Quality of Attention and the Limitations of Instant Expertise

by Gerard Staunton

Pat Comerford in his article “Humanistic Psychotherapists, Car Mechanics, Shakespeare and the DSM-5” (2016) expressed comprehensively his concerns at the prospect of humanistic psychotherapists employing the DSM for diagnostic purposes and invited other humanistic therapists to involve themselves in the debate. He was writing by way of response to Dr Denise Mullen’s article: “Let us make friends with the DSM” (2016), an article I also find useful in terms of structuring and clarifying some of the more important considerations involved.

The therapists’ contract and function
Dr Mullen highlights the dangers attendant on therapists “throwing around diagnostic labels such as ‘narcissist’, ‘borderline’ and ‘psychotic’ inaccurately and unhelpfully” (2016: 21). She offers by way of contrast the more specific claim that an individual meets eight of the DSM criteria for borderline personality disorder (ibid). I would agree that applying a label from a purely theoretical perspective, without clear consideration as to how such a designation may be of practical service in benefitting a client (such as to assist prediction of treatment outcomes), is altogether irresponsible.

There are occasions where, for the welfare of the client, we refer him or her elsewhere for diagnosis before we feel assured we can proceed to engage with his or her issue. If a difficulty emerges regarding sexual arousal, for example, we initially direct the client towards a medical diagnosis rather than assuming the issue is purely or predominantly of psychic origin. But we would be ill-advised, I feel, to seek to perform a medical diagnosis ourselves, either because we have been trained in techniques relevant to consulting a manual or even because we are ourselves medically qualified. It would seem ethically appropriate that, in the latter instance, the therapist ought to refer his or her client instead to another doctor for a quite separate, personally boundaried and contractually demarcated medical diagnosis.

When (in the context of a direct two-party contract) we refer a client to another professional, for example a doctor or a solicitor, such abnegation of our own claims to function as a medical or a legal authority precludes us from suggesting affirmation or opposition towards the judgement of that professional from a medical or legal perspective. But neither are our responsibilities in relation to our function as therapist fulfilled by restricting ourselves to mirroring the client’s responses to such judgements. If, for example, a doctor strongly recommends that a client restrict their workload, which might have implications for the earning arrangements within the client’s household, or a solicitor advises that a client pursue a particular line of confrontation with regard to a legal dispute with an in-law, such recommendations can have more than medical or legal implications, and the therapist has a responsibility to ensure that the client is conscious of these and of the client’s own sentiments in regard to such.

A client approaches a therapist or a solicitor or any other professional in pursuit of a particularly demarcated and accordingly contracted service. If an author approaches a solicitor in regard to a dispute with his or her publisher, it would be presumptuous were the solicitor (even if the solicitor were a respected published author) to offer formal submissions involving literary advice. Similarly, it is not the function of a therapist to formally seek to determine, for example, whether symptoms apparently involving delusionary cognition might not perhaps be secondary effects of a viral infection.

As Pat Comerford emphasises (op cit: 61-3), humanistic psychotherapists do not undertake to solve problems for clients, rather they engage judiciously in a collaborative exploration of clients’ issues with the objective, not of determining actions, dispositions or preoccupations in any favoured direction, but of rendering relatively narrowly determined actions, dispositions or preoccupations more optional and versatile.

Benefitting clients in a contractually ethical context
It needs to be acknowledged that in actual practice, the ethical imperatives are not experienced as being so straightforward. When a therapist is possessed of special knowledge or expertise that could benefit a client significantly, it can feel perverse to withhold a direct declaration of judgement. Dr Mullen attempts to address such a dilemma through an analogy inspired by a personal experience.

Dr Mullen’s example (2016: 20) essentially describes a situation where a car has broken down. Two hypotheses are suggested regarding the cause of the difficulty. The mechanic judges, on the basis of the findings of a “diagnostic test” (ibid), that the difficulty derives from a valve in the emission system. When he eventually makes a replacement, the problem is resolved and the car is effectively repaired. The driver who has towed the car meanwhile insists on sustaining the hypothesis – based on his adamantly promoted intuition – that the difficulty is due to complications regarding the fuel. Tests are run on the fuel accordingly, resulting eventually in disconfirmation of the driver’s hypothesis but only after such having caused considerable unnecessary anxiety, inconvenience and expense to the owner. This example suggests, according to Dr Mullen, that in the context of psychotherapy, “we need the diagnostic equipment (in our case the DSM) to assess accurately the presenting issues” (ibid).

Dr Mullen would appear to arrive at this specific conclusion (involving valorising the DSM) from her analogy, on the basis of a more general inference – that judgements deduced from objective (i.e., universally transparent) evidence are to be valorised whereas judgements based on subjective intuition are to be ignored. This more general thesis seems to me to offer a useful rule of thumb in many relatively straightforward instances. For example, if a therapist feels that he or she ‘knows’ through experience or by reputation that a particular expensive course of study that a client intends to invest in is inadequate and exploitative, he or she ought to be careful not to allow this subjective judgement to contaminate his or her engagement with the client. But if the course provider has been sued and found reprehensible, then that is a matter of record that does not require being withheld from the client. The ‘objective evidence’ criterion here would appear to apply.

