I've been thinking about a post on clinical diagnosis for the last week, but a recurrent health problem forced me to strictly limit my time reading and looking at the computer screen, but things are good again, so here we go.
Cheryl Fuller wrote a post about the current obsession with diagnosis in the mental health field. I have quite a few thoughts related to this subject, so I'll spread them over several posts of my own. Here's Cheryl:
How different Jung's perspective is from what dominates today -- a fixation on diagnosis. In fact, if one is not assigned, then there is no third party payment. We may have rather hugely increased the number of potential diagnoses, but to think the process is actually precise or scientific is to labor under serious delusion. Following Jung's path takes patient and therapist to meaning of symptoms in the context of that patient's life.
When I first started out, all the psychiatric world was divided into 3 parts: psychosis, neurosis, organic brain syndromes. And yes, borderline was in there too along with personality disorders but not as major categories. I can't see that things are better now for having so many more labels. And does diagnosis, especially when considering the types of issues most frequently brought to us in our offices, make much of a difference in what we do, really? And is it helpful to the patient?
In the diagnostic system used for insurance claims, the DSM, checklists of symptoms lend an air of objectivity to diagnostic work. These checklists may include externally observable phenomena, patient and family historical reports and, in some instances, patient reports of conscious, subjective experience, though the latter is deliberately de-emphasized. This sounds like an effort to maximize diagnostic objectivity, so what's not to like?
Anything about a person that can be gleaned over time, drawing on subjective experience, inference and direct observation, can contribute to a richly detailed portrait of psychological life, one that treats the person in therapy not as a package of symptoms to be extinguished, but as a whole human being whose symptoms make sense within the context of a complex, unique, inner and outer world.
Consider a recent post in which I discussed the meaning of skis as a gift in an episode of the TV show, Mad Men. Now imagine, for a moment, that giving a gift is a symptom. A DSM approach to Mad Men would identify only the fact that a gift had been given. But simply understanding that a gift was given, wouldn't tell you if the gift was an expression of love, gratitude, appeasement, guilt or even a symptomatic manifestation of conflicted wishes, as I believe the gift in Mad Men could be construed.
In everyday life, reasonably insightful people take for granted that the most ordinary behaviors can have varying implicit or unconscious meanings that are apprehended based on the context and the subtleties of expression. For example, there are guilty smiles, nervous smiles, stupid smiles of amusement, smiles of delight and smiles of affection. A great deal is inferred automatically and, for most people, the inferences are accurate enough to function in a world populated by other human beings. Persons who are severely deficient in the ability to read behind words and actions have a very hard time making it in the world. But in order to create an "objective" diagnostic system, the idea of implicit or unconscious meanings has been abandoned, as if by closing our eyes to the complexity of human beings, our understanding of people becomes objective and therefore qualitatively superior. It's not superior. It is, in effect, a self-imposed psychosocial deficit.
Think, for a moment, about how you can sometimes recognize that a person who is bragging is doing so in an attempt to compensate for a denied, underlying sense of inferiority. Encountered in another context, a person building themselves up might convey a different subjective feel and meaning. In the DSM, this kind of knowledge about a person is gone, as if it doesn't even exist. Now wouldn't you think that your inference about a person's underlying sense of inferiority would be an important piece of information if you were trying to be of psychological assistance to that person? But seeing this requires the subjective inference of implicit mental activity.
The above example was necessarily simplistic to flesh out some basic concepts. In psychotherapy, everything is far more complex than that, but subjectivity and inference aren't deficiencies in clinical work. Rather, their absence would constitute serious deficiencies.
I have more to say on the subject of diagnosis, but I'm going to take on one issue at a time in future posts.
* I'm using the term depth therapy to refer to any of the many schools of psychoanalysis, including self psychology, Jungian Analysis and psychodynamic therapies.