6 Losses and gains of diagnosis
Having considered some of the general problems with diagnostic categories such as ‘depression’, let’s return to the example of Mario presented at the beginning of the chapter and explore how a counsellor who is aware of such issues might work with him.
Case Study 3: Mario and Emma explore the losses and gains of diagnosis
The following is a transcript of some of the first session between Mario and his counsellor, Emma.
Emma: So what brings you here today, Mario?
Mario: Well, Dr Harris referred me to you because he says I have depression … [pause]
Emma: What are your feelings about that?
Mario: [laughs] Mixed, I have to say, mixed.
Emma: Can you say a bit more?
Mario: Well, I’ve felt like this most of my life: falling into a slump every now and then. I always thought it couldn’t be depression, because I managed to get out of bed every day. You know, I never seriously thought about killing myself or anything.
Emma: So you thought it couldn’t be depression?
Mario: That’s right. But now he says it is. I don’t know. It is a relief because it kind of makes sense of all those times when I’ve felt that way. And my family have been a lot more sympathetic since I told them, they used to just think I was a grumpy so-and-so.
Emma: People are more sympathetic now?
Mario: Yes, like it’s not my fault. And at work I know I could put in for sick leave. I could never do that before. I worried that I’d be fired if I took any time off. Now it’d be discrimination if they did that. And I’ve been reading about other people’s experiences online. It feels good to know that other people have been through what I’ve been through.
Emma: But you still sound quite hesitant. Are there some losses associated with ‘depression’ for you, as well as these gains?
Mario: Absolutely. I mean for a start now I feel like I’m different, you know, and I was trying so hard to be normal. I’m worried that other people will think I’m a freak if I let them know: some kind of psycho. I don’t want my family walking on eggshells around me.
Emma: So you’re worried about how others will view you?
Mario: And how I view myself, I guess. I read all those stories online and I think ‘Is this me?’ I mean some of it fits, but some of it sounds nothing like me. Plus now I’m worried I’ll be stuck like this forever. Before, I always thought that I’d find a way out of it, but if I have this thing that’s an illness, maybe it isn’t in my control to do something about it.
Emma: That sounds frightening, to be out of control.
Mario: [sigh] It is. It really is.
Activity 5 Losses and gains for the counsellor
Look back at the previous lists you made about the losses and gains of a diagnostic label. Take a few minutes to add anything to it, having read the exchange between Mario and Emma.
Now take 15 minutes to create a similar list of the potential gains and losses of embracing a label like ‘depression’ for the counsellor. What might Emma gain if she sees Mario as a man with depression? What might she lose?
Discussion
You might consider that counsellors could be drawn to such labels because they give them a sense of understanding and control from early on with a client. If they’ve worked with a ‘depressed’ person before, they may feel more comfortable and able to predict what will be helpful. They might feel they can look to research evidence to find out what works best with depression. They might even feel a sense of connection with the client if it is something they have been diagnosed with themselves.
On the losses side, therapists like Yalom (2001) argue that there is a danger that counsellors will treat someone as a diagnosis rather than as a human being. They may look for features that fit with their understanding of depression and ignore what is unique for that person. Also, the stigma around mental illness may prevent them from connecting with someone with an unfamiliar, or frightening, diagnosis, or one that it has been suggested by research may be difficult to work.
You might want to look back to this example and consider how counsellors from different approaches might work with Mario’s ambivalence.
Perhaps it is particularly important to reflect on the common everyday perception, explicit in Mario’s account here, that having a diagnosable ‘mental disorder’ means that a person is not ‘to blame’ for their difficult feelings and associated behaviours, whilst not being diagnosable is assumed to mean that they are somehow responsible for them. A particular (but problematic) gain of a diagnosis for many people is the sense that it is, therefore, not ‘their fault’. We might question whether it is ever useful to regard someone as ‘to blame’ for feeling anxious or sad, but also consider the implications of believing that someone with a diagnosis has no control over or responsibility for their emotions and/or reaction to the situation.
Some have distinguished between primary and secondary gains of embracing a diagnostic label, and patient role, for the client. ‘Primary gains’ are the ways in which a preoccupation with one’s symptoms (say being fearful of leaving one’s house) may avoid addressing background difficulties from the remembered past, lived present or feared future. ‘Secondary gains’ would include, for example, agoraphobia being a way of manipulating an errant spouse into being more attentive at home.
Thus, although anxiety and depression are forms of distress, they are not merely distress, as they also generate psychological benefits: they have an ‘upside’, even if that is not necessarily consciously recognised by the client. It is worth noting here that our understanding (and the client’s) of aspects of primary and secondary gains from symptoms are the basis of formulation rather than diagnosis. This distinction will be returned to below.