The central problem in all the diagnostic schemes is to figure out how to avoid a confusion of logical types so that a muddle does not result.

That said, there are some critical and general issues to consider:

1) Is “medical care” about “treating disease” or is it about “promoting wellbeing” i.e. absence of pain and presence of function. All accept that though much of the time it is about “disease”, it is clearly also about the alleviation of suffering (thanks to Norbert Wetzel for this reminder). But in psychiatry, the diagnostic schema are largely phenomenological and categorical, and not suffering-based in the sense that there is suffering that is overlooked with the various symptom checklist. “Symptoms” are divorced form lived experience. This flies in the face of eco-contextual ways of apprehending “reality” in which the describing and identifying of patterned “thingness” creates meaning by virtue of its embeddedness in context.  Meaning is lost through  the other approach of labeling and isolating from context. It is a matter of validity.

Yet for family therapists, the fact that our view is embedded and relative/relational does not mean that there is not also some “thing” that has a kind of life of its own, a pattern that is to some degree self-maintaining, and is one which can be modified with “treatment”.

Image courtesy of Ambro /

Image courtesy of Ambro /

2) In my daily practice of psychiatry, and as I am called to “treat” people, the value to me of diagnosis is that it gives me a “way” of identifying whether there is a something to consider which I have overlooked or not recognized. I walk a fine line between leaning one way or the other because of my own feelings and biases when it comes to “prescribed treatment”. I self-correct in the same way one does on a bicycle, more or less mindfully aware of the necessity of being able to return to “midline”, even if temporarily. In general, a few of the dx categories have significance for me and guide my thinking and recommendations. But that is commonly not the case as well: often diagnostic naming has little meaning to me in the sense of helping me to understand or to decide upon an action. And yet it is still “medical” for me. Why?? Because I care for patients who are in pain and I help them with that pain. Fortunately, unlike much of medicine, when we deal with the pain as pain we are also dealing with the “cause” of the pain. Yet this confounds us because…

3) this is where the logical types problem really is the issue, i.e. what kind of medicine am I practicing?? What is my responsibility, my territory? What is meant by “cause” and how do we  “have something” when it’s presence can be evidence of another “something”, i.e. is it an ailment or is it a disease? When is a thing not a “thing” at all, and when is it wise, ie heuristically useful, to think of a pattern as now having “thingness”? In living systems, this “thingness” is appropriate and fitting, i.e., useful and beneficial, when it is self-maintaining in spite of efforts to induce change by altering context, internal, external, and both.

4) The problem we are having with psychiatric dx is not a lot different than that which we would have with all medical practices which exclude context in their diagnosing. Looking through the spyglass from the other end, how come we content ourselves with struggling with the DSM when there is so much harm done in general by non-contextual classification schemes.  And with that said, if you have appendicitis you don’t want someone to empathize with you, though that is nice and beneficial, you want the damn appendix out, while also having context considered in the overall management of your suffering.

5) I submit we as eco-therapists need to become comfortable with the notion of relational diagnosis and the building of useful distinctions based on the categories, which emerge. We need to challenge ourselves and each other. We can identify patterns and test hypotheses re those processes more gracefully and not simply be “anti-diagnosis”.  We can orient ourselves around diagnosing our own relationship to the matter at hand. Do I need a surgeon, a shrink, a medicine, a family therapist? Let’s see what will work “best”   (a whole other subject and very complicated), while also knowing whatever we think now could change a lot with advances in our knowledge of pattern and relationship.

6) I know this has been very “medical” in its emphasis. That has been because the whole DSM story is rooted in “the medical” location of this essentially social, not scientific, process. I am trying to come at it from “within”. And I also value being a physician…but I think this debate is about a world-view and therefore a matter of survival for us all. We who are ecological in our professional practices have a responsibility and an opportunity to challenge prevailing dominant modes of thinking as they arise in the larger socio/political/economic context.

We will not succeed if we too are in a muddle.

Larry Freeman

About Larry Freeman

CV: Grad med school UCSF 1972. Psychiatrist and family therapist training simultaneous 1972-1978. Strongest influence Carl Whitaker. Integrating psychiatry and family therapy life's work. Multiple work settings now private practice Bellingham WA. Seeking opportunities for teaching/collaboration around model development, implementation, and training. Many workshop presentations 1980 to present at AFTA, IFTA, New Zealand Psychiatry, others. Publications: "Psychobiological Family Therapy: Ecological Psychiatry in Practice" in Keith and Prosky, Family Therapy as an Alternative to Medication, 2003. "The Spirit of Family Therapy", AAMFT Magazine 2013. Current focus developing broader models: "Psychobiological Family Therapy", "Holistic Psychiatry", and "The Spirit of Family Therapy: The Spirit, the"Social Brain", and Family Therapy".