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Should we Diagnose? Some people are uncomfortable with the concept of diagnosis. I find I’m most interested in the differential slithers that divide one diagnosis from another, or that divide what might be regarded as “DSM* Diagnosable” from normal - albeit sometimes unusual - functioning. (For those who don't know, DSM lists all the mental health issues/psychological disfunctions that we currently recognise.)So, some of my interest finds itself peering at the perceptions of the diagnostician – why does he see x when I see y? Some of it finds me sniffing the air, trying to inhale something like a sense of distinction among the shades of what’s unclassified in DSM – the differentials that aren’t explicit. In these, I think much more is left to the diagnostician and their perceptions are at greater risk of staying subjective. I’m sure I’ve been “misdiagnosed” by people who’ve come across me - people who are forming an impression of the who and the how that I am. And I know I have "misdiagnosed" others when I've stayed with my first impression of them, only later realising I've been wrong. Once, during a psychotherapy training workshop, I was asked what I was thinking as I stared for a second into space. I happened to be thinking many thoughts at once. All of them landing simultaneously like darts at the circumference of the moment. So, when I began to tell the workshop leaders the thoughts I’d had they rushed in with their own responses: “Gosh, you must be exhausted, having to work so hard all the time!” (Feeling misaligned, I experienced them saying this with masks of head-tilted sympathy, suitably misattuned to my “pain”.) I felt they caught a quick and superficial glance of something and made sense of it within their own personal experiences. At the time it was their confident certainty that I objected to – they saw the “symptom” in isolation, unattached it from its genuine root and put it somewhere else. So I explained that I wasn't chasing these ideas in a frenzy, and that I don’t frantically busy myself to avoid the pain of being in the world (or, at least, I knew I wasn’t doing so then). That thoughts do come to me simultaneously and travel back outwards together along their respective paths in the same second. That it’s not exhausting, it’s about as busy as breathing. (Although I could have felt exhausted having to explain all this, translating the thoughts into words for their benefit, where, verbally, I can only express one thought at a time and, actually have moved on in my head, so am now separately articulating things from a long way back because they haven’t yet caught up. And still it’s too fast for them…. ) I do accept that this interaction didn't bring out the best in me. They thought I was in denial. I know that my pattern of relating isn't fixed as it changes along with its context, although my (albeit relative) speed of thought might be. I’m in no doubt that the fixed patterns listed in DSM IV exist as I’ve come across many. And I've come across people who present with fixed patterns whoever they’re with; unchanging along with the situation and they're often very aware that they’re unhappy because of it. I can feel confused by the anti-diagnosis stances taken by some. There are classification systems everywhere – DSM/ ICD-10, Personality Profiling - Meyers-Briggs, Belbin, DISC, Psychometric testing, Signs of the Zodiac, Chinese Birth Signs and Multiple Intelligence Theory. Huxley created the ultimate one in Brave New World. Even superficially, a would-be dater might say to her friend “Let’s see……well, he’s more Woody Allen than Sean Penn”. So the receiver tries to find him through her catalogue of memories of others who’ve impressed upon her. It’s a short-cut. And people compare. Why do people do Myers-Briggs? I’ve a dim recollection I was ENTP but it was so long ago that I can’t be 100% and it doesn’t exactly roll off the tongue. And where does that leave me? All the categories merged into an all-embracing grid of, almost, uniformity. At the end of the workshop I went on I knew I was supposed to recognise that we were all of equal worth (not a new concept), but couldn’t remember which type to delegate which aspect of the workload/organisation to. And anyway, don’t most of us just have to do what it says in our job description? I’m imagining there being stigma attached to Myers-Briggs. In the workshop, I see Deirdre from Accounts sobbing uncontrollably, “But I don’t want to be an ISFJ, I want to be ESFP!” - her colleagues shuffling uncomfortably alongside her flagrant display of wannabeism. “But it’s what you are, Deirdre. All the categories are as good as each other!” DSM represents a trawl of those at a distance from a contactful place, whether they’ve gained their ground along the path of Axis 1, 2 or both (In the DSM, Axis 1 concentrates on the mental illnesses and Axis 2 concentrates on the psychological disfunctions). This implies that (for most) there is a way back. Or even, covering new ground, (with the support of Psychotherapy & Counselling and/or medication) to an optimum place of functioning. When people rail against diagnosis I think, at root, it’s because it’s been insensitively explained or inaccurately applied. It’s the diagnostician that's lacking, not the diagnostical manual. I come across people who are enormously unhappy and know that “something’s not right”. They want to know what. Do we say “Well that’s the type of person you are – we’re all different, aren’t we?” (Deirdre and Myers-Briggs). Give them the “something’s not quite right but we’re not sure what” pill? (like many inappropriately prescribed SSRIs). Our Soma? (Huxley, 1932). Or endorse their return to a culture of Narcissism/Appearance (Lasch, 1979) through which to temporarily carve a path (a societally endorsed illusion/delusion?) – until it stops working again. I'll give a couple of imaginary examples to highlight, at least to my mind, the importance of diagnosis. Let's imagine two people - both under forty, both presenting with sudden memory-loss. The first is withdrawn, unspontaneous, frozen and isolated in his contact style. He becomes cautiously available when I name the gulf between us – how I’ll negotiate it respectfully because I sense his fear. I stay committed to meeting him and he eventually begins to make himeself available for longer periods. I stay with the process of just exploring our contact in the sessions and I begin to notice that there is a quality in his avoidances of me that has a different feel to others who have experienced this degree of forgetting. Of course I can only know this because I have had experience of the others. This difference gradually becomes more figural for me so that, when I meet him, it is that that holds my attention. I want to be clear about whatever this "slither" is so I can fairly and accurately help him. I slowly explore our relating, parsing our patterns for palpably differentiated moments of recognition; leafing through my catalogue of what I know so that I can openly meet him in this unfamiliar place. (And I'd argue that every new client we meet should be unfamiliar and new if we are not to stereo-type, and abuse our ability as human beings to catalogue and diagnose each other.) It becomes clear that although what I'm sensing is the client's fear, it isn't quite the shape of avoidant, schizoid or psychotic fear. Or not just that. It's a circumstantially appropriate fear of what he's expecting to happen. His fearful behaviour isn't at all out of touch with reality – it is actually totally connected to it, whilst pretending not to be. Let's now say that this man has committed a crime and, if found to be of sound mind, faces a prison sentence. Although he may well have been upset/angry/disturbed at the time of commiting the crime, it becomes more and more apparent that he wasn’t being commanded and that he hadn’t lost his own will. In short, he was responsible for his actions. He is claiming Amnesia. My sense of him is that he is creatively avoiding a custodial sentence. My sessions with him may well be further complicated by our relating along his path of somewhere along the traits of an Axis 2. Perhaps he considers risking contact with me, then retreating as the stakes, in terms of dis-covery, become too high? I'll now compare him to another client - let's say someone who has recently suffered a blow to the head by a cricket ball. This man is in his late thirties but comes round thinking he's 12. His cultural references are filled with icons from that era. He appears plausibly baffled by concepts such as digital cameras, texting, the internet and alcopops. In our contact he comes across as all up-front. There appears to be no concealment in his presentation. He enthusiastically bubbles his adolescence at me – talking to me as if I am his teacher. I really feel like I'm relating to a 12 year old. It's in the way he yanks his trainers on, the out-dated slang he uses, his exaggerated and boyish facial expressions, the rhythm of his phrasing. And what I know is that his Mum died a few years ago and he's still thinking she's at home. I also know that his Dad served time for physically assaulting the pair of them only – chronologically for him - that hasn’t happened yet. I listen to his dreams and aspirations for his future - knowing he's on a low income in a job he doesn't like - and hearing the discrepancy between what he believed he could have in life and what he actually got. He tells me that, if he can't play for England, he wants to be an architect or an engineer – and he shares with me his passion for taking things apart and piecing things together. He is contactful and spontaneous in this odd present of past and future tense. He believes he is totally and fully himself – and only I know that this isn't really him. I know the falseness of what he's putting out, but he isn't covering up neurotically, narcissistically or knowingly. Nor is there a discrepancy between his thoughts and his expression of them. I find him free, spontaneous, contactful and interesting. I can only be sure about the intricacies of why this is so - and back up what I see with objective phenomena - by having a full awareness of other similar experiences with which I can make a meaningful comparison. My having experience of the one helps me refine my sense of the other. I think it's the care and the honesty of the diagnostician that needs to be held up for examination - not the process of diagnosis itself. We all diagnose to some degree, but we have a particular responsibility to do so with precision and compassion when the results of that diagnosis will have significant implications on a person's life or therapeutic progress. I'd also put forward here the importance of humility - and suggest that those who diagnose others also making a meaningful diagnosis of their own pathology. That they fully examine their own personality traits that are affecting the field, and that might even affect the diagnosis that they're attaching to the other. * DSM - Diagnostic and Statistical Manual of Mental Disorders References: Lasch, C. (1979) The Culture of Narcissism, Norton, New York. Huxley, A. (1932) Brave New World, Harper Collins, London. DSM-IV-TR (2000) 4th edition, American Psychiatric Association, Washington DC. PHG quoted in Philippson, P. (2004) Drive Theory in Gestalt Therapy. British Gestalt Journal, Vol 13, 2. copyright Sarah Fallon 2004 |
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