Captain Cook Had a Treatment Plan

Diagnosis and Treatment in Psychotherapy

Annual Conference of the New Zealand Association of Psychotherapy
Queenstown N.Z. April 2005


Introduction

This paper highlights questions regarding the relevance of diagnosis in psychotherapy and the relevance of treatment methods within the profession. Psychotherapy is viewed as a separate profession with links to psychoanalysis, psychiatry and clinical psychology. Psychotherapy has a primary and consistent focus on the complex relationship between client and therapist.

Arguments are presented which question the need for diagnoses and suggest that treatment is a concept which prevents therapists from viewing the client as a whole person.

Captain Cook set out on a journey which took him into the lives of people he had never met. Along the way he had to find ways to establish effective relationships, how to enhance those relationships and manage the process of change that affected each person. His journey reminds me of the psychotherapeutic process.

Contemplations offshore

“During his stay in Uawa (Tolaga Bay), Cook’s impression of Maori seem to have crystallised. In his rough notes he wrote:

  1. the religion of the natives bear some resemblance to the George Islanders-
  2. they have a god of war, of husbandry &c but there is one suprem god whom the(y) call he made the world and all that therein is-by Copolation
  3. they have many Priests
  4. the Old men are much respected-
  5. they have a King who lives inland his name we heard of him in Poverty Bay
  6. They eat their enemies Slane in Battell – this seems to come from custom and not from a Savage disposission this they cannot be charged with – they appear to have but few Vices – Left an Inscription
  7. Their behaviour was Uniform free from treachery…41” (i)

Anne Salmond in her book The Trial of the Cannibal Dog comments:

”For years, Cook held fast to these conclusions, that Maori were honourable people with ‘few Vices’ and that cannibalism was simply a matter of custom. In this judgment he was influenced by Enlightenment ideals rather than British popular culture, which linked cannibalism with witchcraft and demonic possession. Many of the crew, however, held opposite views about Maori, regarding them as ‘savage’ and ‘treacherous’, and these differences of opinion sowed the seeds of future dissension between Cook and his men about how Maori and other ‘savages’ ought to be treated.” (ii)

When I read Salmond’s book I was impressed with the personal qualities of the courageous Captain Cook and it was salutary to view the process of colonisation through a different lens. The methods Cook employed to establish relationships with people in the South Pacific lead me to think about psychotherapy as a profession in Aotearoa. He had significant success on many occasions and some relationships were close and rewarding for both parties. Other relationships ended in confusion and there were those that ended in tragedy. The more I thought about the way we present our profession to enquirers, intending clients and trainees the more I made links in my mind with Cook’s missions.

My reading caused me to reflect on how much Cook’s training, experience and cultural formation influenced his approach to people he was meeting for the first time; people who thought differently, described their experiences differently and placed importance on different aspects of their lives. His journey seemed to parallel the journey embarked on by some psychotherapists. People are met for the first time, a partial knowledge of their history is gleaned, a diagnosis is made and treatments applied from within a specific knowledge base. Sometimes the formula works, just as Cook found he was welcomed and honoured by some people in the Pacific. Sometimes clients accept the words and actions of their therapist and view them as definitive. Some people in the Pacific believed in Cook’s treatment methods so strongly that the unfortunate repercussions are still with us today. Likewise some of psychotherapy clients live with the idea that they suffer from definitive psychological illnesses defined by members of the profession. Just as some people in the South Pacific did not know there were alternatives to Cook’s diagnoses and treatment methods clients may not know there are alternatives to the practice of defining their dilemmas using definitive psychological descriptors.

Welcome visitors to life onshore

My relationships with psychotherapists in New Zealand leaves me in no doubt that there is real dedication to exercising the utmost patience with respect to the lives of the people we touch. Therapists often live through pain, enlightenment and celebration with clients without forming a specific diagnosis or apply a definitively designed treatment. What we name as transference is entered with trust and insight. The uncertain future of the relationship is surrounded by a faith that life has potential and promise. Clients welcome us to their lives trusting that we will hear the meanings not yet expressed and hoping we will understand without judgment.

Many ships flying different flags

What happens in the practice settings of most of my colleagues seems to be inconsistent with the way we present our profession to those who have not yet become members or people intending to be clients.

