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Pop the Hood and Let Me Have a Look

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Many people think that going to a therapist is like taking your car in to a mechanic: you pull up in the garage, pop the hood (your head), the mechanic-therapist looks around for a bit and finds the broken part, then you both sit around chatting for 6-12 weeks until the new part arrives. Then the therapist pops your head back open again, installs the new part, and you drive off into the sunset.

But of course it doesn’t work this way. People are much more complicated than cars are, and unlike a car, the “faulty” person very often comes in feeling guilty and ashamed of being “broken.” These feelings themselves are often intimately connected to the issues which have brought them into therapy in the first place. And so, if the therapist treated the mind like a mechanic treats a car, pulling it apart and examining the bits as you would an engine, the therapist would only confirm the client’s brokenness and begin the therapy by making the problem worse.

Medical Diagnosis

Similarly, people going to therapy for the first time might expect the experience to be more or less like going to the doctor, the mechanic of the body. You walk in, sit down, describe the problem; the doctor takes a look, tells you what’s wrong and how to fix it; usually prescribing some kind of pill swallow or ointment to apply.

What the mechanic and the doctor do, and the reason why we consult them when are cars and bodies are not working properly, is they are able to “pop the hood” on our cars and our bodies and figure out what’s gone wrong. In other words, they are able to diagnose the problem and then fix it. The word “diagnosis” is from ancient Greek and dia+gnosis means “to know the difference between” or “to know thoroughly.”

In modern day science and medicine, diagnosis is used to mean “the recognition of a disease from its symptoms.” In psychological terms, this means determining a person’s type of mental illness from their visible behaviour and how they describe their emotional state.

In medicine and psychology, the criteria for diagnosis typically consist of a list of bullet-points, and recommendations for which ones are mandatory for diagnosis and how each point is to be valued. The criteria for depression are as follows:

The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

  1. Depressed mood most of the day, nearly every day.
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
  3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
  4. A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
  5. Fatigue or loss of energy nearly every day.
  6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
  7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
  8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition.

The most commonly used diagnostic systems in psychology and psychotherapy are the Diagnostic and Statistical Manual for Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD). Whereas, the ICD covers all of medicine, DSM is psychology specific and therefore generally preferrred by psychotherapists and psychological researchers.

These systems are popular with (most) researchers and (some) therapists because the categories are simple, the method is consistent, and the results are reliable. They require minimal training and are easy to administer because they work on the same basic principle as an online personality quiz: The diagnostician runs through a checklist of symptoms, you say yes, no, or for how long, and then they tally up your results. If you have enough points in a given category, then you qualify for that diagnosis.

Issues with Diagnosis

“The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations. All medical conditions are defined on various levels of abstraction…” (DSM-4, p. xxi)

While this approach is efficient and does have distinct advantages in terms of empirical research, there is also a host of conceptual and practical issues when individual clients are diagnosed this way in psychotherapy.

The following are a few of the basic problems that arise:

  1. Quantification leads to marginalizing and minimizing a person’s suffering if it doesn’t score enough “depression points” or “OCD points” (i.e. it says that their depression isn’t “real” depression).
  2. Objectifying symptoms and illnesses interferes with the efficacy of the therapeutic relationship because it creates psychological distance between therapist and client. This distance insulates the therapist from the client’s problems and makes them less sensitive to the client’s needs.
  3. Treating their illness as an object makes the client feel like they are also being objectified and judged, which feels terrible and makes it hard to trust the therapist, creating resistance to the therapeutic process.
  4. Reductionsim denies that mental health issues are multi-dimensional, interconnected, and extremely complex. Drawing rigid, artificial, and arbitrary conceptual lines between them is inaccurate, confusing, and counterproductive for everyone.
  5. Objectification of the client’s experience reinforces the traditional paternalistic power structure which says that the therapist knows more about the client than the client does. The client is coerced by the authority of the test, and of the bureaucratic system which generated it, into accepting someone else’s definition of their own experience.

On top of these basic objections, there is also the more troubling cumulative effect of the belief that all of human life should be categorizable. This encourages a general cultural expectation of conformity and fear of complexity, which itself promotes prejudiced thinking and behaviour. Categorization directly enforces unfair and damaging cultural norms, stigma, and taboos. It obscures the wide diversity of human experience and places the power to decide what is healthy or not into the hands of an elite, disembodied, ideologically motivated “task force” within the cloister of the scientific/medical establishment.

Meaning is more important than measurement

Mental health is more than simply the absence of symptoms. Just as healthy cardiac functioning cannot be defined as an absence of chest pain, healthy mental functioning is more than the absence of observable symptoms of psychopathology. (PDM, p. 3)

In my opinion, however, the problems listed above are secondary to psychological effects this kind of categorizing diagnosis has on the client themselves.

