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The role of diagnosis in counselling and psychotherapy
The role of diagnosis in counselling and psychotherapy

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1 The complexities around diagnosing mental illness

You will be encouraged throughout this course to relate the material back to individual clients to consider what they may gain, and lose, from embracing diagnoses, and to think about how clients and therapists might work with such dilemmas. Towards the end of the course you will be asked to consider ‘formulation’ as an alternative to diagnosis. Formulation is where, rather than giving a diagnostic label, a counsellor, psychotherapist or other mental health professional gives a description of the experiences that the client is struggling with, along with a theory about the way it has developed over time and how it is currently being maintained. This is then revisited and reconsidered throughout the therapy.

Before we start with a historical consideration of diagnostic systems, let’s consider one person’s experience with a label of ‘mental illness’, to begin to understand the complexities which might be involved.

Case Study 1: Mario and depression

When Mario was in his early twenties at university, he became worried because most years around Easter he seemed to go into what he called a ‘slump’. During this so-called slump he stopped going out with his friends and being involved in the theatre group that he usually enjoyed so much. He worried that people didn’t really like him and imagined the kinds of things they might say when he was out of earshot. Sometimes these worries kept him awake at night. When he was back at home, Mario sought the advice of a family friend whom he knew suffered from ‘depression’. The friend said that Mario couldn’t possibly be depressed, because when someone is depressed they can’t even get out of bed in the morning, and Mario was attending lectures and doing fine in his studies.

The following Easter, when Mario again hit a slump, he felt even worse about it, knowing that he wasn’t properly depressed, so there was no good reason for his struggles. He criticised himself for not being able to do simple things, like choosing what to wear, or complaining to his landlord about the state of the house. Everyone else seemed to manage such things, so what was wrong with him?

Ten years later Mario was working as a researcher for a television company. The pattern of going into slumps had continued, but more frequently. Half the year he felt fine and would throw himself into activities and be the life and soul of the party. The other half he felt like he was moving through treacle. Everything he did was a huge effort and he hated himself for finding it so difficult. Eventually he mentioned this to his GP who immediately diagnosed Mario with ‘depression’, gave him a prescription for Prozac and put him on a waiting list for brief counselling. Partly, Mario was relieved to finally know what was wrong with him, but he was also scared by the label. Did that mean he was always going to be like this? Would he ever get better?

Activity 1 Losses and gains of a label

Think about Mario’s situation and that of other people you have known who have received a ‘mental illness’ label such as ‘anxiety’ or ‘depression’. Spend 15 minutes writing a list of the things a person in today’s society might gain from such a diagnosis, and also what you think they might lose. It might be helpful to also think what is lost and gained from not having such a label. Then watch the video below, ‘Experiences with diagnosis and stigma’.

Gains

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Losses

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Questions

While you are watching, think about the following questions:

  • Are there any further losses and gains to receiving a diagnostic label that you can add to your existing lists?
  • Do the people speaking have the same, or different, perspectives on diagnosis? Who do you agree or disagree with, and why?
  • Does having a diagnosis help people to be less stigmatised or does it increase stigma, or both?
  • What alternatives might there be to diagnosis?
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Transcript: Experiences with diagnosis and stigma

