The stated mission of DxSummit is “to generate a transdisciplinary, international, egalitarian conversation about the possibility, feasibility, and potential implications of new means for conceptualizing mental distress” (http://dxsummit.org/mission). For me, the goal is to reclaim the term “diagnosis” for psychotherapists and counselors in order to think about it in new and more generative ways.
Understandably, some DxSummit participants are skeptical of this goal, which is not surprising given that in recent decades diagnosis has become almost exclusively synonymous with the DSM and the medical model. A small subset of these skeptical participants are resolutely opposed to any approach that invokes the term “diagnosis.” They don’t believe that viable diagnostic alternatives are possible. To them, diagnosis is and always will be oppressive and pathologizing.
Eric Maisel, for instance, has repeatedly argued in favor of abolishing diagnosis. “It is time we placed a moratorium on this illegitimate ‘diagnosing,’” he writes in a recent summit blog post (http://dxsummit.org/archives/2076). His opposition to diagnosis is apparently part of a broader mission to do away with psychotherapists entirely, hence the title of one of his blog posts: “Replacing Psychiatrists and Psychotherapists” (http://dxsummit.org/archives/2032). In this post, he claims that psychotherapists and counselors are bound “to buy our current ‘diagnosing and treating of mental disorders’ model” (http://dxsummit.org/archives/2032). The argument seems to be that because therapists are obligated to abide by the medical model, they should be replaced with “human experience specialists.”
I respect Maisel’s work immensely, but disagree with him on this issue. Psychotherapists and counselors are not bound to abide by the medical model and many already see themselves as “human experience specialists” rather than medical specialists. In fact, psychotherapists adopt non-medical models of conceptualizing clients all the time. They have to because the DSM is atheoretical about the causes of the disorders it catalogs.
Therapists regularly employ interpersonal, humanistic, existential, cognitive-behavioral, and narrative conceptualizations of client distress (among others). None of these approaches require adherence to a medical model. Thus, I am confused by Maisel’s contention that psychotherapists are “violating their licenses and their oath to diagnose and treat mental disorders” any time they function as “human experience specialists” (http://dxsummit.org/archives/2032). I don’t recall taking a strict oath of allegiance to the medical model. Is there a secret psychotherapists handshake that nobody told me about, too?
Part of Maisel’s opposition to reclaiming diagnosis is rooted in a distinction he draws between observing a symptom and then calling it a disorder versus diagnosing a real illness based on a demonstrable underlying cause. Legitimate medical diagnosis, he claims, does the latter, whereas psychotherapists illegitimately do the former. Never mind that, even in medical diagnosis, underlying causes are not always clearly observable—lots of diseases are diagnosed by inferring causes, but that’s a discussion for another day.
Maisel’s criticism only holds if we adhere to an extremely narrow definition of psychological diagnosis. Such a definition seems yoked exclusively to the medical model categories found in the DSM. This is not surprising, considering the DSM’s hegemony the past thirty-five years or so. Maisel’s provocative challenge to those of us wishing to develop new alternative diagnostic approaches reflects this narrow definition of diagnosis. He states:
The challenge for any contemporary psychotherapist who wants to retain an ability to “diagnose and treat” is simple to describe: give me an example of your updated diagnostic system. Tell me how you would test to confirm your diagnoses and how you would distinguish one cause or source of a problem from another cause or source of a problem. Give me your taxonomy—your naming system and your rationale for using it—and let’s hold it up to scrutiny. If you want to continue diagnosing, put up the names of your “mental disorders” and let’s look them over. And don’t forget to clearly indicate what you are counting as causes! If you don’t take causes into account, you still aren’t really diagnosing. You are merely inappropriately cataloguing.
Maisel’s concerns are perfectly understandable, but in my view reflect a rather procrustean perspective on what diagnosis is.
Maisel erroneously presumes that any new diagnostic system would involve medical model categories, hence his chiding that those looking to develop alternatives must “put up the names” of their new “disorders.” Why does he assume that alternative diagnostic approaches must necessarily involve a categorical system of professional name calling?
The issue of cause is an important one. If diagnosing involves attributing cause, as Maisel claims, then he is right to criticize the DSM—a system that has traditionally been atheoretical about causes. Defining diagnosis as cause means that the DSM does not technically qualify as a diagnostic system at all because it merely offers descriptions, not causes.
Maisel’s definition of diagnosis as cause fits with the way in which the term has often been used in psychiatric diagnosis. This is ironic given that the DSM’s atheoretical stance directly contradicts this definition. However, the word diagnosis does not technically mean “cause.” Actually, the word has origins in ancient Greek and literally means “to discern or distinguish” (http://www.etymonline.com/index.php?term=diagnosis). To discern or distinguish something is far broader than presuming to have uncovered its cause.
Discerning or distinguishing is essential to effective counseling and psychotherapy. Without making distinctions and using them to strategize about how to talk to clients and think about their difficulties, psychotherapy is not likely to prove very helpful.
If we reclaim the original definition of diagnosis as discerning or distinguishing, then even Maisel engages in it. On his website, Maisel outlines a view of human functioning in which he divides personality into three aspects:
our original personality (the endowments and blueprints we are born with), our formed personality (the track our personality takes in the crucible of living), and our available personality (the amount of “free” personality left us with which we monitor ourselves and make changes). (http://ericmaisel.com/upgrading-your-personality/)
When working with clients, Maisel undoubtedly distinguishes among these three aspects of personality. He uses a scheme of his own devising in order to make important distinctions that guide his work. In so doing, he provides a basis from which he and his clients can move forward in not only differentiating, but also addressing, client problems. This is diagnosis, albeit not of the medical model variety.
What about alternative diagnostic systems? Maisel asks that such systems be put forward for examination. This is a perfectly reasonable request, but one difficult to meet at the moment given that the very purpose of DxSummit is to bring people together to discuss and develop the new alternatives Maisel wishes to critique. In other words, said systems have yet to be developed, which is why DxSummit is planning a small two-day meeting in Washington, DC this August for interested parties to begin discussions about such alternatives. Maisel has even been invited to the summit as a participant. Perhaps he will share his “three aspects of personality” diagnostic scheme there.
At the summit, people will come together to begin discussing what an alternative diagnostic system for conceptualizing human distress might look like. I believe it is time to reclaim diagnosis as an essential tool by which psychotherapists can discern aspects of human psychological functioning, with the goal of helping people through talk therapy.