If I stand back and view the public face of psychotherapy in most countries including our own I see a divided profession. In practice we are primarily concerned to assist with making the unconscious conscious and work with the complexities of the relationship between two people in a consulting room. We follow a client’s life story without using designed formulations promoted in the literature and in training programmes.

The public image of our profession is different . It is one of a divided self where modalities compete for attention and support the idea that therapists use a variety of ways to diagnose and treat people. Our Association Handbook does not mention diagnosis or treatment in relation to psychotherapy but when I am asked to assess a candidate for membership I am asked to forward the name of my main modality. All the modalities I have researched over the years have diagnostic formulae built into them and methods of treatment which are often designed to treat specific conditions or aspects of personality functioning. Generic training programmes are few in this country and most training opportunities expect trainees to adhere to specific formulae which are diagnostic and promote methods for treatment.

The chart in my cabin

My definition of psychotherapy is ‘a process which encourages creative, well informed and safe contacts between two people in order to explore emotionally significant aspects which enhance or inhibit paths to healing, personal energy, creativity and secure intimate relationships’.

Mapping the chart

In order to practice safe and effective psychotherapy we need to reflect on the way clients present, our personal and professional responses to their presentations and whether we and our clients are safe within the relationship.

I have been taught many ways to reflect on the work I do. My formal education covered theology, psychology, social work and counselling . Initial instruction in these disciplines encouraged me to search for certainty and to respect research findings because they contained facts. During my tertiary education I took papers in philosophy and discovered that certainty is extremely elusive if it exists at all and we make meaning of the world by naming some phenomena as factual. The result is I have an inner ambivalence toward any process which seeks to define, make certain or propose definitive pathways for people. I now reflect on my work with a conscious (or unconscious) rejection of any temptation to place a template over that which is within a client or that which is within me.

When I studied psychology I was accepting of the idea that people’s behaviours could be grouped into categories, symptoms could be put into ‘sets’ and specific psychological illnesses could be established by combining these ‘sets’ of symptoms. Undergraduates were expected to trust textbook summaries listing the origins and expressions of depression, psychosis or ‘abnormal’ behaviour. There was often a footnote in these works pointing out there may be exceptions to the rules but somehow a small number of exceptions did not mean the conclusions might be invalid.

I worked in a psychiatric clinic for six months. Patients were known by their label. The ‘obsessive compulsive’ was in room three and the ‘paranoid schizophrenic’ in room five. In the 1970s and 1980s the search was on to find neurological and chemically based treatments for ‘conditions’ and this often clashed with the work many of us were trying to do using therapy, social work and family based interventions. We were attempting to work with the person and I had been trained to be curious about association patterns instead of deciding the patterns formed the basis of some kind of illness.

My formal training as a pastoral theologian, a counsellor and then as a social worker engendered a fascination with the way clients constructed their thought patterns, their intricate emotional life and the dreams they had. I became a member of the Psychotherapy Association in order to learn more about the intricacies of the psyche. I had little attraction to facts about people because I sensed facts altered quickly in the presence of strong emotions. I heard presentations at conferences highlighting the uncertain world of emotional existence and the powerful world of verbal and non verbal associations. On the other hand I heard presentations illustrating how much therapists wanted to categorise client’s emotional lives, find formulae for managing them and reassurance in what they perceived as predictability in thought patterns.

The ship’s company

There is a place for diagnosis and treatment for intervening in people’s lives. I have never been certain where the boundaries are with regard to interventions appropriate for a psychologist, interventions best carried out by a psychiatrist and processes which belong in the psychotherapy setting but I am certain that many situations demand competent diagnoses and treatment in order to keep clients safe and functioning well in their social and cultural settings.

We refer some of our clients to professionals who are trained in administering treatments or interventions based on sound research. They apply medications or behaviourally focused management for clients who need expertise which lies outside our particular competence. We could not work without these colleagues. There are few definitive boundaries. In our association we have psychiatrists, psychologists, health specialists and medical practitioners who practise what I know as psychotherapy in addition to enhancing and saving people’s lives using other appropriate interventions.

