Engaging with the discourse of diagnosis in therapy (with particular reference to addiction)
by Gerard Staunton
In this article I suggest an approach to the issue of discourse around diagnostic categories, focusing mainly on addiction, with the aim of situating such discourse in the best service of therapy.
Issues and individuals
Clients and practitioners both tend to employ terms related to diagnostic discourse such as ‘addiction’ and ‘depression’ as reference points. For example, clients self-identify as addicts, present with issues of addiction or relating to addiction. Practitioners are alert and draw attention to dynamics of addiction. Clients discuss their relative freedom from—or susceptibility to—addiction.
In my practise of psychotherapy such terms are used both by my clients and by myself frequently enough. I do not observe the use of these terms as offering insights or illuminations in themselves; often enough, in fact, they evoke confusion, referring to something not sharply focused, or easily or consistently defined, but rather a phenomenon remaining stubbornly elusive. But it is this very function of indeterminately marking out a space for the elusive that seems to recommend them for use to client and to therapist alike. Analogous to the use of x and y in algebra, they can serve as generalisations, very deliberately broad and vague terms traced in tentatively until some more individually relevant positioning of the issue is derived.
The label of addiction as a viable and flexible mutual reference point shared between client and therapist represents, as suggested above, on one level the unknown, a mystery, an enigma. It represents that which eludes articulation and it represents experience not answerable to perception. At an initial time of crisis when a client finds that he or she requires intervention from addiction or mental health services, clients are generally in a state of disorientation which does not allow them to articulate their experience adequately and faithfully. In so far as personal disclosures by clients are concerned, practitioners at such times tend to be forced to rely on the “particularities” rather than the “singularities” respecting the client (Vanheule, 2014: 103). In other words, the practitioner may gain a sense of the client’s predispositions towards crisis and underlying vulnerabilities without having any enlightenment as to why such latent predispositions and vulnerabilities which remain dormant in other individuals, and which had lain dormant in the client until recently, should actually manifest as full blown addiction or mental illness.
An analogy might be drawn with psychosomatic illnesses. Often in such instances, the client suffers from some really existing but relatively trivial organic complaint. Such represents a particularity concerning the client, something the client shares more or less in common with other clients suffering from that same particular complaint. But what has effected the transformation of this initial minor adversity into an enigmatic crisis is singular in response to the client’s unique set of experiences and system of associations. What is decisive tends not to be something structural regarding the fundamental personal dynamics of the client but rather something transitional—a special intensification, complication or combination of pressures that causes the client’s experience to become unanswerable to perception. By this I mean that the client is in receipt of a phenomenon that seems impossible to articulate with any approach to adequacy.
This is not the kind of information that will normally be forthcoming from the client at the time of crisis. Such information may be withheld through shame or embarrassment. Particularly unwelcome impressions or experiences may have been repressed. Often such experience is of a sexual nature but there are other experiences too painful to bring to recognition (e.g. betrayal by one whom one has idealised). Sometimes clients will not be aware of how deeply affected they have been by experiences because it feels wrong or absurd to be so deeply affected by something seemingly trivial relative to what might conventionally be regarded of more serious concern. What has affected the client tends essentially to be sensitive matters of some sort that require being explored at a time of safety, with care and discretion, being allowed appropriate patience and adequate time. Also, an opportunity for reverie is required; the client needs to be able to advance and retreat from progressive and illuminating but often initially troubling insight; to oscillate between playfulness, seriousness, admission and repudiation. This then is a crucial consideration. The singularity of the client requires a specific response from the therapist; a response that is unique to the client.
Formal aspects of diagnosis
When a client who is externally perceived or self-perceived as ‘addicted’ or suffering from a ‘disorder’ first presents in the context of an emergency to a doctor, a psychiatrist or another relevant service, the client’s presentation and self-disclosure tends not to be characterised by clarity or comprehensiveness but by hesitation, confusion (or contradiction) and general uncertainty. It would be surprising or perhaps even disconcerting if some of this hesitation and uncertainty failed to manifest through the diagnostic process.
