Drop the disorder: Response to Gerard Staunton’s “Engaging with the discourse of diagnosis in therapy (with particular reference to addiction)”
by Pat Comerford
Staunton (2020) has offered the counselling community a useful framework for a discourse on the role of ‘diagnosis’ in the particular area of addiction counselling. He shows how the humanistic psychotherapist could possibly respond to persons who present with the ‘diagnosis’ of ‘addict’. His insightful article has provoked some personal reflections. As part of the discourse I wish to add some observations that especially resonated with me on the issue of ‘diagnosis’, and its ramifications for addiction counselling.
Legal use of DSM-5
While I am no “friend” (Mullen, 2016: 20-22) of the Diagnostic And Statistical Manual Of Mental Disorders – 5th Edition (a.k.a. DSM-5, American Psychiatric Association, 2013), I do accept that people may attach themselves to a ‘diagnosis’ as a “reference point” (Staunton, 2020: 16) in their relationships with themselves and others. I have previously made it clear, however, that it is not legally within the brief of counselling and psychotherapy for the humanistic psychotherapist to make ‘diagnoses’, since this is a core function of the medical profession and for those who have been trained to ‘diagnose’, as in the work of clinical psychologists (Comerford, 2016). I have also written how the ‘diagnostic mindset’ is anathema to the humanistic psychotherapist (Comerford, 2018). We are trained to be psychotherapists and counsellors, not medical or psychological clinicians.
DSM-5 Diagnosis is the ‘what?’
To say “‘I am an alcoholic’” (Staunton, 2020: 18) implies that the person has met the diagnostic criteria of the DSM-5. There are persons who have adopted the DSM-5 “label” (Staunton, 2020: 16) as one definition of themselves and for some people this ‘label’ is used as their primary, and sometimes overarching, definition of themselves. The essence of any labelling is focused on an ‘object’. It is a way of defining the ‘what’ of the object, a naming of the object.
The analogy relevant to object and or objects is the activity of shopping. The majority of us who shop, will rely on the label to inform our choices of what objects to buy, and we do so, generally, in an unquestioning manner. The label is the end result of the process known as ‘branding’, thus we have the term ‘brand name’. By extension, the label gives us information on the ‘brand’. The label also shapes and confirms our shopping preferences and biases. As shoppers, historically, we have developed biases about the different labels or brands. Parents will be familiar with the battles with teenagers in making sure that the latter are wearing the right label or brand name. Not wearing the socially desirable label may trigger feelings of not belonging or perceiving oneself as an ‘outsider’. Effective branding is about appearing different, yet the same, and is essential to achieving successful sales with consumers.
The labels in the world of shopping are used to promote a favourable perception and to influence how we respond. The labelling employed by the DSM-5 is always problem-based, and is driven by an illness narrative. It also influences and shapes the personal perceptions of those using this manual.
The label is a way to identify or name the problem presented by the person “at a time of crisis” (Staunton, 2020: 17). The DSM-5 meets its own goal of identifying ‘what’ the problem is. The person is now considered as having a problem. She or he becomes identified as the “sufferer” of an illness (Staunton, 2020: 17). The DSM-5 medicalisation or diseasing process (McHugh, 2018) has then the potential of marking the person as ‘the problem’ and, in turn, activating their latent feelings of “shame and embarrassment” (Staunton, 2020: 17), as regularly reported to me over the last thirty-five years of addiction counselling. The label confers on the person the ‘what’ of the person but it does not give us any insight into the essential ‘who’ of that same person.
Addiction, ‘what?’ and ‘who?’
We may ask the question ‘what is an alcoholic?’ and the DSM-5 addresses this type of question. To the question ‘who is an alcoholic?’ the DSM-5 users cannot give an answer. When I say ‘I am Pat’, I am responding to the question ‘what is your name?’ I am giving my label, as it were, but not who I am. The journey of my life is about discovering and learning about ‘who is Pat?’ and not ‘what is Pat?’ There is no manual for defining or making clear the answers to the ‘who’ question. Mullen (2016), nonetheless, has written that the goal of the DSM-5 is to address solely the ‘what’ question: “It largely spells out what we are looking at and is our best source of help in sorting pathology in order to unlock, manage, and understand what we are encountering” (21). Close reading of the DSM-5 chapter ‘Substance-Related and Addictive Disorders’ (APA. 2013: 481-589) confirms this to be so, defining what is addiction and what is its pathology. It is the person we are encountering not the ‘pathology’ or the ‘what’! To meet with the person, we will also need to be open to facilitating and having an encounter with “mystery”.
