When I was at university many moons ago, the classes for the subject Psychopathology were always jam-packed with curious students. After all, who would not be intrigued by OCD (obsessive compulsive disorder), DID (dissociative identity disorder), various phobias, schizophrenia, psychosis and the like? This is the stuff movies are made of, right? And on some level the Psych Pathology course did not disappoint – it was truly fascinating. But on another level I have come to realise: diagnosis is a tricky, sticky affair. Let me explain…
Diagnosis, as you can imagine, is done by comparing what you see in the client to what you read in the “Bible” of Psychiatry – aka the Diagnostic and Statistical Manual of Mental Disorders, in short “the DSM”. Professionally I “grew up” on the DSM-4, but since then the world has moved on to the revised 5th edition. It certainly is a work in progress and we’ll probably never see a final, final version! (The International Classification of Diseases, in short the ICD, which is now on version 11, is another frequently used manual, but as I am more familiar with the DSM, I’ll stick to that for the moment.) So – in the DSM, all mental ailments are categorised, described symptom by symptom, also assessing for how long the person has had the symptom, and to what extent it impacts on his/her life. This helps figuring out what is wrong with the client, and can help pave the way to deciding in what way the treatment will progress. It also gives a common language to psychologists and the doctors who refer their patients for therapy. Indeed, it squarely places the practice of psychotherapy within the medical model, to the extent that therapists sometimes use the terms “client” and “patient” interchangeably.
In many instances, diagnosis can be a wonderful tool to give clients a sense of relief and hope. “Finally I know what is the matter with me! This feeling I have, has a name! Many others struggle with it – to the extent that it is recorded on the DSM, and –more importantly – that Google will have thousands of links to click to learn more about it,” these clients would say. A weight has been lifted off their shoulders. Whatever ailment they are experiencing, is “normalised”. In my opinion, this is especially powerful in the case of some anxiety disorders (e.g. post-traumatic stress disorder or panic disorder), developmental or neurological disorders (e.g. autism or dementia), and disorders which clearly have a biological basis (e.g. schizophrenia). Here, diagnosis gives us a “handle” on the problem. It can also open the door to NDIS funding and support if a person is diagnosed with a long-term disabling mental illness – often a welcome relief for already-struggling families.
But when does diagnosis become “tricky and sticky” as suggested in the title?
It becomes “tricky” when things are a bit murky. When there are 9 symptoms, but the client only shows 3. When the manual states that the problem should have been going on for at least 14 days, but the client is only on 8 days. When normal deeply emotional reactions are pathologised. When we jinx the outcomes of our assessment by the very questions we ask, and the way we ask it. Especially the results of quantitative assessments (where you fill out a questionnaire and you get a number at the end) can be misleading. To give you an idea of what I mean, consider the following scenarios:
My colleagues and I had a little laugh last week when we filled out an online questionnaire to determine our specific strengths. Two questions that had us perplexed were (1) “I always wake up in the morning eager to start the day and excited about what it holds” and (2) “I am able to resist temptation”. Without providing context to the questions, the scorer of the answers could easily get a very skewed picture!
My response to Question 1 would be: No – I do not like it when my alarm clock rings in the morning. I am not a morning person. I never wake up feeling a brilliant zest for life. But give me half an hour, a quick shower and a cup of coffee and I am totally pepped for the day and all bright-eyed and bushy-tailed! So… what do I answer? “Never”? “Always”? “Some of the time”? Similarly, what is meant by “resisting temptation”?! If it means (almost) never speeding, not smoking and never nicking anything from anywhere, then it is resounding YES! I “Always” can resist a temptation! But what about the “temptation” of being Miss Have-a-Chat and distracting busy colleagues with non-work-related chatter? How about my having another chocolate… or two? No golden buzzer for me there! (More like an epic fail!) So… how do I answer that question on the assessment questionnaire? What does “temptation” even mean?! I honestly do not know!
