ARTICLE: October 2011

A question: What’s in a label? Or put more directly and in regards to a psychotherapist’s tools and their clinical usefulness: What are some of the benefits and pitfalls of the tools of diagnosis and assessment, especially in consideration of the multiple ways in which their usage might affect client treatment? Broadly speaking, how might these tools be seen as either supportive or detrimental to effective treatment? Furthermore, let us consider how using these and other means of categorization might influence how we treat a client’s presenting condition, and also how we treat the client as a unique individual; for treatment is meant to treat, and in this offering I will look at how diagnosis in particular, and assessment generally, might allow a clinician to best serve their clients. In doing so, I will also attempt to unearth some of my own biases regarding the matter, and although we’ve begun with mostly questions, it is my intention to end with mostly questions – a move from posing them to practicing them therapeutically, and thus applying and processing their assured uncertainty in a curious and receptive manner.

From my perspective, pretty much everything a clinician does might be considered ‘assessment’; and, it seems that self-assessment is very often why a client comes to see a therapist in the first place. The client seeks the support of a new perspective in assisting them in re-assessing their life and its many conscious and unconscious choices. I very much appreciate the role assessment plays in offering clients the new possibility of therapeutic thrust and traction with whatever might be troubling them. Without assessment, where might the therapy’s thrust be found or take place? Assessment is both the subtle and bold act of daring to be incorrect, and in this daring and dancing both client and therapist slowly and carefully fumble their way towards greater client integration, functioning, and health.

On the other hand, I understand diagnosis to be one of many assessment tools, and when used as such it seems to be a potentially powerful aid in the service of client growth – a powerful tool that is, if we ‘hold’ our diagnoses lightly and remain open to the great mystery of the actual ‘human unfolding’ before us. That said, when diagnosis is used for other ends such as premature labeling, solely for acquiring insurance coverage, or for some other pigeonholing agenda, I then feel diagnosis a disservice to clients. Or, as McWilliams (2011) cautions, “When any label obscures more than it illuminates, the pratitioner is better off discarding it and relying on common sense and human decency…” (p.19). From my perspective, when a given client truly has a severe condition, then the ‘shorthand’ of diagnosis seems likely to be in the client’s best interest.

For myself, it really does seem to boil down to the ‘degree of severity’; but who’s to assess severity? The clinician does this, and so the wheel of assessment continues to turn round and round. However, even when a ‘severe diagnosis’ is made, I believe that the wheel of assessment should always be moving, even if only minimally – for even though there is the ‘shorthand’ assessment via a diagnosis, a skillful clinician does not loose sight of the ‘longer hand’ and complexity of reality. “Ongoing willingness to reassess one’s initial diagnosis in the light of new information is part of being optimally therapeutic” (McWilliams, 2011, p.19). Lastly, A diagnosis is a construct – assessing when it serves client growth and when it does not is an unfolding process. Even though a given condition may appear ‘stone-like’ or permanent, as a clinician I feel it important to remain open to the potential for change, fluidity, and more full expressions of freedom.

I very much appreciate the diagnostic distinction we’ve discussed between ‘pathology’ and ‘conceptualization’ – between a disease-based perspective on the one hand, and using ‘naming’ to establish an effective therapeutic framework on the other (Craven, 2011). For myself, and for this very reason, I am drawn to working via a health-based perspective – one in which the tools of assessment (including diagnosis) are used primarily in the service of client self-awareness. As intimated, the simple act of naming can oftentimes ease anxiety of some ‘unknown thing’ that acts upon us unconsciously; when used in the service of client empowerment and insight, I see diagnosis as a beneficial choice – it aids therapist and client in creating a metalevel from which to marshal their therapeutic efforts. Being skilled in diagnosing also allows the holistically-inclined therapist access to the often-formidable world of the medical model perspective.

It seems to me that using diagnosis from a pathologically-based appreciation accomplishes the exact opposite of a collaborative approach, and thus instead encourages the non-permeable categories of ‘therapist’ and ‘patient’. These designations of course serve to a certain extent; however, it is essential to recognize them as designations, as this in my opinion is foundational to creating a therapeutic alliance between therapist and client. In the DSM-IV-TR this same sentiment is echoed, “…there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (p.xxxi, 2000).

Just like a soup can’s label lists the ingredients contained within, so too does a diagnosis list elements of a client’s psychological and inner constitution; and neither says anything definitive about the experience of ‘tasting’, of the unique flavor that each will exhibit. A diagnosis is a beginning, a conventional ease of communicating that ‘points towards’ an infinitely complex client psychology; but again, it is only a beginning – where diagnosis finds its limitations, the process of assessment continues on indefinitely.

REFERENCES

American Psychiatric Association: Diagnostic and Statistical manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Craven, P. 2011. fall quarter. Diagnosis, Assessment, & Therapeutic Strategy A, HPC 5200. Class Lecture. John F. Kennedy University, Pleasant Hill, CA.

McWilliams, N. 2011. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2^nd ed.). New York, NY. Guilford Publications, Inc.

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