Thursday 18 November 2010

Labels, Boxes, Maps – The Question of Diagnosis

I believe that CBT is at its strongest, and most proven, when tackling specific mental health diagnoses such as depression, social anxiety, sexual addiction, etc. However, diagnosis and classification is a controversial topic within the field of counselling & psychotherapy, and many therapists question the status of such diagnostic categories, whether found in the DSM-IV or not. Rogers (1951, p. 223), for instance, considers that ‘a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise.’ The other extreme view is strongly represented within the addiction counselling field, where many counsellors see addictions as discrete 'disease' entities, following the view set out by Alcoholics Anonymous (Alcoholics Anonymous, 1976; Thombs, 1999), rather than as being on a continuum of behaviours, feelings and thinking shared by all human beings (and even by other animals). While I hold the continuum view of addiction, and of mental illness in general (Gilbert, 1992), I also feel that some sort of classification is helpful, and that it is important to try to define entities such as depression etc, albeit not in a rigid way.

Some of the controversies involved might be resolved by looking at the idea of definitions in general in a less rigid way. Finch (1995, p. 35) describes how Wittgenstein queried the notion ‘… that concepts should have definite and clearly bounded meanings, each concept only applying to all the things that have a particular definite feature in common.’ It is hard, for instance, to find any common denominator for all the things called pictures or games. Rather than requiring common features in the definition of a concept, Wittgenstein suggested that the presence of ‘family resemblances’ is sufficient; this means that different instances of a concept share some overlapping features with others, but there is no single common feature (Finch, ibid.; Vyse, 1997). Many definitions of mental health problems seem to fit this description quite well.

Carl Jung was of the opinion that ‘Clinical diagnoses are important, since they help give the doctor a certain orientation; but they do not help the patient. The crucial thing is the story’ (1963, p. 145). I would strongly disagree with this, as my experience is that a definite diagnosis is often very welcome to clients, helping to name and normalise their problems, to “put some shape on them”. However, this does not mean that I necessarily support the "Disease Concept" of addiction (Thombs, 1999; Peele and Brodsky, 1991; Miller and Rollnick, 1991). Peele in particular (1998) has argued for a view of addictions that sees them as real entities, which are nonetheless on a continuum with non-pathological experience. Similarly, Gilbert (1992) suggests that the Disease-Centred, “Platonic” approach to mental disorders such as depression (seeing them as qualitative variations from the normal), which was pioneered by Kraepelin in the early 20th century, is only one possible approach. The alternative Person-Centred or Biopsychosocial approach, where disorders are seen as quantitative variations from the norm, Gilbert traces back to Hippocrates.

Such diagnostic classification addresses our need to be able to approach problems in a systematic way. Orme (1984, p. 68) contends that ‘…anyone thinking he can help someone who is in psychological difficulties, who cannot at the same time systematically label those difficulties, is going to be as much use as a surgeon trying to set a broken limb with no knowledge of anatomy.’ Similarly, research into a particular disorder requires mutually agreed definitions. On the other hand, psychological difficulties may be less objective, and more socially constructed, than are anatomical distinctions. Young points out that diagnostic technologies such as the DSM-IV ‘… are an integral part of the historical formation of some of the disorders … that they now identify and represent.’ (1995, p. 107).

The bottom line for me is that many clients seem to find an appropriate diagnosis, along with education in the relevant Cognitive-Behavioural model, very relevant to some of their mental health problems. It provides them with both a map of the territory in which they find themselves lost, and a highly motivating sense of identification with others in a similar predicament.


Alcoholics Anonymous (1976) Alcoholics Anonymous. New York: A.A. World Services.

Finch, H.L. (1995) Wittgenstein. Shaftesbury, Dorset: Element.

Gilbert, P. (1992) Depression: The Evolution of Powerlessness. Hove: Erlbaum.

Jung, C.G. (1963) Memories, Dreams, Reflections. London: Fontana.

Miller, W.R. and Rollnick, S. (1991) Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guilford.

