Tuesday, August 14, 2018

On Psychiatric Diagnostic Categories from the Point of View of Humanistic-Experiential Psychotherapy

Entry for 12 June 2018 [revised 14 August 2018]:

This started out as a long email to Ueli Kramer & Antonio Pascual-Leone, posted, with their permission, only now two months later (a piece of unfinished business after my return from China).

I was stuck waiting in the Chinese Consulate in San Francisco for hours today, so you now have to suffer through the following screed:

Thanks for your responses and questions.  I taught in a clinical psychology doctoral course for almost 30 years, and also taught Abnormal Psychology on many occasions, as well as using different structured psychiatric diagnostic instruments.  Like you, I am intimately familiar with the very messy, complicated process of applying psychiatric labels to people in both clinical and research settings.  I studied with Ted Sarbin, and have what I consider to be a healthy ambivalence about the larger DSM/ICD enterprise.  On the one hand, I’m very aware of and have witnessed the various difficulties with stigmatisation, reification, questionable reliability and validity, conceptual muddiness/overlap, lack of etiological basis, and philosophical disharmony with humanistic-experiential approaches.  I also strongly believe that the language we use and the implicit assumptions and metaphors that it contains are important and powerful, for better or worse.  I regard language use as an ethical issue.

On the other hand, these categories have their merits and uses: (1) I’m aware that there are regularities that the diagnostic categories seek to capture; it’s not only or simply a social construction. I’m a dialectical constructivist here: the labels both point to something in the world and are at the same time a social construction of what’s there.  (2) Some clients find acquiring a diagnostic label to be clarifying and validating. I don’t want to deprive them of that, although I don’t mind reminding them that the categories are social constructions cooked up by groups of people as part of a political process.  (3) To progress and disseminate our work we have to be able to communicate with researchers with different philosophical perspectives and lived experiences, including those who exist in an unreflected way within a diagnostic system and psychiatric language that they are attached to and that feels like home to them. They will feel threated and will fight us if we try to take their cherished language from them.  (4) Some labels are more useful, reliable, valid etc than others, or at least less broken or over-simplifying than others; others, I think, pretty much suck and best consigned to the dustbin of history.  

Given these complexities, here is the course of action I have long tried to follow:

First, I try lead by example: I try to keep my language as clean as possible.  I personally find the word “disorder” to be stigmatising, so I try to always say “difficulties” instead; this has the advantage of allowing me an alternative gloss for favourite abbreviations like PTSD (“post-traumatic stress difficulties”).  I personally find “borderline personality disorder” to be especially problematic and therefore moved first to “borderline processes” and then, following Margaret Warner, to “fragile process”, which I find to be a far more accurate term anyway.  I replace “schizophrenia” with “psychosis”.

Second, although I do have my strong views, I try to avoid being polemical or confrontational. Snark such as inveighing against the evils of the “medical model” can be fun but it just puts some people off, and of course also ignores the fact that this too is a kind of stigmatising diagnosis, which for starters ignores the fact that there are many quite different “medical models”.  The main point here, however, is I understand that people are typically very attached to forms of language that are familiar and comfortable to them.  This can be difficult at times and I’m not sure that I always succeed.  In general, I try to assume good intentions in others, even when I experience their language as unreflected and potentially offensive or even harmful to some.  When this happens I go back to my first strategy of leading by example; and I expect others to extend the same respect for my use of language that I offer them: we may not agree with the language the other person uses, but I expect us to respect each other’s need or habit of using that language, at least for the moment.  This means that sometimes I will need to provide translations of my favoured ways of talking, even though I find these translations not to my liking.  At times, gatekeepers may even try to suppress my favoured ways of talking, in which case I will try to find a mutually-acceptable compromise. Only as a last resort and for carefully-considered pragmatic reasons will I capitulate to using language that I do not agree with.

Third, I think it’s very important for us to dialog about these differences in language, to try to develop both our understanding and our language more fully so that it increases in accuracy, transparency, respect and usefulness for our clients and research participants. That’s why I raised the issue when I saw your article.

See: Kramer, U., & Pascual-Leone, A. (2018). Self-Knowledge in Personality Disorders: An Emotion-Focused Perspective. Journal of personality disorders, 32:329-350. DOI: 10.1521/pedi.2018.32.3.329

1 comment:

Robert Elliott said...

A further thought occurred to me last week: There are three things wrong with the psychiatric label "Borderline Personality Disorder": "Borderline"; "Personality"; and "Disorder".

(1) "Borderline": The original idea was that this was on the border between psychosis and neurosis; almost no one thinks "neurosis" is a useful concept anymore, which means that there is nothing on one side of the so-called "border".
(2) "Personality": The concept of problems of "personality" as distinct from other kinds of mental health problems also seems increasingly suspect. Maybe there is a continuum between processes like depression or anxiety and supposedly broader processes like avoidant or antisocial, but any kind of clear dichotomy? No so much.
(3) "Disorder": Stigmatising and not useful. "Difficulties" is much more useful and carried less baggage.