instance, looking at Otto Kernberg’s map of mental disorders, it gives a neat order that the analytically minded might enjoy. As the spiral continues, the person struggles more with their functioning, leading to biological impairments. In the model below, as functioning worsens a "pathological personality" is most likely characterized by a personality disorder. If one's sense of self and other (i.e. identity) is distorted, a borderline personality disorder may be present. If our perception of reality is affected, a psychotic state might occur.



Yeomans, Carkin, & Kernberg, 2015

Some people see personality disorders as a form of interpersonal disorders, as they all show some impairment in interpersonal functioning. This is not to diminish the personal responsibility of the individual, but to foster a clearer understanding. Some person-centered approaches at times turn away from the pathological label and rename a personality disorder a “personality disorganization” (not to be confused with the same term used in the image above), more clearly implying that growth and healing is possible. Most likely, seen from a systemic lense, Kernberg’s map would be different alltogether again.


Why diagnosing people is hard


The moment we label something or someone, we invariably fall short of something. It’s an abstraction. A concept that helps us find common symptomatic denominators. And yet it can help us come to an additional understanding, communicate with other (para)medical practitioners, and find out what potential treatment may be helpful. It’s not per sé bad or wrong, so long we don’t misrepresent that this diagnostic label is the factual truth with a capital T.


Diagnosing in therapy walks a fine line, entwined with ethical considerations. It holds power, shaping how clients see themselves and are seen by others. Each label carries weight, potentially altering a person's self-concept. In this process, psychologists wield significant influence, prompting a need for careful reflection on the impact of our words and diagnoses. The act of naming an experience should aim to empower, not confine, recognizing the individual beyond the diagnosis.


The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) and the ICD-11 (International Classification of Diseases, Eleventh Revision; https://icd.who.int/en) are the basic classification systems in the field of mental health. They provide a common language for diagnosing and treating mental disorders. The DSM-5, primarily used in the United States, outlines criteria for mental health conditions, facilitating clarity and consistency in diagnosis. The ICD-11, maintained by the World Health Organization, is used globally, covering both physical and mental health conditions. Both manuals are tools for professionals, guiding the diagnostic process and ensuring that treatments align with research and clinical evidence. They are a way for professionals to communicate to another, and can also help with research on mental health. Comorbidity, pressure from insurance companies, and clients lying can also make the diagnostic process hard. Often people have more than one diagnosis, known as comorbidity. For instance the common co-occurrence of anxiety and depression, illustrates the complexity of mental health states that defy singular diagnoses. This reality underscores the necessity for a more nuanced approach that transcends rigid labels. Moreover, immediate diagnostic requirements by insurance companies, can push therapists towards quick classifications, often before a comprehensive understanding of the client's situation is achieved. Finally, the challenge of malingering, where patients may withhold truth (to obtain secondary benefits like medication, financial benefits, attention, etc), adds another layer of complexity to diagnosis, highlighting the delicate balance therapists must maintain between skepticism and empathy.


These research-based classification systems, based on the medical model, are helpful and yet also fall short. In a proper diagnostic report, ideally there is not just a label, but some sort of diagnostic formulation, discussed with your client, that represent their story. This more nuanced and personalized narrative, though still never representative of the full picture, helps add more context. In the dance of diagnosis and treatment, it's the steps not scripted by manuals that often lead to the true rhythm of healing. Reflecting on this, psychiatrist Irvin Yalom, mentioned to avoid diagnosis as much as possible:

"Today's psychotherapy students are exposed to too much emphasis on diagnosis. Managed-care administrators demand that therapists arrive quickly at a precise diagnosis and then proceed upon a course of brief, focused therapy that matches that particular diagnosis. Sounds good. Sounds logical and efficient. But it has precious little to do with reality. It represents instead an illusory attempt to legislate scientific precision into being when it is neither possible nor desirable.