Diagnosis also has a place in psychoanalysis and I am making a distinction between psychoanalysis and psychotherapy. It is that analysis is applied to or by the client and therapy is dependent on a developmental process. There are situations where the two coexist. Where analysis is used as part of the therapeutic process it usually accompanied by a diagnosis and I am not sure the two belong within the same therapeutic relationship setting.

Defining the strategy before approaching the shore again

The following definitions are offered to facilitate discussion:

Diagnosis is the process wherein the therapist relies on a summary of symptoms, behaviour or communications which are then ‘contained’ in a category descriptor and used to find a way forward for the therapist. Where diagnosis encourages the therapist to expand their knowledge and participate in a critique of chosen diagnostic categories the process may be useful in challenging therapeutic assumptions. Where the diagnostic process defines the client and informs them they have a particular ‘condition’ or ‘fault line’ the therapist is ignoring multi- faceted aspects which impinge on client growth and development.

Treatment is the process wherein the therapist chooses to apply a formula for healing which relies on method, a belief that client dilemmas have causes which can be defined and a framework dependent on stages. Treatment ideas assist therapists to contemplate effective ways to communicate with clients. Treatment applied by adhering to defined methodology assumes the client will benefit from being treated in the same way as other clients and may ignore individual or cultural difference.


Is the travel guide book helpful?

The idea that we can diagnose the person we are meeting as a client has its origins in the practice of dividing people into component parts. I am not sure what it is that psychotherapists can claim to diagnose with confidence. Are we confidently diagnosing ‘psychological’ factors? If this is the case do we know where the psyche is, where it begins and where it ends? Are we diagnosing presenting issues? If so, how informed are we by the client in order to decide the extent of the dilemmas and how they link with facets we may not be competent to diagnose? Our diagnosis is probably based on having met the person in our consulting room. The relationships they have with other people are reported rather than experienced by us. Their social and cultural setting exists in a different atmosphere from that which we have created in our therapy room.

I have gained so much from supervision over the years and yet I have always been aware of the way we discuss the client’s process and mine in a setting removed from the way life is being lived. Diagnosis freezes people in a time warp. It relies on stories having a beginning and an end, events existing in defined moments and the idea that client and therapist issues are the same today as they were yesterday. From this limited perspective we then choose a treatment. In most supervision sessions we would agree to “try something out and see how it goes” but the die is cast and the client is unaware we have been conditioned to approach them with a plan in mind in case we need it.

If we acknowledge psychotherapy as a ‘process’ rather than an ‘intervention’ we have a dynamic view of what is occurring within and around a client and ourselves as therapists. When clients tell their stories in therapy it is tempting to listen for organising principles. One organising principle we use is association. We notice client’s association patterns and refer to client’s ‘dissociating’. We have a tendency to follow the client story by giving it a form we construct in our own minds. The next step is to reach for an explanation as to why this pattern exists, diagnose it and subsequently choose a treatment approach.

Over the last two decades I have been strongly influenced by implications we can draw from quantum physics, research into that elusive concept, ‘mind’ and stories I have heard from clients relating experiences of being diagnosed and treated in therapy. I have learnt from these sources that it is impossible to separate one thought from another, one emotion from another and one state of being from another. Parts of each person have been given names and therefore we perceive them as separate entities. Mind, emotions and events are not separate states and do not exist on their own. The same is true of association patterns. The patterns which seem to be there are formulations in the mind of the therapist and may not be perceived as such by a client.

Diagnostic procedures name emotions, behaviours and thoughts as if they have a continuous existence. The client whose personal and social history is known to us and seems to exhibit “ a disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment may be described to a supervisor the next day as being ‘dissociative’. (iii) The client who has had ‘one or more manic and or depressive episodes’ may be described to a supervisor as bi polar. (iv )

These clients have expressed thoughts which, in a moment of time, were surrounded by complicated associations linked with that moment and the atmosphere of relationship within the therapy room. To assume continuity of thought, behaviour and emotion on into the next hour or the next day ignores the reality that clients are changing constantly. It is impossible for clients to have contracted a set of symptoms which, when summarised by the psychotherapist, fix the client in time as ‘depressed’ or ‘disordered’ or ‘dissociated’.

