by John Rowan
(Editors’ Note: This is an updated version of an article by John Rowan, of the same title, that we published in Issue 52, Summer 2007).
It is quite a frequent custom, in counselling and in psychotherapy, to give people labels. ‘This woman is depressed.’ ‘This man is anxious.’ ‘This girl is anorexic.’ ‘This boy has an antisocial personality.’ In some agencies it is compulsory to give such labels. Some insurance companies and some employers will not pay out for treatment unless a label is given. Increasingly in the United States these have to be psychiatric labels taken from DSM-IV, the medical diagnostic manual.
I saw recently a leaflet headed “Understanding and Helping with Depression”, in which a one-day workshop was offered, designed to answer questions such as “What is depression and how can we help people to help themselves?” “Ways to overcome depression?” “Practical techniques that lead to change.” “Challenging negative thoughts, irrational beliefs and thought distortion.” “Information on anti-depressant drugs.” This worries me because it assumes that there is something called depression, and also that suitable techniques can get rid of it. Indeed, it goes on to say that “There will be techniques to teach your clients procedures for overcoming depression.” There are books on how to deal with your depression, many of them.
Now in humanistic psychology there has long been a critique of this kind of thing. First, the question of whether there is such a thing as depression. I took part in a research study once where we were given a set of case vignettes and asked to say which of the people were suffering from depression. As I read through the descriptions of the people and their problems, the word ‘depression’ never occurred to me. And it struck me that when people come to see me as a psychotherapist, I do not devote any time to labelling them. Nor am I particularly interested in the labels other people have given them in the past. And I believe that the whole idea of labelling someone as ‘anxious’ or ‘depressed’ or ‘psychopathic’ is a dubious one.
Some years ago I had to write a second edition of my book The Reality Game (1998), and a number of things had to be changed because of the fifteen-year interval between its first publication and the present. But when it came to the chapter entitled “Diagnosis” I found that the main thing I had to do was to change the title to “Assessment”. Some new references had to be added, but the intent of the chapter was unchanged. It still warned against labelling. And writers like Mary Boyle have said things like this: “The problem with this language is that it confers on these concepts a permanence and solidity which is quite unwarranted, and suggests that they are entities possessed by people.” (Boyle, 1996:7)
Once you give a person a label, there is a real danger that you will respond to the label instead of to the person. Other writers are often saying this kind of thing:
Calling individuals phobic, obsessive-compulsive, histrionic or dependent personalities holds at least the suggestion that they are in a class by themselves, that is, that they are a different kind of human being.
(Costello et al., 1995:71)
It is a whole person who comes into my consulting room, and it is a whole person who has to be met and engaged with. I do not want to reduce the person to something smaller and simpler, and try to engage with that. Years ago, I came across a wonderful book by Eileen Walkenstein, a senior psychiatrist, called Shrunk to Fit (1975); the first chapter is entitled ‘Human Beings Can’t Be Diagnosed!’ As I understand it, all the humanistic approaches – person-centred (Farber, Brink and Raskin, 1996), gestalt (Yontef, 1993), existential (van Deurzen-Smith, 1997), psychodrama (Dayton, 1994), biosynthesis (Boadella, 1988), psychosynthesis (Whitmore, 1991), dreambody work (Mindell, 1985) and the rest – have in common that they do not want or need to reduce the person to some label or other. And the newer approaches such as narrative therapy (Freedman and Combs, 1996) take the same view.
The Medical Model
A second and separate point is that to talk in terms of labels like ‘depression’ is to adopt a medical model of disease and cure. The latest version of this is of course DSM-V (2013) which is currently arousing much controversy. Again this is something that does not fit with the humanistic outlook as I understand it. One of the characteristic things about the humanistic approaches to psychotherapy is that they reject the medical model. I myself am happier to talk in terms of growth and development than in terms of cure. One of the paradoxes of therapy is that the less we talk about curing the patient, overcoming the illness, dealing with problems directly, the better we can attend to and be with the client. It is this quality of presence that is the key thing for me if real change is being aimed at. Rather than enquiring as to what the client would like, it seems better to raise my own awareness of what it is like to be with the client and listen to them at all levels, and with all my ears. Some of the people in the person-centred, gestalt and existential traditions have been particularly eloquent about this. For example, I liked the statement of Joen Fagan:
The therapist is first of all a perceiver and constructor of patterns. As soon as he is informed of a symptom or a request for change, and begins listening to and observing a patient and responding to him, he begins a process that I refer to as patterning. While diagnosis is a more common term, it has the disadvantage of provoking the analogy of the medical model and implying that the purpose of the process is arriving at a specific label.
As a gestaltist, Joen Fagan seems to me to have a pretty clear idea of what this is all about: she prefers the analogy of an artistic creation, where new patterns are seen continually. And Gary Yontef chimes in, in his chapter on diagnosis: “But there is no Gestalt therapy cookbook. Cookbooks are for craft, and therapy is an art. And I think that doing therapy is an art that requires all of the therapist’s creativity and love.” (1993:282). Yontef speaks sometimes rather dogmatically or carelessly in rigid categories, but this statement of his seems to represent his more considered core views.
