7 Working without diagnosis

If we abandon the medical categories of ‘depression’ and ‘anxiety’, how then do we understand and work with human misery? The first point is about words: different cultures vary in their description of transient inner states. The second point is that as we grow up we learn in our particular culture how to express the feelings we do and in what context. Our capacity to reflect on these feeling rules are important in understanding why the broad description of ‘neurosis’ typically involves ‘insight’. The depressed or agoraphobic patient is fully aware of their distress (indeed, they may be obsessed by that awareness), whereas someone diagnosed with ‘psychosis’ is generally seen as not having such insight.

Thus we cannot really understand the distinction between productive and unproductive expressions of distressed feelings unless we understand what is expected of people in different societies in different times. For example, the challenge of agoraphobia emerged largely in a period when women were expected to appear more and more in public spaces and were at risk of being outside the protection and control of men (de Swaan, 1990). In industrialised societies the challenges of most work roles require confidence and motivation; these are undermined or displaced by fear and sadness and so incapacitate the worker. Thus, when discussing emotions we need to be constantly aware of their meaning in different times and places. Different words are used and different rules apply over time and from place to place. A fundamental problem with a categorical view of mental illness is that it offers concepts that are imposed independent of time and space.

At the same time (as I argued earlier), it might be quite legitimate to claim that there are certain predictable aspects of fear and sadness that really do apply in all contexts (and to all mammals, not just humans). A different way of putting this is that ‘depression’ and ‘anxiety disorders’ are medical constructs: they are words. However, people are really distressed in particular ways. The meaning of these real experiences is then open to reflection within the person and negotiation with others.

One meaning that can be attributed is that ‘depression’ or ‘anxiety’ are medical conditions to be treated by drug or talking ‘treatments’. Alternatively, the person and their friends and family might ‘work out’ what the distress means without professional help. If a distressed person seeks help from counsellors or psychotherapists, then they are more likely to enter a negotiation of meaning in which the professional develops a view (a formulation) of what the presentation of distress means for the client.