Sets of symptoms are put together by psychotherapists using categories defined by researchers who have never met the clients. I have seen clients struggling with their unique emotions and their overwhelming need to behave in ways that cause them pain but I resist giving these definitive descriptions such as ‘depressive’, ‘bi polar’ or ‘post traumatic’ episodes.*

Therapists usually agree that it is important to establish a relationship with the client as a whole person. Information from the scientific world encourages us to acknowledge that each time we intervene in one aspect of a person’s existence we are having an effect on another. Intervention in emotional arenas has a profound effect on physical health, intellect, relationships, social and cultural connection.

A diagnosis using psychological terminology establishes the view that the psyche is separate from the rest of the person and assumes healing will take place by attending to ‘psychological’ factors which inhibit growth. The person (or client) is now seen to be divided within themselves and dependent on psychotherapy in order to be healed.

When a physician diagnoses a person’s physical ailments they usually point to a body part which can be touched, viewed via an electronic scan and repaired. In our profession we cannot point to the psyche and be sure that it exists. Clients and therapists assume there are psychological elements which need attention and assume that any healing which seems to take place need not be subject to any reality testing. Once we have established a psychologically based diagnosis we may diminish the person by accepting the notion that each person is the sum of separate parts and give them the message they are the same as every other person who has a similar set of symptoms. The idea that each person is unique has thus been jettisoned in order to make a generalised diagnosis.

Irvin Yalom writes, “Though diagnosis is unquestionably critical in treatment considerations for many severe conditions with a biological substrate (for example schizophrenia, biploar disorders, major affective disorders, temporal lobe eplilepsy, drug toxicity, organic or brain disease from toxins, degenerative causes or infectious agents) diagnosis is often counterproductive in the everday psychotherapy of less severely impaired patients… A diagnosis limits vision, it diminishes the ability to relate to the other as a person….And what therapist has not been struck by how much easier it is to make a DSM-IV diagnosis following the first interview than much later, let us say, after the tenth session, when we know a great deal more about the individual?…A colleague of mine brings home this point to his psychiatric residents by asking: “If you were in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?” (Rosenbaum, personal communication, Nov 2000)” (v)

* Related professions different in kind from psychotherapy are specifically trained to name sets of symptoms and apply treatments designed to alleviate and heal illness and disease.

This land is your land

Debates surrounding diagnosis and treatment continue to surface in psychotherapeutic literature and it is impossible to cover all the fascinating questions which address ethical, philosophical, therapeutic, psycho-biological and cultural factors. The practice of assigning categories of psychological illness or disturbance across cultures is overdue for review. The culturally based advice in the Diagnostic and Statistical Manual of Mental Disorders is being updated and research is being called for to address weaknesses in these publications.
The DSM –IV cautions psychiatrists by stating “It is important that the clinician take into account the individual’s ethnic and cultural context in each of the DSM-IV axes”. It continues, “ There is seldom a one-to-one equivalent of any culture-bound syndrome with a DSM diagnostic entity”. (vi)

When reading this I forgave the labelling of cultural process as a syndrome. Unfortunately the next pages highlight comparisons between ‘cultural syndromes’ and categories in the DSM. A kind of psychiatric colonisation is attempted. The following serves as an illustration:

“Falling out or blacking out: These episodes occur primarily in southern United States and Caribbean groups. They are characterised by a sudden collapse, which sometimes occurs without warning but sometimes is preceded by feelings of dizziness or ‘swimming’ in the head. The individual’s eyes are usually open but the person claims the inability to see. The person usually hears and understands what is occurring around him or her but feels powerless to move. This may correspond to a diagnosis of Conversion Disorder or Dissociative Disorder”. (vii)

It is possible that these symptoms have a cultural explanation which cannot be defined using concepts which originate in another culture. The DSM does what colonisers have often done; it attempts to fit aspects of human behaviour into its own frame of reference. The behaviour is labelled as an episode, and the symptoms are cross referenced to categories designed by another culture. The behaviours are also viewed as ‘disorders’.