Humanistic psychotherapy, mystery, the unknown and ‘who?’
Cosmologists are very comfortable with the use of the word ‘mystery’ in their work (Krauss, 2009). For them mystery means that they do not know everything about the billions of galaxies in the Cosmos. Their comfort with mystery also conveys their attitude of openness, curiosity, a willingness to learn and understand more about the Cosmos and not just our planet Earth. Their limitless curiosity fuels the desire to understand the relationship between the Earth and the Galaxies in the Cosmos. Staunton (2020: 16 & 21) brings this same demeanour about mystery or the ‘unknown’ into his relationships with persons who self-identify as addicts.
You will not find the word ‘mystery’ in the DSM-5 manual. The manual was written to address the profane dimension of being human, not its mystery. It does not address the question of ‘who’, nor does it claim this to be its goal.
Yet, this does not have to hinder humanistic psychotherapists as they explore with persons their given ‘diagnostic label’ in a spirit of openness and curiosity as advocated by Staunton (2020). In this joint exploration of the label with the person it is critically important, nevertheless, to post a warning: the diagnostic label does not represent the ‘who’ of the person I am in relationship with. We must make sure that we humanistic psychotherapists are not seduced into relating to a diagnostic label or ‘disorder’, rather than relating with the mystery that is the person in front of us! So, it is essential not to limit our journey into the unknown by relying on labels in our relationships.
A person may attend for psychotherapy to address specifically their addiction, and we then appropriately attend to this. And some people we work with may report being satisfied with their given DSM-5 diagnosis and also find it helpful. The humanistic psychotherapist will naturally accept unconditionally the person’s satisfaction.
In the meantime, the diagnostic label of ‘addict’ is not the sum total of the person, of the mystery. As Staunton (2020) has clearly pointed out, we need to stay close to the mystery of being human – the ‘who’ of the person and not the ‘what’. In other words, humanistic psychotherapists are the cosmologists of the person, while the users of the DSM-5 manual are the mechanics of the person (Comerford, 2016). Mechanics are important and valuably skilled people we rely on when our cars need fixing, but people are not cars! The humanistic psychotherapist is focused on hearing the ‘who’ of the person they meet with.
Horton Hears a ‘Who’
In the beautifully crafted animated film ‘Horton Hears a Who’ (Hayward & Martino, 2008) we are shown what it means to hear or listen. The film is an account of how the character Horton, an endearing elephant, comes to hear a ‘Who’ residing on a speck of dust on a clover. The film is wonderfully rich with meanings about being in the world. It is also an excellent representation of the cosmological view of humans in the Universes or “Multiverse” (New Scientist, 2020) – we are but a speck on a speck in the Great Cosmos. The film is a reflection of what humanity is like and could become.
Horton is a humanistic elephant, so to speak, who is open to hearing even when he cannot see the ‘Whos’ of ‘Who-ville’. Horton has an “unconditional positive regard” (Rogers, 1957: 96) for the voice he hears. Staunton (2020) advocates the same attitude of ‘unconditional positive regard’ when we meet with a person who has been given the diagnostic label of ‘addict’. As humanistic psychotherapists we need to be open to different voices and be prepared to engage with the differentness in others and even in ourselves, just like Horton.
When I meet a person for the first time in the therapy space I do not ask ‘what is sitting before me?’ as the DSM-5 users would tend to do. Instead, my internal question is ‘who is sitting before me?’ This requires me to hear and see the whole person before me. I need to drop the disorder label as recommended by Watson (2019). That is not to say that there are not some therapists who may have ‘what’ as their frame of reference question. They are not humanistic psychotherapists, in spite of any claims to the contrary. Asking the ‘what’ question is to objectify both the person and myself. It is to keep ourselves outside of the encounter with mystery, leaving both the person and the humanistic psychotherapist disconnected, alone and unmet! It is to stay with the disorder label.
