Introduction:
Medicine
and
Psychology
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The practice of medicine and the practice of psychology
have evolved from two different traditions. The practice of medicine evolved
as masters passed on to their students various oral traditions about healing
treatments and remedies. It didn’t even matter if anyone knew why a
treatment worked; all that mattered was that someone could say, “In
these circumstances, this treatment seems to work.” If
an extract of willow bark relieved a headache, then so be it. Only later
would scientific inquiry be utilized both to find new treatments and to validate
old ones—such as discovering in willow bark the chemical we now know
as aspirin.
Since oral lore
decisively linked the illness with the cure, medical treatment then, as now,
therefore depends on diagnosis. First the
symptoms are carefully identified, and then the
cure—traditionally associated with those particular symptoms—is
applied.
Psychology
works on entirely different principles. Unlike medicine with its traditional
history of effective remedies, psychology began, more or less, by looking
for problems that could be treated with known scientific principles. Such
was the early psychological clinic started by Lightner
Witmer [1]
in 1896, when Witmer applied abstract psychological
principles to solve educational problems.
Hence the tradition
of psychology is to use scientific
research
to investigate known psychological procedures to determine how effective
they might be in treating a particular symptom. Essentially, every time someone
comes up with a new therapeutic idea, it must be investigated with sound
research to determine if it really works. A failure to recognize this
fact leads to a massive confusion about the role of diagnosis in clinical
psychology.
For example,
if someone is depressed, we might, in a particular case, diagnose it with
the full
DSM-IV [2]
nosology of Major Depressive Disorder, Recurrent,
Severe Without Psychotic Features, With Melancholic Features, With Full
Interepisode Recovery, Superimposed on Dysthymic Disorder. But what does
this tell us? Not much.
A physician might
say, “OK. It’s major depression, let’s try an antidepressant
medication.”
Fair enough. After all, if someone breaks his leg the treatment doesn’t
hinge on why he broke his leg. And, to be more fair, let’s acknowledge
the field of medicine called “wellness” which does look at some
of the “whys” of illness and treatment.
But a psychologist
has to ask why. “Yes, but why is he depressed?” And in answer
to this question the diagnosis tells us nothing. |
“Real”
Psychological
Diagnosis
|
Real psychological diagnosis, therefore, is not the naming
of the disorder, it’s the naming of the “Why” of the
symptoms associated with the disorder. And real
diagnosis emerges from within the treatment itself. It comes from talking
about your life, listening for
unconscious
conflicts, and interpreting
dreams.
It’s really a bit like defining a hole by marking out the contour of
its rim. First you determine what’s there—or to be more accurate
in speaking about a hole, what’s lacking. Then the work focuses on what
the lack signifies. You have to look
honestly
at your life—especially your past. You have to recognize all that
you’ve done and all that you’ve failed to do. And then you can
begin to make peace with the lack, to listen to what it tells you unconsciously,
and to adjust your life to accommodate it.
Naturally, this
approach drives
managed
care and insurance companies nuts. Just like our culture in general,
they become nervous around ambiguity and mystery. They demand the outward
appearance of legal
“truth.”
And, like most everyone else, they’re quite willing to settle for illusions
such as diagnoses. It keeps them happy. |
Emotions—
Not
Historical
Truth
|
If, for one reason or another, you manage to get a
psychological diagnosis, you really have to be careful, because if a diagnosis
becomes a matter of
identity
based in pride, it can be almost impossible to give up that identity in order
to find true
healing.
All of which
brings me to a final point about searching through past events in order to
make a diagnosis. Remembering the past is of no value in
psychotherapy
except in recovering any emotions from the past which were never properly
voiced and which therefore keep you from having open and
honest
interactions with others.
For example,
during the psychotherapeutic process you will experience many
emotions that are similar to the emotions you
felt as a child. Disappointment. Anger. Confusion. Feeling misunderstood.
Feeling devalued. Feeling abandoned. Many different events—some of them
just chance occurrences during psychotherapy (for example, a key to the restroom
not in its proper place; a session cancelled because of the
psychotherapist’s illness; etc.) and some of them deliberate therapeutic
interventions by the psychotherapist (for example, a charge for a missed
session; an interpretation of a dream that touches a truth you don’t
want to hear; a calculated decision not to respond to an e-mail message;
a declined invitation to a wedding or graduation; etc.)—will trigger
these emotions.
This triggering
process is technically called
transference.
So, when you
feel an emotion in psychotherapy, the therapeutic task will be to name it
as an emotion and understand it as an emotion—not get
caught in it as if it were your helpless destiny. For if you get caught in
it, you will feel like a victim and will blame the
psychotherapist for your pain, and the entire therapeutic process will feel
like judgment and criticism. And then, in deep bitterness, you will want
to “get away” from the psychotherapy
just as you wanted to get away from the original emotions as a
child.
Psychotherapy,
therefore, isn’t necessarily a matter of discovering
historical truth;
it’s about learning how to function capably and
honestly in the present. To go about that process,
one works with emotions, wherever they come from. Historical events can fall
where they want.
Well, then, do
you still want a diagnosis? Then open up the DSM-IV and pick one.
The real issue
in regard to healing is not the diagnosis but the ability to retire the diagnosis
for the sake of health.
So ask yourself,
“What is more important? Having the diagnosis, or being free of
it?” |
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