Landing with luggage

Early this year I accepted another invitation to work with Maori health professionals to teach them foundation skills I normally teach to Pakeha counsellors and therapists. I realised I would be taught by my students perhaps as much as I could teach them. I expected to discover ways of adapting European based theory and practice to make it relevant in a different cultural setting. I was surprised to find myself re examining some of the basic tenets of psychotherapy, especially the traditional notions of diagnosis and treatment.

I have addressed some aspects of working cross culturally in previous publications and that is a separate study. (viii) In this paper I am highlighting important issues for psychotherapy in any setting. These issues have been underlined by my experiences in teaching within a different culture.

What follows is a set of questions which lead me to wonder whether diagnosis and treatment can ever be part of my practice.

Diagnosis revisited

  1. When there seems to be one client in the consulting room there may be others who are ‘physically present’ whom we cannot ‘see’. These people are not just held in memory or gathered in by association, they are there to be consulted. How can I proceed with a diagnosis of one psyche defining it as an entity within one person? How can I delineate its features using language created by people I have never met?
  2. Individuals have a ‘separate’ physical body separated at birth and separate when death occurs. Does this separate physical body ‘contain’ and keep control of the psyche? The psyche is heavily influenced and molded by forces outside of the physical body which are connected with other bodies on earth and beyond. How can I be certain a diagnosis based on what I have heard from one person will be sufficient to explain individual pain, inhibition or unease? Where is my deep respect for people if I introduce them to a diagnostic explanation which narrows to concepts such as disorder, dissociation, depression, paranoia, repression, drives or injunctions?
  3. Integration is built with support, initiatives and nurture embedded in cultural belief systems. Mind, emotion, physical form and spirit can all be spoken of as separate entities but they do not act in isolation from each other. If I address ‘mind’ I am addressing connections which are woven tightly together. A diagnosis which has its foundation in the separation of mind, body, spirit and emotions assumes disintegration has occurred. How can there be disintegration when there is no separation? How can I make a diagnosis which addresses emotional forces within one person when those emotions are intricately bound to the emotions of another and to a spirit world woven into the world we call reality?
  4. Personal pain, described as emotional pain or trauma by European based theorists, is not confined to the present moment and may exist on a timeline reaching deep into a timeless continuum
  5. Associated events, relationships and formative intrusions may have happened to an unnamed historical figure in a cultural setting whose influence affects “the client” in ways that remain in the shadows of anonymity. How can I form a diagnosis of human pain which sets it within a specific time frame or views it as existing only within the lifetime of one person?
  6. That which gives rise to personal pain or inhibition may not have a defined beginning. The idea that causes exist as separate entities is questionable within the context of life surrounded by constant ebb and flow. A diagnosis which postulates causes is likely to ignore the complexity of one life being a woven tapestry. To ask when pain began or when dis ease was first formed is to ignore the interconnections scientists are examining and to reject the idea that there is a powerful collective unconscious.