The ‘formal findings’ themselves, that is the findings that declare themselves ultimately based upon scientific criteria—transparent to the general informed reader and open to attempted replicability through experimental testing, claim no infallible authority over the individual instance but rather a prediction supported by general statistical evidence. It is my observation from my examination of diagnoses that the formal report tends to remain modest in its claims and careful to acknowledge alternative interpretations of the client’s symptoms than those conforming to the favoured diagnostic hypothesis. And informally, according to my client’s accounts, diagnoses are often suggested initially in a tentative manner, e.g. ‘It looks like you may be suffering from an anxiety disorder’ or ‘It appears to me that you may be bipolar’. Yet once formalised, the diagnosis is framed so that it now represents an element in an official and authoritative discourse – a judgement that can now be interpreted as relating to an individual’s fundamental psychic structure rather than relating to a specific transitional contingency. This occurs almost invariably within one exclusive context – an individual’s abdication of agency. Individuals generally become diagnosed in regard to addiction or mental health conditions only when they confide that they no longer feel able to rely on their own judgement.
Clients may welcome such a diagnosis and find it useful as it can orient them towards some initial capacity in regard to a sense of responsibility and agency. There is a difference between an individual telling him or herself: ‘I am an alcoholic’ or saying instead ‘I find myself compelled to drink’ and a difference between the self-statements: ‘I am paranoiac’ and ‘I can’t stop these intensely irrational suspicions’. The former statements (‘I am alcoholic/ paranoiac’) convey an acknowledgment and an alertness to the dangers of indulging with a particular fantasy where the latter statements seem to emerge within the entertainment, to some degree, of such an indulgence.
The client’s identification with the diagnostic statement can assist him or her in avoiding ‘addictive’, ‘anxious’, ‘paranoiac’ and ‘depressive’ behaviours. But it is not the statement ‘I am an alcoholic’ that is provoking the individual to drink. It is the statement ‘I must have a drink’. The latter statement is not an evaluation or a judgement; it involves the actual subjective experience. This experience requires sensitive understanding and must be explored along its own spoken and performative terms.
A diagnosis tends to be regarded as a viable hypothesis (that might potentially turn out to be the factual truth, the exact definition as to the phenomenon). But it might be better regarded instead as one viable perspective, not exclusive of others. Suzette Haden Elgin gives an example of how when a perspective – one insight among many – is invested in and regarded instead as an exclusive hypothesis, it can engineer an evaporation of any alternative insight:
Once we had evidence that painkilling drugs work by locking into specific receiving sites in the brain – at actual anatomical sites, not figurative ones – we had a real problem with the equally inescapable evidence that pain can be eliminated without drugs. An immediate search for some way to fit all this into one reality resulted in the “discovery” that the brain, when properly stimulated – for example, by hypnosis – manufactures its own “painkilling drugs” which lock into anatomical receiving sites just as morphine does. It was then possible to be comfortable with the known facts about pain again.
(Haden Elgin, 1983: 181)
When an individual makes statements such as above ‘I am an alcoholic’ or ‘I desperately need to drink’ to a diagnostician, they are not attended to as a psychotherapist might. For one thing, the spoken dialogue with the diagnostician will become raw material for written documentation and the prospect of such a conversion (from speaking to writing) radically affects communication and understanding from the outset as Good explicates in the context of medical training:
Thus writing is multifaceted. It authorizes the medical student, justifies the interaction with the patient. It organizes the conversation with the patient, the whole process of working up the patient. It is written for an audience: other physicians who will not only make decisions based on the document, but judge the student based on its writing.
And it is a critical dimension of formulating the patient as a project for treatment.
(Good, 1994: 77-78)
A diagnostic process observing the conventions of the Diagnostic and Statistical Manual (DSM) similarly observes particular audience conventions.
The individual’s statement that ‘I’m an alcoholic’ might be received in such a context as a positive realistic accurate and undistorted perception. His or her statement that: ‘I feel I need to drink or else something terrible might happen. I feel relief the minute I hit the pub’, might be regarded as more indicative of distorted perception.