Drop the disorder (1): Alternatives to psychiatric diagnosis
With the mounting number of critiques of the efficacy of psychiatric treatment and practice (Greenberg, 2013; Johnstone, 2000), the pace has gathered in efforts to develop alternative ways of understanding people who are in times of crisis or emotional distress, that do not rely on a “functional psychiatric diagnosis” (Cromby, 2019: 262), that is, the DSM-5. These alternatives are humanistic ways of getting to know and understand ‘who’ I am relating with in this “here-and-now” relationship (Yalom, 2002: 47). The persons I relate with have their own unique ‘stories’ and the DSM-5 does not facilitate access to these stories of the ‘unknown’ person in front of me. It has as its primary goal: to determine a diagnostic label, to make a diagnosis.
The first alternative to psychiatric diagnosis is ‘formulation’ (British Psychological Society, 2011), which is: “an individual summary or story about the origins and meanings of a person’s difficulties”; in other words, to know and understand their story (Johnstone, 2019a: 13). The defining feature of this alternative is that the ‘formulation’ is created and agreed upon by both the person and the therapist, with the latter only being the guide. This enables the person to become an active participant in the therapeutic relationship, and, importantly, in their personal story and journey.
A second alternative to psychiatric diagnosis or labelling is the “trauma-informed approach” (Johnstone, 2019a: 16), which attempts to understand the person with a: “What happened to you?” not “What’s wrong with you?” type of question (Johnstone, 2019a: 16). This approach to understanding the person bases its orientation in trauma studies, attachment theory and neuroscience (Kezelman & Stavropoulos, 2012; van der Kolk, 2014). It recognises the influences from the mind, body, relationships (childhood and adult) and the world we live in now.
Connected to the ‘trauma-informed approach’ is the third alternative to the psychiatric medical orientation, the reflexive investigative consideration of: “Adverse Childhood Experiences” or “ACEs” (Felitti et al., 1998: 245). This classic work has shown the “relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults” (Felitti et al., 1998: 245). The ‘ACE’ framework has also been used, in a non-psychiatric manner, to understand and explain the potential causes of ‘addiction’ (Anda & Felitti, 2011).
Drop the disorder (2): The Power Threat Meaning Framework
More recently, an important development in alternatives to historical psychiatric efforts to understand emotional distress is: “The Power Threat Meaning Framework” (a.k.a. PTMF, Johnstone & Boyle et al., 2018; see PTMF Summary, Johnstone, 2019b). In the PTMF Summary of this meta-framework it states that:
The framework summarises and integrates a great deal of evidence about the role of various kinds of power in people’s lives; the kinds of threat that misuses of power pose to us; and the ways we have learned as human beings to respond to threat. In traditional mental health practice, these threat responses are sometimes called ‘symptoms’.
(Johnstone, 2019b: 1).
It is further noted in the Summary:
The Framework also looks at how we make sense of these difficult experiences, and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt.
(Johnstone, 2019b: 1)
The four core questions employed in this approach reflect the main aspects of the Framework, summarised in these questions, which can apply to individuals, families or social groups:
1. ‘What has happened to you?’ (How is Power operating in your life?)
2. ‘How did it affect you?’ (What kind of Threats does this pose?)
3. ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)
4. ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)
(Johnstone, 2019b: 1)
There are two further questions addressed by the ‘PTMF’ alternative to the traditional psychiatric diagnostic model which allow for both the therapist and person to ponder on and which:
… help us to think about what skills and resources people might have, and how we pull all these ideas and responses together into a personal narrative or story:
- ‘What are your strengths?’ (What access to Power resources do you have?)
- ‘What is your story?’ (How does all this fit together?)