Flashback to 2003 when I started out as a psychotherapist. In my first session with clients I would invariably try to figure out where they fit in diagnostically… which meant that I asked questions like this to a patient that looked depressed to me:
- Has your mood been low, say for… two weeks or so…?
- Have you had trouble falling asleep lately?
- Has your appetite gone down… over the past two weeks?
- Did you find yourself being less able to concentrate and focus recently?
- Have you been feeling hopeless… for about 2 weeks…?
So – diagnosis is “tricky” because of variations in the interpretation of questions by clients, and because the very questions may lead us to certain overly-narrow diagnostic conclusions. And quite honestly – I would do the exact same treatment for someone who is clinically depressed and someone who technically falls short of the diagnosis but still experiences low mood or a change in functioning!
Do you see the problem here? The problem is NOT that I am checking for symptoms to get a full picture of what is happening for my client. The problem is the WAY I ask it, the way I lead my client to respond, and the way my questions leave out anything that was not listed as a symptom in the DSM. A much better way would have been: “Tell me about anything that you have been concerned about lately, anything in your daily living and patterns that has changed for you and that is a source of worry for you.” And if I did not get too much from this very broad question, I could have probed further: “Any changes with sleep? Eating? General mood or feeling of wellbeing?” By doing it this way, I would have gained a much clearer picture without suggesting anything to my client. (Compare this to studying the little pamphlet that comes with all medicines, especially the “possible side effects” sections… I bet you that knowing that nausea COULD be a potential side effect will make you more likely to feel just that little bit of a turn in the tummy! We indeed see what we look for.)
The client thus gets caught up in a compelling narrative of mental illness – unable to see the story lines that belie the diagnosis, unable to move beyond the diagnosis. The diagnosis sticks relentlessly like blue tac to a woolly carpet.
How do we as psychotherapists then navigate our way around this trickiness and stickiness? For me, the answer lies in understanding that our profession finds itself on the dynamic boundary between medicine and philosophy. (This relates to my previous post about Psychology being both a science and an art.) It is of the utmost importance that we have an excellent grasp on diagnoses, symptoms and the medical jargon that we will receive in referral letters from doctors. Yet at the same time, we need to remember that our clients are ever so much more than what can be summed up in a symptomatic check list. Their lives and identities are much richer and more complex and unique than could be portrayed by a single diagnostic term. This is why manualised treatments often fail – it simply forgets the uniqueness of every person’s story, and feels mechanical and contrived. Personally, I would run for the hills the moment my therapist whisks out a manual to proceed with my treatment!
Even in naming the problem we can allow for much more creativity and ownership on the client’s side by steering away from clinical diagnoses to softer, more humane terms. Michael White and David Epston, the gurus of narrative therapy, have done ground-breaking work in helping young clients externalise problems by naming them creatively: “encopresis” becomes “Sneaky Poo”, “low mood” becomes “The Grumpies”, a “phobia” becomes “the Freaky Fear”. Similarly, instead of calling a cluster of symptoms “major depression”, a client might rather refer to it as “a very long winter”, or “the grey blanket”. Winston Churchill famously called his experience of depression “the black dog” – this is where the name of the “Black Dog Institute” (an Aussie not-for-profit institute providing services in diagnosing and treating mood disorders such as depression, anxiety and bipolar disorder) comes from. Don’t you just love their logo?
Apparently this hand signal was Churchill’s victory peace sign. It symbolises hope and success. But, even in times of victory, mental illness (i.e. the shadow of the black dog) is lurking in the background for those struggling with it. However – and this is important – it is never the essence of who they are. It is there – but it is but a shadow.
For clinicians then, the wisdom lies in being able to understand, make and explain diagnoses, value the potential benefits of having a name for what clients’ experience… and simultaneously to help our clients connect to their true essence. This is where the pure gold of growth lies: in acknowledging and holding our shadows, our diagnoses, gently… whilst reaching out to a story defined by a narrative of individual, unique mental health. Not by tricky, sticky mental illness.
Felix & Sage Psychology