But in therapy these statements will be received differently. The latter statement may describe a distorted perception but with the individual articulating it in this way, he or she is authentically trying to communicate the mystery of the phenomenon, to establish an algebra of the unknown in tandem with the therapist. Whereas the statement ‘I’m an alcoholic’ evades any such encounter and may even involve a denial of agency.
Informal aspects of diagnosis
As suggested above, the diagnostic process also contains informal aspects. The practitioner’s interpretation or comments respecting the formal findings are themselves informal attributes. The same formal evaluation might be interpreted very differently by some other practitioner, familiar or unfamiliar with the individual being evaluated. Diagnosis cannot be expected to be a purely abstract exercise divorced from individuals’ concerns and interests in the everyday. The diagnosis might, for example, affect whether the individual remains at liberty or goes to jail, retains a job, enjoys custody of a child, claims certain welfare benefits or academic assignment exemptions. It can represent a certain degree of amnesty from responsibility in respect to conflicts with partners, family or friends. Diagnoses moreover are made in the context of what treatments are practical or reliable or available and sometimes in regard to which are currently fashionable or recommended. A practitioner might at times see fit to refer the individual to therapy but this may depend on whether the practitioner has reason to be personally assured of the appropriateness of referral to some particular therapist with whose practise he or she is familiar. The context of the client’s own presentation of their issue may affect evaluation also, for example when a client seeks the intervention of mental health services after a negative drug-induced effect or seeks exemption from work or study on the basis of anxiety or depression.
Felicity Callard documents a series of psychiatric diagnoses she received, drawing attention as to how:
… the diagnostic terms are used for several distinct purposes: to underpin a medical insurance claim; to justify to an employer why an employee was not at work; to ensure that an employer fulfilled particular duties in relation to an employee; to capture a case history that would later be appended to a larger set of clinical records; to speak across clinical boundaries (here, between psychiatry and psychotherapy) to ascertain whether psychotherapy might be appropriate alongside pharmaceutical treatment; and to inform an employer how an employee was likely to perform in the future.
(Callard, 2015: 530)
I do not mean to suggest that whenever a client receives a diagnosis through a drug-induced experience or through seeking an exemption, the significance of such a client’s appeals for intervention ought to be trivialised or discounted. The appeal for intervention may be significant if it seems an excess reaction to circumstances and could in some instances represent a transitional critical development involving a client’s abdication of agency.
A diagnosis is not some abstract exercise in categorisation. It involves a practical overview and it is often arrived at in the context of a crisis. It is designed to help the individual address the concerns and considerations that have arisen from that individual’s current predicament; concerns and considerations which may need to be estimated urgently and on the basis of what are likely to be—given the individual’s perturbed state at the time—highly unreliable disclosures. Dodes and Dodes (2014) refer to this potentially distorting factor in evaluations in the specific context of Alcoholics Anonymous surveys, noting that “… self-reporting is a tricky methodology, prone to the illusions of self-deception and imperfect memory” (43). Self-deception and imperfect memory can be particularly pronounced at the time of crisis when a diagnosis is considered requisite.
It is important, when referring to diagnostic issues, to candidly acknowledge the pragmatic dimensions of diagnosis and to avoid being complicit with any evasion by the client of such aspects. Clients might not have confided details of substance abuse for example at the time of diagnosis or may have represented the effects of a failed suicide attempt as being due to an accidental overdose. Clients will therefore need to be informed in advance that, where relevant, their admissions may have to be reported. In my experience such alerts have not inhibited clients from speaking candidly and they have given expression to feelings of relief and satisfaction after having done so. Clients may have experienced improvement in their general state of well-being since they were diagnosed as suffering from a ‘disability’, and feel that this evaluation no longer accurately applies to their situation or condition; but they may feel anxious in regard to acknowledging this apprehension directly—even to themselves, because of the prospect of potentially foregoing relevant benefits that continue to offer them a significant sense of security.
It is well to regard a diagnosis not as simply a hypothesis as to psychic structure and predictive behaviour but as a strategic response made in the context of a complex crisis at one particular time.