However, consider a somewhat more complex and pertinent example: A client diagnosed as suffering from clinical depression and in recovery from substance addiction is attending a therapist with the desire of generally improving his life, his career opportunities and romantic relationships. Therapy has proceeded relatively smoothly and considerable progress has been made. Then one day the client arrives to announce he has suffered a ‘major setback’. Attending a wedding brought back memories of his own former wife. He describes how suddenly for the first time he felt on a deep level the extent to which he had hurt and disappointed her. (He explains that previously he had recognised as much intellectually but had persisted in cherishing the sentiment that he in fact was the injured party and had continued to resent her for having, so he felt, callously deserted him when he was most vulnerable). Overcome by his feelings, the client had to hurry back to his car where he wept copiously. Otherwise, he declares, he would not have been able to avoid crying publicly.

The client declares his intention of asking his psychiatrist to increase his medication dosage. The therapist carefully encourages the client to elaborate on what he has experienced as a setback and on his motivation in regard to seeking increased medication.

The sense of a major setback reveals itself as evoked through associations between the client’s present feelings of fragility and more ominous apprehensions of fragility suffered by the client in the past. Differentiating between his state now and state then, the client declares himself as feeling very sad but very lucid. He realises in the course of speaking that he is impelled to ask for an increased dosage not because he senses a need for such or welcomes such but because he deems it an upfront and responsible thing to do. The therapist intuits that while it is important that associations around the client’s feelings of fragility are effectively addressed in therapy, the client’s stability is not at risk and that significant developments in awareness occurring for the client could be negatively affected if medication is increased.

But how ought the therapist to proceed in regard to this intuition? Should he or she look for objective evidence from the perspective of a conventional diagnosis and seek a relevant self-report from the client? If he or she does, then I suspect that the client might indeed figure as particularly subject to depression, scoring (on the DSM checklist) as intensely affected by guilt, low self-esteem and perhaps in (temporary) withdrawal from routine engagements. The client’s interview with the psychiatrist might further confirm this scenario.

It is not my habit to request a self-report in the context of suchlike instances. Instead I might carefully recommend to the client that he or she (regardless of prevailing constraints such as time restrictions) talk with the psychiatrist, allowing himself something approaching the same uncensored freedom of expression as he or she has enjoyed talking in therapy. And it is my recurrent experience that psychiatrists in consequence do not increase the medication dosage. Many times they reduce it and offer much appreciated encouragement to the client (e.g., by informing them that such an imagined aberration on their part represents a very normal human reaction).

There are many other aspects of this instance to which the therapist would need to pay attention. He or she would need to consider, for example, whether the sudden lowering of the client’s defences indicated lack of vigilance on the therapist’s part in regard to the effect of the therapy on the client. He must consider potential implications of the client’s dramatic reversal of disposition and potential associations between the client’s former reactions involving substance abuse and his current intention to seek an increase in regard to medication dosage. The therapist might need to apply particular scrutiny towards words and phrases such as ‘feeling overwhelmed’ and explore what exactly they signify to the client.

Formulaic approaches based on restricted enquiry and rigid categorisation offer little likelihood of taking adequate account of such subtleties and nuances. The central importance of intuition and metacognition (experiential learning) is recognised not only with respect to therapy but with respect to medicine:

Intuition is the close companion of metacognition in the experiential repertoire of the primary care physician. Its importance is enhanced by the doctor’s capability to develop and maintain a relationship with the patient. Often the power of intuition grows from reflections about the complex patterns of behaviours, perspectives and feelings that constitute their relationships.

(Quirk 2006: 57)

Supervision offers an invaluable metacognitive resource for the therapist and assists in identifying potential errors affecting intuition. Along with aggregation bias (inappropriate inference on the basis of aggregate data) and gender bias (the conviction, without supporting evidence, that the gender of a client counts as a significant factor in their diagnosis), Quirk particularly highlights anchoring, that is the “tendency to focus on salient features too early in the diagnostic process” as a prevalent error (ibid: 61). It would be unfortunate for a client if his or her therapist, for example, were to be tempted to focus over-emphatically on the more sensational details of a client’s history regardless as to whether these represented features of the client’s presenting issues or revealed themselves as significantly problematic for the client. For the therapist, unsolicited, to actively seek out the salient for prioritised attention – through scrutinising the client for indications of inclusion within some DSM classification – would seem only to aggravate the liability of falling victim to this particular error.

Issues of agency
I have referred above with approval to Pat Comerford’s affirmation that humanistic psychotherapists do not perceive clients as being invested with faults to be potentially repaired. Neither, I suggest, do we view them as dispossessed of agency. In both these regards, diagnoses in relation to clients might be expected to differ radically from diagnoses in relation to cars.