Commentary
Being given a mental health diagnosis, such as depression or anxiety, is experienced by people very differently, depending in part on whether it results in better access to treatment such as therapy, or being disempowered and marginalised.
Jim Brown
I more or less self-diagnosed … And I went to see my GP, and I put it to him, and he said, ‘Yeah, I think you’re probably right, and we can make an appointment for you to go and receive the diagnosis formally.’ And, it was a bit of a relief ’cause I thought well, yeah, okay, this is a bona fide illness, so it’s not my fault. But, the more I thought about this, the more I really didn’t like it. I was gonna have to go to see an expert who was gonna charge me £350 to tell me what I already knew, and give me a one-way ticket to disability. And, the more I thought about it, the more I didn’t like it. And I thought there’s got to be a better way. There must … there must be a better way than this. And so I went back to my GP and I explained to him, yes, I had these highs and lows but I didn’t really want to be a professional disabled person thanks very much. There’s got to be a better way. There’s always a temptation to go for a diagnosis, because that kind of lifts it off your shoulders and then the professional is responsible for it. But in doing so, you kind of give up your own responsibility for your own wellbeing.
Stephen Fry
I think it helps to have a diagnosis. I’m sure of it. Apart from anything else, it’s … it cuts off all kinds of other diagnosis – well, it’s not this, it’s not that, it’s not that. And that can be good. Of course, like any diagnosis it could be that the one thing it is, is the worst thing it could be which I don’t think it is in the case of, um, bipolar disorder. And not knowing whether what you have is, is actually classifiable and recognisable as a condition that is in the Diagnostical and Statistical Manual and is, you know an ‘official’ thing that has its indicators and symptoms that are recognised. If you imagine how much of a relief of the mind it is when something physical is traced to the source, then imagine how much more so when it is something to do with your state of mind.
Trisha Goddard
I wouldn’t have liked that label, I talk about, um, I have had depression or I live with depression, but I’d already been quite vocal about labels. I had a sister who had schizophrenia and I really despised people talking about schizophrenics or manic depressives or depressives, you know, because we don’t talk about cancerous people, you know. And I think that if you label somebody enough – and I’d say that to everybody, anybody – if you label that person or that group of people enough, they take on a victimology, they see themselves as victims … I prefer to think of myself as someone who happens to have depression as part of their make-up, but has learned coping mechanisms.
Commentary
One of the problems with diagnosis can be that it sometimes exacerbates the stigma experienced by people with mental health problems.
Trisha Goddard
And I wasn’t surprised to find out when I was involved in the Community Attitudes and Awareness Programme, when we did a lot of research, we found one of the highest levels of stigma towards mental illness within the mental health profession. That’s because it’s like – I’m treating them, it’s not me.
Stephen Fry
The real problem with it is other people. That’s the bigger problem. All, all the seriousness that I’ve discussed of this condition is absolutely to be addressed and not to be taken lightly, but really, it is society and stigma that I think lie at the heart of, of the problem of mental health in this country and will continue to do so.
Trisha Goddard
And I think that’s something that has to be watched very carefully because once someone’s got this label of depression or anxiety or whatever, you’ve got to be very careful that you don’t label everything they do in every reaction as a symptom of what you’ve labelled them.
I had a cab driver once who said, he’d gone to Hellesdon, which is a psychiatric hospital near Norwich, and had to pick somebody up. He said, ‘Oh, you know’, he was going on about how he wouldn’t have one of ‘them’ from ‘there’ in his cab, ‘because you don’t know what they’re going to do’ and ‘you just can’t take your eyes off them’. And I just let him chat on and I said, ‘So are they scary?’ and “Oh, yes, yes, you can always tell when you’ve got one of them in the cab, you know, I always keep my eye in the mirror and what have you’ and I said ‘I expect you’ll be keeping your eye on the mirror now, won’t you?’ and he said ‘What do you mean?’ and I said, ‘Well, I’ve been in a psychiatric hospital. I spent five weeks’ and he said, ‘But you seem normal.’ I said. ‘What the hell is normal? Cycle on the washing machine.’ That’s my slogan, ‘Normal is a cycle on a washing machine.’
Jim Brown
I think what would help is if people would just be prepared to discuss it more openly, particularly in a working environment, because work for me, the working environment is where the stress can be the worst. Because you’re expected to perform. You’re contracted to perform. You’re there to earn money … really, and your employer has a right to expect that you will deliver something. And if you start to lose confidence in yourself, then that can kind of be a self-fulfilling prophecy. So we need to find a way of talking about this and opening up the workplace, really, so that people can say, ‘You know, I’ve experienced … I’ve had these experiences which made it difficult for me to do my job, or whatever.’ We need to find a way to make it ordinary.
Stephen Fry
It’s much easier for me in my ‘business’ to say that I, I have this condition. No one’s going to sack me, no-one’s going to think that I’m not up to the job. They may even think I’m better qualified for it in some strange way. You know, such is the obeisance that we pay to, to, to show business and the creative arts. But the people who work in teaching and spot-welding and factories and offices around the country, they’re not in such a happy condition and I think it’s not they that need, well partly they need to feel, I hope that they’re not alone, and that what they have needn’t hold them back, but also those around them need to know that, er that um, you know, this is something that is, their attitude can make a huge difference.
Trisha Goddard
I noticed, I went onto a website, about my film credits, and I thought, ‘Oh this is interesting’ and I went on and it said I had been in a number of films, Shaun of the Dead for instance , what have you, and I thought, ‘That’s pretty good’ and then I saw industry, umm sort of, warning or issue, and I thought ‘What’s that?’ and I clicked on that, and this is on the internet, and it said ‘Warning, has suffered from depression. May not complete.’ So, you know, depression is still a bigger issue on a release form for me than breast cancer, go figure. [Laughs] I, you know, there is more an issue of me not completing a film or a project through depression than a reoccurrence through breast cancer.
End transcript: Experiences with diagnosis and stigma
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Experiences with diagnosis and stigma
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Discussion

We shall come back to Mario’s example later in the course and see how a counsellor might work with him to explore the losses and gains of taking up the label of ‘depression’.