Orme, J. E. (1984) Abnormal and Clinical Psychology: An Introductory Text. London: Croom Helm.

Peele, S. (1998) The Meaning of Addiction: An Unconventional View. San Francisco: Jossey-Bass.

Peele, S. and Brodsky, A. (1991) Love and Addiction. New York: Taplinger.

Rogers, C.R. (1961) On Becoming a Person: A Therapist’s View of Psychotherapy. London: Constable.

Thombs, D.L. (1999) Introduction to Addictive Behaviours. 2nd edn. New York: Guilford Press.

Vyse, S.A. (1997) Believing in Magic: The Psychology of Superstition. Oxford: Oxford University Press.

Young, A. (1995) The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press.

Wednesday 3 November 2010

Help Yourself: The value, or otherwise, of self-help books.

I was recently involved in a discussion on this topic on the Dave Fanning Show (30th October, 2FM), and I thought it would be useful to share some thoughts here. I often recommend and make use of self-help books, but I am also wary and critical of them, as they aren’t all helpful, and some may even be damaging.

First of all, I am a fan both of self-help (in fact, I think therapy should ideally be a kind of facilitated self-help) and of books (as anyone who knows me will know), so “self-help books” sounds like a match made in heaven. However, I think real self-help books need to be distinguished from those that are just inspirational, and self-help books which are based on sound psychology need to be distinguished from those that probably aren’t. And, of course, even the best self-help books need to be used, and their suggestions practiced, not just read and admired (sometimes, I think, they are not even read, just bought with the proverbial good intentions and left on a shelf to be examined thoroughly “someday”).

The best self-help books are concrete and specific, challenging as well as supportive, not overly “dumbed-down”. And they don’t claim to be earth-shatteringly new; on the contrary, any plausible self-help book should claim to be in line with current best practice in the area it addresses (e.g. improving confidence, healing relationships, achieving more career-wise, reducing anxiety, or whatever).

More specifically, many of the best ones are based on some version of CBT principles. Positive Psychology and affirmations, for instance, are not enough on their own to effect real change in most circumstances. And changes in our thinking can only change our behaviours and emotions, it can’t directly change objective reality. And there are limits in life - many things are impossible. Any other view can just raise false hopes, leading to increasing disappointment rather than positive change, and often to guilt and self-recrimination for not “getting it right”.

I should finish by making some helpful suggestions…

Here are some self-help books I think are amongst the better examples of the genre, including some that go way back:

Weekes, C. (1995) Self Help for your Nerves. Reissued edition. Thorsons.

(First published in 1962).

Scott Peck, M. (2008) The Road Less Travelled: A New Psychology of Love, Traditional Values and Spiritual Growth (Classic Edition). Rider.

(First published in 1978).

Jeffers, S. (2007) Feel the Fear and do it Anyway. 20th Anniversary edition. Vermilion.

Burns, D.D. (1998) Feeling Good – The New Mood Therapy. 2nd edition. Avon Books.

Burns, D.D. (1989) The Feeling Good Handbook. New York: Plume.

Davis, M. et al (1995) The Relaxation & Stress Reduction Workbook. 4th Revised edition. New Harbinger Publications.

Neenan, M. (2009) Developing Resilience. London: Routledge.

A couple of good Irish ones:

Tubridy, A. (2008) When Panic Attacks. Gill & Macmillan.

(Burns, incidentally, has a book with the same title).

Bates, T. (1999) Depression: The Commonsense Approach. Newleaf.

And here are some that I currently recommend to clients:

Kennerley, H. (2009) Overcoming Anxiety: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

Gilbert, P. (2009) Overcoming Depression: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

Davies, W. (2000) Overcoming Anger & Irritability: A self-help guide using Cognitive Behavioural Techniques. London: Robinson.

There are many others in the Overcoming series which may be useful depending on the issues – check them out

That’s all for now. There will be no blog next week, as I will be on holidays. In the meantime, help yourself, read a book…