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Diagnosis
in Clinical Psychology

 

 

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Page Contents: Introduction / “Real” Psychological Diagnosis / Emotions—Not Historical Truth

 

Introduction:
 
Medicine
 
and
 
Psychology

IHE 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 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 psychotherapeutic idea, it must be investigated with scientific research to determine if it works in general as well as other treatments generally work.

Failure to recognize this difference between medicine and psychology 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?

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.

  

To be fair, let’s acknowledge the field of medicine called “wellness” which steps beyond traditional medical treatment and 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. Real diagnosis emerges from within the treatment itself. It comes from talking about your life, listening for unconscious conflicts, and interpreting dreams. It’s 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. 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.

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, that give the appearance of truth. 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, 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, charging you 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 your e-mail message; a declined invitation to your 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. 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?”

 


 

Gratitude
 

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Notes:

1. McReynolds, P. (1987). Lightner Witmer: Little-known founder of clinical psychology. American Psychologist, 42, 849–858.
 
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.

 
Additional Resources
 
Wellness:
Center for the Advancement of Health  is dedicated to a belief that “health care should direct its energies toward treating the person, not simply the disease.” It seeks to strengthen the capacity of the biobehavioral research community to conduct high-quality research; communicate research findings to decision-makers and the public; and translate and integrate research findings into the real world of health care policy and practice.
HealthCastle
HealthGate
Virtual Naval Hospital: Patients HomePage  provides a broad range of medical information for the consumer specifically relating to Wellness issues.
WellnessWeb
 
Related pages within A Guide to Psychology and its Practice:
Dream Interpretation
Honesty
Identity and Loneliness
Legal Issues
Managed Care and Insurance Issues
Medication Issues
Personality
Psychological Testing
Questions and Answers about Psychotherapy
Repression
Spiritual Healing
Types of Psychological Treatment
The Unconscious
 
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A Guide to Psychology and its Practice

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