What About Meaning?
DxSummit has seen several posts presenting exciting new ideas for classifying and diagnosing human problems. Peter Kinderman, for instance, has proposed a “problem list and formulation” approach in which clinicians list however many presenting problems a client brings to session. Jeffrey Rubin has put forward ideas for a “Classification and Statistical Manual of Mental Health Concerns,” shifting psychotherapists from experts at eradicating disorders to empathic helpers who listen to and work with people to address their concerns. Both approaches show much promise and are especially notable because they remain within the “atheoretical” approach made famous by the Diagnostic and Statistical Manual of Mental Disorders (DSM).
What do I mean by an “atheoretical” approach? When using this term, I refer to any approach that allows clinicians from whatever theoretical orientation to use it without having to compromise their perspective. A psychoanalyst, a behaviorist, and a medical model psychiatrist could all employ Kinderman’s problem list and formulation approach because it requires nothing more than having them list what problems a client has. No particular solution is required for remedying these problems. This is just like past DSMs (and I say past because, unlike earlier versions, DSM-5 does not describe itself as atheoretical and seems to be shifting more overtly toward a medical model when it comes to etiology). That is, the approaches of Kinderman and Rubin are “atheoretical” about how a problem should be treated. This provides them with the possibility of being used by a wide swath of helping professionals.
But what about meaning? That is, it seems to me that many psychotherapeutic approaches—including but not limited to psychoanalytic, interpersonal, cognitive, humanistic, existential, feminist, and constructivist approaches—emphasize human meaning in understanding and addressing client difficulties. Psychoanalysts, for example, published the Psychodynamic Diagnostic Manual (PDM) several years ago, which explicitly roots its particular brand of diagnosis within a psychodynamic theoretical orientation that attempts to assess the quality of a client’s “relationships, emotional regulation, coping capacities, and self-observing abilities” because “a clinically useful classification of mental health disorders must begin with an understanding of healthy mental functioning” (http://www.pdm1.org/). The PDM approach reinvigorates and reinstitutes the use of psychodynamic meaning conceptualizations (long ago banished from the DSM) in order to understand and diagnose client dilemmas. Similarly, constructivist therapists working within a personal construct psychology orientation have long conceptualized assessment and diagnosis using George Kelly’s notion of “transitive diagnosis.” A transitive diagnosis attempts to measure a client’s personal constructs, which are conceived of as bipolar dimensions of meaning that clients create in order to understand and interpret events. “Diagnosis” involves measuring and understanding the client’s personal construct system through sophisticated and idiographic assessment techniques such as the repertory grid. Finally, even humanistic psychotherapists have built into their theoretical approach a system for diagnosing human problems. Carl Rogers, for example, saw human suffering as resulting from conflict between the need for self-actualization and the need for unconditional love and acceptance. Measuring such discrepancies by use of Q-sort technique is another “classic” assessment technique rooted within a meaning-based approach to diagnosing human suffering in terms of congruence between self and experience.
All these approaches are different from those offered by Kinderman and Rubin in that instead of being atheoretical, they are explicitly theoretical in their emphasis on seeing human problems as products of psychological meaning-making processes. Their explicitly theoretical bent means that, in the long run, their usage may turn out to be less widespread than Kinderman and Rubin’s alternatives, even if ultimately used in conjunction with these alternatives. My purpose here is to offer a clarion call to all the psychodynamic, interpersonal, humanistic, existential, cognitive, feminist, and constructivist therapists out there—essentially any psychotherapist whose conceptualization scheme involves mapping and understanding human meanings: We want to hear from you here on DxSummit. Your voices should be part of the conversation we are having about the future of diagnosis. Diagnosing human meaning-making is an important part of moving forward in advancing new (and sometimes old and rediscovered) diagnostic alternatives. How might your ideas fit within the frameworks Kinderman, Rubin, and others are beginning to put forth? Speak up! We’re listening!