Though diagnosis is unquestionably critical in treatment considerations for many severe conditions with a biological substrate (for example, schizophrenia, bipolar disorders, major affective disorders, temporal lobe epilepsy, drug toxicity, organic or brain disease from toxins, degenerative causes, or infectious agents), diagnosis is often counterproductive in the everyday psychotherapy of less severely impaired patients.

Why? For one thing, psychotherapy consists of a gradual unfolding process wherein the therapist attempts to know the patient as fully as possible. A diagnosis limits vision; it diminishes ability to relate to the other as a person. Once we make a diagnosis, we tend to selectively inattend to aspects of the patient that do not fit into that particular diagnosis, and correspondingly overattend to subtle features that appear to confirm an initial diagnosis. What's more, a diagnosis may act as a self-fulfilling prophecy. Relating to a patient as a ‘borderline’ or a ‘hysteric’ may serve to stimulate and perpetuate those very traits. Indeed, there is a long history of iatrogenic influence on the shape of clinical entities, including the current controversy about multiple-personality disorder and repressed memories of sexual abuse. And keep in mind, too, the low reliability of the DSM personality disorder category (the very patients often engaging in longer-term psychotherapy).

And what therapist has not been struck by how much easier it is to make a DSM-IV diagnosis following the first interview than much later, let us say, after the tenth session, when we know a great deal more about the individual? Is this not a strange kind of science? A colleague of mine brings this point home to his psychiatric residents by asking, ‘If you are in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?’

In the therapeutic enterprise we must tread a fine line between some, but not too much, objectivity; if we take the DSM diagnostic system too seriously, if we really believe we are truly carving at the joints of nature, then we may threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture. Remember that the clinicians involved in formulating previous, now discarded, diagnostic systems were competent, proud, and just as confident as the current members of the DSM committees. Undoubtedly the time will come when the DSM-IV Chinese restaurant menu format will appear ludicrous to mental health professionals." Chapter 2 - Avoid Diagnosis in The Gift of Therapy by Irvin Yalom.

Psychiatric Diagnosis vs Clinical Case Formulation


Clinical case formulation offers an alternative to psychiatric diagnosis, focusing on restoring meaning, agency, and hope for individuals. Unlike diagnoses, formulations consider the unique contexts of people's lives, including cultural settings where alternatives like narrative therapy or community-based approaches play a significant role. Here is an example of what a clinical case formulation might look like. Jane is 20 and has started to hear critical and hostile voices. The psychiatric diagnosis is likely to be ‘psychosis’ or ‘schizophrenia.’ In contrast, a written formulation shared and developed with Jane over a few weeks or months might look something like this:

You had a happy childhood until your father died when you were aged 8. As a child, you felt very responsible for your mother’s happiness, and pushed your own grief away. Later your mother re-married and when your stepfather started to abuse you, you did not feel able to confide in anyone or risk the break-up of the marriage. You left home as soon as you could, and got a job in a shop. However, you found it increasingly hard to deal with your boss, whose bullying ways reminded you of your stepfather. You gave up the job, but long days at home in your flat made it hard to push your buried feelings aside any more. One day you started to hear a male voice telling you that you were dirty and evil. This seemed to express how the abuse made you feel, and it also reminded you of things that your stepfather said to you. You found day-to-day life increasingly difficult as past events caught up with you and many feelings came to the surface. Despite this you have many strengths, including intelligence, determination and self-awareness, and you recognise the need to re-visit some of the unprocessed feelings from the past.

While the medical model offers a structured approach to diagnosis, clinical case formulation provides a personalized narrative, emphasizing the causal factors like social and relationship adversities, as highlighted by Lucy Johnstone and others, that contribute to mental distress.

But how does one get to a formulation in the first place? According to the scientific model there are questions and hypotheses drawn; ways to answer the hypotheses (often with the help of empirically validated assessments), and an eventual conclusion.