Experiences of psychiatric diagnosis are indispensably mediated: even if one’s clinician speaks extensively face to face about diagnosis, there is always a much wider set of discourses and traces that frame the meanings of the diagnosis.
(Callard, 2014: 530)
Engaging with the issue of diagnosis in therapy
No fundamental difference in approach is required, in my experience, in engaging with diagnosed as distinct from non-diagnosed clients. But the fact that a client has been diagnosed will inevitably constitute an element of their issue, their history and context and must be accordingly assimilated as such within the therapeutic procedure.
When exploring any client’s issue, it is important to attempt to identify what it is that actualises it as a therapeutic issue. So a client may initially simply state that they want to resolve their addiction but on exploration, the client confides that he or she wishes to recover some capacity, quality of relationship or fluency of intuition that he or she has lost. It is important to establish what the client authentically desires, not only because this is required to motivate the client towards commitment to the therapy, but also as this will serve the therapist and client as a reliable index of how effectively the therapy is proceeding. Often a client may show reluctance in expressing his or her authentic desire through feeling that this desire is fantastical. Confronting such inhibitions represents a very significant element of the therapy as also may exploring clients’ sense of which desires are real and which fantastical. For example, a client may consider it fantastical to expect to even approach, let alone actually engage with or court some idealised other, while considering it realistic that the desired individual may somehow eventually come to recognise the client’s love and virtues and merits and accept the proposal the client would like to make without the client ever actually endeavouring to make it.
I frequently encounter with clients who have been diagnosed, a complication I also encounter with clients who have previous experience of attending therapy or counselling— they may come already assured as to the clarity of their narrative. Exploration here involves encouraging elaboration so that the client expresses something faithful to what was experienced rather than to what has been repeatedly retold. Apparent connections may involve assumptions made by the client or suggested by others to the client. Any hypothesis requires a more careful and methodical pursuit. (Generally, associations prove more reliable when they emerge after some initial resistance on the client’s part).
Exploring the onset of the crisis
Often when a client seeks to communicate clearly and exactly a significant issue (e.g. the pain of bereavement, the state of depression or creative block) or how they experience their particular ‘addiction’, they can find it difficult to reflect on their experience faithfully— especially when the therapist encourages elaboration, resulting in frustration and perplexity. It helps to demarcate clearly when and how the issue developed into being problematic. This helps to establish when and how the client largely lost effective control of his or her situation, leading to an abdication of agency. Often this happens at a time when supports have been lost, when (through shock or sleeplessness, for example) the client could not orientate themselves and at a time when the client had difficulty finding articulate expression.
Clients commonly express great surprise at revisiting such onsets of crisis (a revisiting they have tended to avoid before then). They are surprised by how blurred their perception was at the time and how little they understood as to how their self-representations would be interpreted. They are surprised at how many significant and influential factors now appear obvious but went altogether ignored at the time. They are also surprised at the realisation of how, up to this present revisiting of those critical events, they had implicitly somehow imagined that their diagnosis had explained their difficulties. Now they realise that the ‘why’ remains as remote and mysterious as ever. And they become ready to effectively pursue that mystery.
Words like ‘addiction’ and ‘depression’, if uncritically assumed to be fixed in meaning, can threaten to foreclose any such mystery. I have found it most rewarding and effective for myself and my clients to discover what we mean by such categories through the process of our rapport and to use such terms and categories in a way that continues to leave the way open for such discovery.
Gerard Staunton is a humanistic psychotherapist, working in Cork.
Callard. F. (2014). Psychiatric Diagnosis: The Indispensability of Ambivalence, Journal of Medical Ethics, 40(8), 526-30.
Dodes, L. and Dodes, Z. (2014). The sober truth: Debunking the bad science behind 12-Step programs and the rehab industry. Boston: Beacon Press.
Elgin, S.H. (1983). More on the art of verbal self-defence. New Jersey: Prentice-Hall.
Good, B.J. (1994). Medicine, rationality and experience: An anthropological perspective. Cambridge: Cambridge University Press.
Vanheule, S. (2014). Diagnosis and the D.S.M: A critical review. London: Palgrave Macmillan.