The diagnosis of experience diminishes the meaning of both terms. There is the universal tendency of mind to order experience into form. The Diagnostic and Statistical Manual of Mental Disorders, with its now famous (or is it infamous) acronym DSM, is an externally regulated, standard language of general psychiatric knowledge for researchers, diagnosticians, insurers, and clinicians alike. It has become a dogmatically applied numerical system, a form of nosological tyranny imposed upon the field, attempting to diagnose all ordinary and extraordinary psychological experiences.
James Hillman goes even further: The whole of that thick, heavy, and lightweight book [DSM] provides accounts of the various ways the daimons affect human fate and how sadly and strangely they often appear in our civilization. This book prefers to connect pathology with exceptionality, exchanging the term “abnormal” for “extraordinary” and letting the extraordinary be the vision against which our ordinary lives are examined. Rather than case history, a psychologist would read human history; rather than biology, biography; rather than applying the epistemology of Western understanding to the alien, the tribal, and nontechnological cultures, we would let their anthropology (their stories of human nature) be applied to ours.
Even at its finest, collecting biographical information about the patient is a form of objectification of the person’s subjectivity. It is a type of intrusion into one’s emotional life without regard to the consequences and ramifications of such psycho-peeping. Like biography, making diagnoses is a prying, peeping, and even predatory process; like biographers, psychological diagnosticians are “psycho-plagiarists” (novelist Vladimir Nabokov’s term).
Despite wishful thinking by DSM proponents, psychotherapy as a treatment modality is not designed to cure DSM’s illnesses, or any other categories for that matter. Rather, it is at best geared toward potentially remedying the deficits and resolving the conflicts of the individual. The patient’s expressions of distress, whether they take the form of depression or anxiety, somatization or dissociation, still will always differ from patient to patient, person to person. One of the qualifications of the therapist is the lack of interest in quantification. Thus the good psychotherapist undoes the diagnoses.
As David Shapiro says that the neurotic person does not simply suffer neuroses, as essentially one suffers from tuberculosis or a cold, but actively participates in it. Thus the creation of categories rarely serve the patient, and what is more, could counterserve to stigmatize. In fact, such labels often end up being used for procedural, bureaucratic, or even punitive purposes by the practitioner. M. F. Basch has pointed out that, in regard to borderlines, diagnosis is often a sign of the therapist’s negative feelings toward a patient who will not play the game by the rules and leaves the therapist at a loss.
Worse is that the whole field, in fact, is in the untenable position of attempting to define sickness before it has defined health. Such a stance fails to recognize that psychotherapy as a major modality of treatment accomplishes its art by not being illness-specific, but person-specific. The individual is not a diagnosis, and any such equation or categorization is a form of misguided reductionism. Even the characteristic imprint that the patient leaves behind, which Leston Havens calls “fossil diagnoses,” is phenomenologically more relevant than any formal classification. The former is a sudden, sometimes powerful experience of “here is a new person,” an experience that normally causes an element of surprise. This means not only once or twice, but progressively seeing the patient in a fresh way.
In the final analysis, evaluating and understanding patients in psychotherapy requires finding new approaches or pathways that are not easily subject to the regulated tyranny of diagnostic formulae. W. H. O’Hanlon captures this notion with his “possibility therapy,” which is the antithesis of an attitude of foreclosure that circumscribes who the patient is or what his or her future will be. In M. White’s words, it is a stance of “indeterminacy within determinacy,” for which the only capacity that a therapist needs is a curiosity, a capacity that evokes a certain relentlessness to break up our familiarities.
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T. Byram Karasu, M.D. is the author of Life Witness: Evolution of the Psychotherapist