The significance of ‘PTMF’ is that it provides a context for the therapeutic relationship to be grounded in participation, empathic understanding, and empowerment (for an overview see Johnstone & Boyle, 2018). It is a compelling substitute to using the institutionally and socially established ‘disorder’ diagnostic method (for reflections, see Johnstone et al., 2019). It is also a potent alternative way to respond to the “…psychiatric and biomedical understandings of emotional and behavioural difficulties and distress….” (Cromby, 2019: 261).
Inside out and outside in: final reflections
Staunton’s (2020) article shows how in his practice he is being ‘alternative’ in his humanistic relationship style of relating with persons designated as ‘addicts’ by the medics and/or by the person themselves. He writes unambiguously: “Words like ‘addiction’ and ‘depression’, if uncritically assumed to be fixed in meaning, can threaten to foreclose any such mystery” (Staunton, 2020: 22).
This note of caution is a buttress to humanistic psychotherapists when confronted with the DSM-5 Manual’s taxonomy of fixed labels of ‘mental disorders’ or ‘mental illnesses’ (APA, 2013). His contribution to the work of humanistic psychotherapists allows for how we might engage with ‘difference’, as defined, and sometimes experienced as a felt-sense of imposition, by a ‘diagnostic label’, from our particular phenomenological start point. Staunton (2020) fully understands how we need to see more than the label of ‘addict’ and to see the whole person and appreciate their mystery so as to support them to begin their journey into their own ‘unknown’.
It baffles me how the DSM-5, basically a classification document, and a professional’s subjective opinion are used to make a medical diagnosis so as to arrive at a physiological- based illness explanation for emotional, psychological and or behavioural distress, including addiction, and for which there is no evidence, to date, to support this conjured medical hypothesis (McFarlane, 2019; Lynch, 2018; Frances & Whitaker, 2014).
In a recent important critical response to pluralist therapy (Cooper & McLeod, 2011; Finnerty, et al., 2018), the writers noted that:
As Rogers stated, ‘therapy is diagnosis and this diagnosis is a process which goes on in the experience of the client’ (Rogers, 1951: 223), which is why empathic understanding is so central and the relationship conditions are proposed as necessary and sufficient.
(Ong et al., 2020: 178).
That is to say, it is the person who is their own ‘expert’, not the psychiatrist, the clinician, the pluralist therapist, nor the humanistic psychotherapist. The person-centred approach of Carl Rogers (1980) posits and maintains this ontological principle. These alternatives to the psychiatric framework are significant resources for developing an ontology of the person rooted in the belief in the person’s self-healing powers formed from their “actualising tendency”, the fulfilment of their potential (Rogers, 1963: 1-24). It is essential that humanistic psychotherapists do not establish themselves as ‘experts’, but to primarily attend to enabling and empowering the person’s ‘actualising tendency’, and not to diagnose and label them.
The work of humanistic psychotherapists and counsellors can be accurately expressed as a process of engaging from the ‘outside’ to ‘in’, in order to promote and enhance an ‘inside out’ understanding and experience of self and others. I, therefore, have always regarded the journal title Inside Out as an incomplete description of psychotherapy and counselling. It tells only one half of the relationship, that of the person the humanistic psychotherapist is in relationship with, but not of the therapist themselves. Personally, I think a complete title would be Inside Out – Outside In (Gijbels, Sapouna & Sidley, 2019)
Krauss, the cosmologist, stated in his YouTube video lecture (2009) that: “the universe remains mysterious”. May we never lose the sense of mystery in our relationships with each other and particularly in our work as humanistic psychotherapists. Dropping the disorder focus and pursuing alternative ways to the psychiatric medical approach, as recommended in this article, so as to relate in a fully humanistic sense with the persons we meet in our practice, are important ways of being in relationship that are worthwhile counterpoints to the profane goals of the DSM-5. Krauss (2009), however, in the same YouTube video goes on to say: “Humility is that we don’t understand everything”, and acknowledging this allows us to stay “…open for …discovery” (Staunton, 2020: 22).
Pat Comerford is an IAHIP accredited humanistic psychotherapist and supervisor in private practice, with thirty-five years experience in addiction counselling.
I want to express my sincere gratitude to Dr. Emma Hickey for introducing me to the PTMF.
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