Next to listening to people’s life stories, there are all sorts of research based assessments to help come up with a diagnostic label and can inform a clinical formulation as well. There are simple self-reported questionnaires (e.g. a complaint questionnaire asking you how anxious or depressed you feel), to more thorough assessments like an IQ test (e.g WISC/WAIS), personality tests (MMPI, SCID-5, NEO PI-R, etc) or disorder-specific tests like the ADOS and ADI-R for autism. Additional tests that are considered less valid yet can reveal rich unconscious material are projective tests like the Thematic Apperception Test or Rorschach inkblot^0 test, or one that I enjoy are the river cards where I ask clients to make a story regarding their life with a beginning, middle and end.



Processdiagnostics - Using the therapy itself as a way to understand what's going on.


Processdiagnostics are not per sé empirically validated tools, and occur during the process of therapy itself^3. There are some questionnaires on therapeutic preferences (C-NIP) or the therapeutic relationship (e.g. Working alliance inventory, Session Rating Scale, Helpful Aspects of Therapy Scale, etc.) that can be very helpful. Yet most process-diagnostic work unfolds organically during the process of therapy.

How is the relationship unfolding between client and therapist? How is this person related to autonomy, competence and connectedness? What values do they hold dear and how do they act (or not) on them? What is the content of what someone says (what is being said) and what is the process (the interaction in the therapy room, what is said in between the lines, the deeper contextual layer)? How does this person show up in their relationships? What is being viscerally evoked in the client during the sessions? These are questions that can guide such an unravelling.

Going back to the elephant metaphor: in therapy you look at the elephant in the room and address it whenever appropriate and possible. The uncomfortable we’d rather not look at but know that is there. Using the therapy as a way to foster understanding and healing, means


Are people against diagnosis?

Where there was a strong anti-psychiatry movement in the past, now it seems that almost everyone has become an expert of the mind and mental health. And of course, we all have minds and our lived experience. Hence everyone has a first-hand opinion. And psychobabble has become very common. Suddenly everyone feels competent to “diagnose” someone they personally know as narcissists or borderliner. As recently mentioned by therapist Chance Marshall:




People who are into psychobabble are normally not really interested in doing a full-fledged psychodiagnostic assessment. When someone randomly throws around personality disorders onto other people or considers themselves above average intelligent, they often don’t actually want to sit down several hours for a full fledged assessment. Then they are weaponizing their therapy-speak.

Moreover, some people, both within and outside of the therapy field, want to get rid of the current model all together, often times speaking from a position of newfound expertise and authority. People that feel they now know find it easy to disregard the past, past research and thought. When dealing with vulnerable people, as any caring profession does, an open, humble, curious and "beginner's mind" seems crucial. We want to offer the best care, and be careful to not create further harm.


And the truth is we never really know a person. Even if someone comes and pours their heart out in the therapy room with all their joys, pain, fears, shames and desires. Does that person fully know themselves? Probably not, otherwise they might not be in therapy to begin with. We are initially not aware of unconscious motives. And chances are a person acts differently in the presence of other people. So the person reveals another more relational or systemic layer depending on who they interact with. This happens the moment you see them coming with a partner or family member and watch them interact, and often behave differently to when they would speak alone with you.

So, what really creates understanding?


Three things come to mind, what can really help when it comes to understand what goes on.


A) Common Sense. As they say, common sense is the least common of all senses. It's the bedrock of practical judgment and intuition that guides us through the complexities of human behavior and mental health. By tapping into our innate wisdom, we navigate the nuanced landscape of psychology with a grounded perspective.


B) Common Humanity. This principle reminds us of our shared experiences, struggles, and capacity for resilience. We all suffer, we all experience joys and the myriad of emotions in between. How these experiences are flavoured makes us different, but in our essence there is more that connects than divides us. In the context of psychotherapy, recognizing our common humanity fosters empathy and compassion, allowing for a deeper connection between therapist and client. It is the acknowledgment that, at our core, we all seek understanding, acceptance, and meaning.