Of course it is impossible to avoid prescriptive assumptions altogether. As I have argued elsewhere (Rowan, 2005), even the interventions of person-centred counsellors are more prescriptive than they seem. For example, the question – “What are you feeling right now?” – implies that the client should be feeling something; the client should be in touch with his or her feelings; the client should be able to name the feelings; the client should be able to trust the counsellor enough to share these feelings; the client should be present in the here and now; and so forth.
The question may then be raised as to what we do instead of diagnosis or assessment. One alternative is well described by Diana Whitmore. She has a whole chapter on this, in which she says, among other things:
Whether the counsellor knows it or not, she will hold a particular perception of the client which, unless addressed, will remain unconscious. From her unconscious perception choices of how to work with the client are still made. Thereby the counsellor risks imposing her own judgements of normative health, losing sight of individual uniqueness and manipulating the client’s psyche towards her unverified perception. Psychosynthesis suggests that it is both wise and practical for the working hypothesis to be consciously created, loosely held and eventually verified or adjusted.
This is a good statement of the humanistic position. And her latter point, of the looseness of the way in which our guesses are entertained, is an important one. It is well stated by Freedman and Combs (1996) when they quote the celebrated injunction of narrative therapy – “Flirt with your hypotheses, but don’t marry them!” And it can be seen that Whitmore (1991) emphasises creativity in this, just as Fagan (1972) did.
More recently, Lucy Johnstone and Rudy Dallos have given a good account of the whole question of categorising clients. They say:
Formulation should be an ongoing process rather than a one-off expert pronouncement, and therefore one would hope that reformulation based on the client’s feedback would ensure that unhelpful formulations are revised or abandoned. Unfortunately this does not always happen.
(Johnstone and Dallos, 2006:215)
In their summary they say: “The potential criticisms and limitations of formulation echo the potential criticisms and limitations of therapy itself.” (230). These seem to me to be wise words.
If we must categorise clients, to suit the requirements of some employing organisation or other, there is always the excellent book by Barbara Ingram (2006) which at least uses psychological labels rather than psychiatric ones, and is very sophisticated in all its recommendations for action, including its suggestions as to what to do with such labels once we have got them.
To sum up, then, I just want to draw people’s attention to the humanistic position on this, because there seems a great danger of it being eroded by all sorts of influences rife today. There is a great tendency to rely on brief therapy, as has been clearly demonstrated by Neimeyer and Norcross (1997), and brief therapy lends itself very easily to diagnosis and contracts and treatment plans which are much more rigid than anything I would be happy with. More and more courses seem to be adding modules on assessment, often led by psychiatrists, and one can only be suspicious of this development. Are the students really being told the difficulties and objections, or are they being taken down the path of a real belief in the value and importance of once-for-all assessment? These are difficult times, and I think we have to consider these questions very thoroughly if we are going to make sense and not going to be caught out in sad contradictions.
John Rowan is an internationally recognised psychotherapist, author and consultant.
Boyle, M. (1996) ‘Schizophrenia: The fallacy of diagnosis’. Changes 14(1): 5-13.
Boadella, D. (1988) ‘Biosynthesis’. In J. Rowan and W. Dryden (eds.), Innovative Therapy in Britain. Milton Keynes: Open University Press.
Costello, T.W., Costello, J.T. and Holmes, D.A. (1995) Abnormal Psychology. London: Harper Collins.
Dayton, T. (1994) The Drama Within. Deerfield Beach: Health Communications. Diagnostic and Statistical Manual of Mental Disorders (2000). (4th edn.) Washington DC: American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders (2013). (5th edn.) Washington DC: American Psychiatric Association.
Fagan, J. (1972) ‘The Tasks of the Therapist’. In J.Fagan and I. Shepherd (eds.)’ Gestalt Therapy Now. London: Penguin.
Farber, B. A., Brink, D.C. and Raskin, P.M. (1996) The Psychotherapy of Carl Rogers. New York: Guilford Press.
Freedman, J. and Combs, G. (1996) Narrative Therapy. New York: Norton.
Ingram, B. (2006) Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. Chichester: Wiley.
Johnstone, L. and Dallos, R. (2006) Formulation in Psychology and Psychotherapy. London: Routledge.
Mindell, A. (1985) Working with the Dreaming Body. London: Routledge.
Neimeyer, G.J. and Norcross, J.C. (1997) ‘The future of psychotherapy and counselling psychology in the USA.’ In S. Palmer and V. Varma (eds.)’ The Future of Counselling and Psychotherapy. London: Sage.
Rowan J. (1998) The Reality Game: A Guide to Humanistic Counselling and Psychotherapy. (2nd edn.) London: Routledge.
Rowan, John (2005) The Future of Training in Psychotherapy and Counselling: Instrumental, Relational and Transpersonal Perspectives. Hove: Routledge.
van Deurzen-Smith, E. (1997) Everyday Mysteries. London: Routledge.
Walkenstein, E. (1975) Shrunk to Fit. London: Coventure.
Whitmore, D. (1991) Psychosynthesis Counselling in Action. London: Sage.
Yontef, G. (1993) Awareness, Dialogue and Process. Highland: Gestalt Journal Press.