However when clients discuss the events precipitating a psychiatric intervention, they often refer to themselves in precisely such reified terms. On being asked why such an intervention came about, clients commonly give it as their impression that some kind of deficit had been detected within them: ‘I was thinking strangely at the time’, ‘I was behaving oddly’. When exploration of such strangeness of thought or oddness of behaviour, however, reveals no obvious concern so alarming as to warrant any kind of radical action, a more informative portrait tends to reveal itself, involving generally a novel situation of vulnerability (often caused by recent loss of, or recent distancing from, routine supports), a state of shock or panic or other condition (e.g., sleeplessness) that inhibits their capacity to engage correctively with disorientations and, crucially, an inability or unwillingness to effectively articulate their motivations, perceptions, apprehensions and experiences. In general, they tend not to feel possessed of agency and to feel the need of a radical intervention, a need usually communicated initially either to intimates or to doctors, police, teachers, church members, and so on, though sometimes directly to psychiatric services.

According to the recollections of clients, at such junctures they are seeking some basic relief and security rather than aspiring towards any more exact sense of purpose. They feel the need for reliance on external rather than internal resources and authority. In summary, they perceive themselves as patients rather than agents, service-dependants rather than service-users (the specific phrasings here are mine, not the clients’). At such times of intervention, the client’s perception of his or her state and circumstance as fundamentally passive renders the terms of comparison governing Dr Mullen’s analogy (involving clients being metaphorically represented by cars) not altogether provocative. But the same metaphor, I would argue, reveals itself as wildly distortive when applied in the context of a client’s engagement with a humanistic psychotherapist.

A client who is accepted for therapy must come as an agent, being in receipt of adequate supports and being able to engage and articulate, at least tentatively, personally nominated issues and objectives. A client’s application for psychiatric intervention may be urgent and arbitrary but a client cannot engage a humanistic psychotherapist arbitrarily, it being a basic principle of humanistic psychotherapy that a fit must initially be established between the individual client and an individual therapist. This prerequisite (including, for example, a capacity for transference) is not only important in ensuring some possibility of the work proceeding valuably; it represents a basic safety concern. And one can only establish such a fit regarding relatedness on a uniquely individual basis – it cannot be established on the basis of a typology. The communication that the client meets eight of the DSM criteria for borderline personality disorder conveys no adequate information to the psychotherapist in such context. It is not only that, as indicated above, self-report may distort in suggesting concerns that are excessive in terms of what applies in reality. A self-report that suggests an absence of such concerns may also be significantly and dangerously distortive. The relatively uncensored environment offered through psychotherapeutic process often prompts important admissions not ventured in the context of a psychiatric intervention – for example, the information that what was presented to authorities as an accidental overdose represented in fact a deliberate suicide attempt. (The client will readily venture such admissions even though fully informed and aware that such admissions must be reported).

The relatively uncensored environment of therapy allows also for recovery of repressed memories, for confession of embarrassments, for recognition of unsuspected connections and for the exploration of dreaded or unacknowledged fantasies. The client becoming possessed of such knowledge becomes more able to advance their own sense of agency and to express such to positive effect in communication with others, including in communications in a psychiatric context.

Clients cannot be reckoned in the round. If someone we love deeply were seeking therapy, we would not wish them to be considered as any client whatever, but with due regard to their singular complexity, their wealth of potential and liability to adverse circumstance. Not as any old car to be simply got on the road again but as a Grand Prix racing car to be handled with highly individualised care.

The testimony of a Grand Prix mechanic as to what his work actually involves may offer justification for such a modification of the client/car analogy:

One learns to understand the feel of the work, whether something is either right or wrong. It’s almost a sixth sense, a sort of inner knowledge that tells you that the work you have done is finished and that the car is safe to leave your hands. It is the knowledge that a nut and bolt are tight, and not merely cross-threaded; it is understanding the feeling transmitted through the spanner to the hand, that the threads you are working are of the same type, not a mismatch of metric and imperial sizes. The awareness that a bolt is tightened just right – neither loose nor so tight that the thread is stretching, the material yielding to the point that it appears to be freeing again. An understanding of the difference, felt through the fingers, that a crankshaft is turning freely or that the bearings are fractionally too tight. A difficult concept to put into words, but knowledge of vital importance. A craftsman from any trade will tell you the same story. Like the maturation of a fine wine, it is a proficiency that has to be nurtured slowly and with great care. There are no shortcuts.

(Matchett, 1999: 10-11)

Gerard Staunton is a humanistic psychotherapist working in private practice in Cork.

Comerford, P. (2016). Humanistic psychotherapists, car mechanics, Shakespeare and the DSM-5. Inside Out, 79, 60-70.

Quirk, M. (2006). Intuition and metacognition in medical education: Keys to developing expertise. New York: Springer.

Matchett, S. (1999). The mechanic’s tale: Life in the pit-lanes of Formula One. London. Orion.

Mullen, D. (2016). Let’s make friends with the DSM. Eisteach, 16(1), 20-22.