C) Scientific Inquiry. The scientific method is one of the best analytic tools to move from observation to an empirically supported and replicable interpretation. It only becomes tricky if scientific inquiry with humans becomes dogmatic and disregards common sense, our underlying common humanity, or unfalsifiable claims pertaining to subjects like spirituality. Science, when applied with humility and openness, enriches our understanding of the human condition, driving forward innovations in treatment and therapeutic approaches.


Science is incredibly useful to foster a better understanding of our minds and wellbeing. But only when based on common sense and common humanity as a foundation. Remember the elephant in the mist? The only way to “see” the elephant is by integration. By not falling prey to the different schools of thought. By communicating and collaborating with another. And by realizing that every single person is just approaching one small part of the whole elephant. And when the mist eventually subsides, the people that were arguing “This beast has a trunk” “No, it has a tail!” “No, it has big legs!”, will all be astonished by its beauty and laugh at their simplistic representations and interpretations.


Footnotes


^0 The Rorschach test is still very popular in Japan and, to a lesser extent, in German speaking countries. In Japan it is even considered to be “the pillar of psychological testing in psychological assessment” (https://jsrpm.jp/english/). Since the test continues to be widely used despite the criticism to it’s validity, it has been called the “Dracula” of psychological tests “because no one has ever been able to drive a stake through the cursed thing’s heart.”


^1 This parable already appeared in ancient Asian texts, of blind men touching an elephant for the first time and getting into a fight because they cannot agree:

A group of blind men heard that a strange animal, called an elephant, had been brought to the town, but none of them were aware of its shape and form. Out of curiosity, they said: "We must inspect and know it by touch, of which we are capable". So, they sought it out, and when they found it they groped about it. The first person, whose hand landed on the trunk, said, "This being is like a thick snake". For another one whose hand reached its ear, it seemed like a kind of fan. As for another person, whose hand was upon its leg, said, the elephant is a pillar like a tree-trunk. The blind man who placed his hand upon its side said the elephant, "is a wall". Another who felt its tail, described it as a rope. The last felt its tusk, stating the elephant is that which is hard, smooth and like a spear.

[…] the parable implies that one's subjective experience can be true, but that such experience is inherently limited by its failure to account for other truths or a totality of truth. At various times the parable has provided insight into the relativism, opaqueness or inexpressible nature of truth, the behavior of experts in fields of contradicting theories, the need for deeper understanding, and respect for different perspectives on the same object of observation. In this respect, it provides an easily understood and practical example that illustrates ontologic reasoning. That is, simply put, what things exist, what is their true nature, and how can their relations to each other be accurately categorized? For example, is the elephant's trunk a snake, or its legs trees, just because they share some similarities with those? Or is that just a misapprehension that differs from an underlying reality? And how should human beings treat each other as they strive to understand better (anger, respect, tolerance or intolerance)?


^2“A map is not the territory it represents, but, if correct, it has a similar structure to the territory, which accounts for its usefulness. If the map could ideally correct, it would include, in a reduced scale, the map of the mapt; the map of the map; the map of the map, of the map; and so on, endlessly, a fact first noticed by Royce. If we reflect upon our languages, we find that at best they must be considered only as maps. A word is not the object it represents; and languages exhibit also this peculiar self-reflexivenss, that we can analyse languages by linguistic means. This self-reflexiveness of languages, introduces serious complexities, which can only be solved by the theory of multiordinality, […]” Alfred Korzybski, Science and Sanity, p. 58


^3 In the ideal treatment there is a path where either a diagnostic assessment, process diagnostics or specialized assessment is applied. Assessment -> Diagnosis -> Treatment  Plan -> Treatment -> Routine Evaluation/Monitoring -> Relapse Prevention -> Finish Treatment


  • If diagnosis is unclear proceed to either: a) -> specialized assessments/testing 

      b) -> start therapy and conduct process diagnostics


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