Firstly, by viewing mental health only in terms of the presence or absence of statistically categorized “problems,” the DSM and ICD criteria encourage the mental-health community to define psychological “problems” in terms of should and shouldn’t. Either we do feel in a particular way, but shouldn’t, or we don’t feel in a particular way, but should.

This “should” is implied by the diagnostic structure itself and it is psychologically powerful. The fact that we are even being judged in this way implies that there is something basically wrong with us, that we should be something other than what we are. It feels like we personally have made some grievous mistake in our own development. So our turning out to be bad, deficient, incomplete, or unacceptable (i.e. “mentally ill”) means that we have failed as people and as human beings.This is one of the most damaging things you can possibly say to someone and it is often this exact feeling that brings clients into therapy in the first place. Objectifying them with DSM-style testing and diagnosis confirms this feeling and makes the problem worse, not better.

For example the view that men should be sexually attracted to women and women should be sexually attracted to men has caused untold suffering for homosexual and queer people across the world. The shame of being sexually “deviant” would be bad enough without the aggression, abuse, and violence which queer people of every stripe have had to endure for centuries.

A perhaps less glaring example would be successful people who should be happy, but aren’t. Because the DSM and ICD offer no empathy-based understanding of what depression is and what it might mean to the individual person, being diagnosed with Major Depressive Disorder can be confusing, painful, and even traumatic, thereby making an already bad situation worse.

This connects with the second negative effect of a quantifying approach to psychopathology: By judging a person’s health only by the presence or absence of specific symptoms, you overlook what each “illness” means to the person who is struggling with it. Depression means something very different for the person who was sexually abused than it does for the person who’s dog has died.

When working with human beings, understanding both the meaning of the events which give rise to their “problems,” and the personal meaning of the “problem” itself, is vital for appropriate and effective treatment. The reductionist checklists of the DSM and ICD ignore these meanings entirely, thereby de-humanizing the client, making the process more difficult, and doing more harm.

Vive La Différence

“When we diagnose, we are describing a pattern, a particular Gestalt, never a person. All people are unique. Labels, however well intended, cannot do justice to human complexity.” (Greenberg, 2016, p. 3)

Systems like the DSM and ICD are research-based and this is what creates the problems which have come up in this article. The purpose of scientific research is to get a bird’s eye view of a particular subject; to escape from the bewildering information overload of human experience which so easily confuses and misleads us

In other words, scientific research is specifically designed to make the world easier to understand by generating broad, generalized views of clearly-defined problems. This is an incredibly important tool and in the last two centuries it has helped us learn and understand more about the earth, the universe, and ourselves than at any time before.

But, to get this clear view of what is really happening “under the hood” of the collective human mind empirical research uses averages and trends and complex statistical methodologies which intentionally erase individual differences. This is extremely useful when you’re thinking about populations of thousands and millions of people, but it’s useless when working with individuals and small groups. Individual people’s problems and challenges are very, very non-general. What makes each of us who we are as people and as selves are the unique experiences and one-of-a-kind personal-historical details which have led us to be where we are right now.

These concrete emotional realities of individual people and small groups are the center of the psychotherapeutic process and so generalizing simply does not work in the therapeutic context. If we allow ourselves to be lured into treating a unique client in terms of a statistical norm, we not only ignore all of the fascinating, quirky, hilarious, terrifying, and weird stuff that happens inside their heads, but we reduce them from living, breathing people and turn them into objects-of-study. We insult their humanity and strip them of their dignity as thinking, feeling, autonomous and self-responsible human beings.

It’s Not The Tool, It’s How You Use It

Which is not to say that psychotherapists shouldn’t use diagnostic tools, but they need to think deeply and carefully about how the use of that tool distorts their view of their clients and how it structures the interactions which grow out of that view. Yes, it’s important to know what the characterstics, prevalence, and outcomes of depression, or anxiety, or bipolar, or borderline, or schizophrenia generally are, but only insofar as it opens an empathic window into the client’s specific experience.

And in my view, using reductive and generalizing tools like the DSM to diagnose and determine the shape of interactions with clients turns the client into a statistics and impairs the therapist’s ability to see and interact with them on a concrete, emotional, meaningful human level.

References

DSM-5 Diagnostic criteria for depression: https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria/

Etymology of “diagnosis”: https://www.etymonline.com/word/diaGnosis

“Mental Disorder” quote: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.

“Absence of symptoms” quote: Lingiardi, V., & In McWilliams, N. (2017). Psychodynamic diagnostic manual: PDM-2.

Greenberg, E. (2016). Borderline, narcissistic, and schizoid adaptations. New York, NY: Greenbrooke Press