Characterological diagnosis: labelling or liberating?

Humanistic and Integrative Psychotherapists can get very squeamish about the use of diagnosis in psychotherapy. Diagnosing characterological or personality types is seen as a step too far towards the medical model: clients are pathologised in the diagnosis and subsequently treated as if they have a psychological flaw that requires ‘fixing’ or ‘curing’. We tend to believe that diagnosis treats people as if they had something wrong with them when in fact we are all just imperfect creatures doing our best given the hand we have been dealt.

I’d like to offer a different view of diagnosis: one that equally rejects the paradigm of pathology but that rehabilitates the use of diagnosis as a tool for empowerment for both therapist and client.

My personal view is that  the real villain of the piece in humanistic psychotherapy is not the use of diagnosis, but the discourse of ‘health’. When we make subjective differentiations between what is ‘healthy’ and ‘not healthy’ for our clients we impose upon them a pathologising framework which is, in my opinion, far more insidious than any diagnosis of characterological difference.

I use diagnosis all the time in my therapeutic work with clients but with two essential caveats: i)  I have no investment whatsoever in the client making any behavioural change to comply with an arbitrary, subjective and purely cultural notion of ‘psychological health’ , and ii) I have no judgement on the choices they make providing their choices don’t impinge upon the human rights of others.

I think that our squeamishness in the humanistic therapy world in dealing with psychological diagnosis is because we rarely have an open discussion in which we critically analyse our most basic philosophical assumptions about psychotherapy and its uses.  I think our fear is not really about labelling our clients’ psychological processes, but about imposing moral and critical judgements upon them. Sadly however, abandoning the use of diagnosis doesn’t mean that we automatically abandon our privileging of certain societal norms. I frequently see humanistic psychotherapists and person centred counsellors impose a set of expectations which they deem to be ‘psychologically healthy’ without any critical analysis or reflection upon these assumptions.

I would like to argue for a case where we use characterological, clinical diagnosis to both empower our clients and liberate ourselves from the constraints and serious limitations of a ‘one size fits all’ psychotherapy.

Take, for example, the apparently straightforward example of ‘expressing feelings’ in therapy. Most humanistic therapists would take the view that suppressing feeling is ‘unhealthy’ and expressing feeling is, ergo, ‘healthy’. Straightforward, or not so? Let’s take a  client with a masochistic style: this client’s sense of self is predicated on his or her capacity to tolerate deprivation. Expressing deep affect is not only distressing for this client, it challenges his very notion of self and identity and can precipitate a psychological ‘collapse’ that the therapist isn’t expecting and doesn’t know how to respond to because it appears more traumatic than it ought to. Now, this isn’t to say that we should collude and avoid deep affect with this client, but a deeper understanding of the client’s response to affect should help the therapist pace the work appropriately and have a stronger empathy with and understanding of the inevitable feeling of ‘collapse’.

Or a client who has a histrionic process. She will express feelings with gusto and quite often throw a bit in just to please the therapist.  I think we have all had experiences where the therapy is ‘stuck’ because the client is on a treadmill of expressing lots of feelings without actually digesting any of them. This is an entirely different process requiring an entirely different therapeutic response. How do we judge this if we have already abandoned the notion of a characterological diagnosis?

My view is that we all of us conform to loose characterological types – often combining several at once in different aspects of self – and that an effective therapist will work sensitively, respectfully and skilfully with each process within us, at no point discounting our humanity or individuality.

But all to what point? What is the purpose of psychotherapy?

I believe that clients come to us because they don’t like the fit of their own skin, and we simply help them to fit into it more comfortably: that actually all we can do is help our clients to be more themselves, not to adapt to some arbitrary notion of psychological health.

Or, in the words of Arnold Beisser, ‘Change occurs when we become who we are: not when we try to become who we are not’.

This entry was posted on Wednesday, July 20th, 2011 at 5:51 pm and is filed under Humanistic therapy, Intersubjectivity, Psychotherapy, Structures of the self, Training. You can follow any responses to this entry through the RSS 2.0 feed. Responses are currently closed, but you can trackback from your own site.

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