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.

References

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.