Treatment revisited

  1. Treatment implies focus. It selects an aspect to be treated and keeps it in view. My experience leads me to the conclusion that I cannot be selective. Cultural formation is woven and the spaces in between speak of connection rather than selection. Where is the ‘individual’ who needs ‘treatment’? Where is ‘the person’ to whom the treatment should be applied?
  2. Treatment is based on a formula. A formula implies a stepped process with a beginning, a mid phase and an ending. Where is the beginning, the mid phase and the ending when it comes to human process? Are all individuals able to respond to the beginning place, the middle phases and the endings which have been built into the formula? The formula is likely to have been tested. The assumption is that the psychological profile of research subjects is exactly the same as the psychological profile of any individual client.
  3. Treatment is targeted. In psychotherapy treatment is usually targeted behaviourally, biologically, psychologically or emotionally. Treatment targets assume people are the sum of separate parts and they often assume a specific starting point somewhere within a separated system. Treatment is often designed to target ‘disorder’. Where is the disorder and can there be a decision as to where to target treatment when are no separate entities to aim at?
  4. Treatment is applied. I have developed caution with regard to seeing myself as an agent of treatment. I do not possess any tangible evidence which people can see or touch to prove my expertise in applying therapeutic treatments. Treatment modalities exist in name, in a variety of literary forms and in the minds of people who view them through different lens. They do not exist as definable methods. I find it difficult to imagine where my authority would come from in order to give myself permission to treat a person with something as intangible as therapeutic method. The establishment of relationships means being comfortable with uncertainty rather than certainty. It means acknowledging I can never really know a person of any culture (including my own) well enough to apply a method to their person.
  5. Treatment implies resolution. Being in another culture has taught me about continuity. The idea that pain or trauma can be treated and then feel resolved or closed is an idea that seems to run counter to life that ebbs and flows within a constantly changing universe. What is it that is being healed through psychologically based treatment? Is it an aspect of the psyche? If so, how can one aspect be healed without affecting another? If all aspects of the individual psyche are affected are they all automatically healed? If treatment is applied to an individual does this make them an agent in their own healing and how is this linked to the way healing is dependent on the lives of significant others who have not been invited in to the treatment process?
  6. Treatment is usually applied within a specific context. Because treatment is applied to a problem or a psychological state of being it is applied in context. The idea that treatment should be honed or narrowed to manageable steps is indicative of the belief that specific contexts are important. The separation of one context from another is a process applicable in some cultures but not in others. A whole of life view demands that change to one aspect of a nurturing system does not take place without taking care to include all aspects. Support for people should involve healers, advisers, historians, spiritual guides and links with ancestors to address any matters which may be inhibiting the fullness of life within the nurturing community. Knowing this, it is difficult to imagine why I would contemplate treating one aspect of a person’s life in any cultural setting without making associations with other aspects and without being as inclusive as possible. I may well agree to confidentiality and work with an individual but I will be aware that the idea of targeted treatment within a defined and separated context is a denial of the wholeness my profession espouses.

Notes in the log

My conclusion is that definitive diagnoses constructed around the client rather than with the client are contrary to what we know about human development. I am also suggesting that treatment designed by a theorist who has never met the client fails to acknowledge their unique place in the world and their unique psychic development.

The psychotherapy profession has many practitioners whose practice addresses the questions developed in this paper. The public face of psychotherapy is different. It promotes division and separation and suggests strong links with professions whose role it is to analyse, diagnose, treat and search for definitive solutions to ill health and dis ease. Training courses which perpetuate divisiveness through adherence to specific methodologies promote the belief that the psyche can be defined, analysed and changed using the same methods in any setting.

I look forward to a time when psychotherapy discovers the possibilities in developing theory and training opportunities which focus on how to manage complex relationships without applying designed formulae and methods. That will usher in a new era and those of us who can hold ourselves and others safely while uncertainty and possibility reign will be eager to learn more.

A.Roy Bowden
April 2005

References

(i) Salmond, Anne (2004) The Trial of the Cannibal Dog, Captain Cook in the South Seas Penguin Books, p 128
(ii) Salmond, Anne (2004) The Trial of the Cannibal Dog, Captain Cook in the South Seas. Penguin Books, p 128
(iii) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p477
(iv) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p350
(v) Yalom Irvin D (2003) The Gift of Therapy Harper Collins, Ch 3
(vi) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, Appendix One, p844
(vii) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994,
Appendix One, p 84
(viii) Supplementary readings with reference to psychotherapy in bi cultural settings in Aotearoa:

Bowden A R (2003) Choosing to Cross by Sea, Keynote Address, Regional World Congress Conference, London, Ontario, Canada
Bowden A R (2002) Is there a Psychotherapy for the World? Keynote address, World Congress for Psychotherapy Wien, Austria
Bowden A R (2002) Psychotherapy as a Container for Philosophical and Bi Cultural Pratice in Aotearoa, New Zealand in Mythos – Traum – Wirklichkeit A Pritz & Thomas Wenzel (eds) Facultas Universitatsverlag, Wien, Austria
Bowden A R (2002) Psychotherapy in New Zealand in Globalised Psychotherapy Alfred Pritz (Ed) Facultas Universitatsverlag, Wien Austria
Bowden A R (2001) A Psychotherapist Sings in Aotearoa Caroy Publications, Plimmerton NZ
Bowden A R (2000) Bi cultural practice in Aotearoa Psychotherapy In Australia (Jnl) Vol 7 N1
Bowden A R (2000) Individuation in a Culture of Connection Forum (Jnl) NZ Assoc. Psychotherapists Vol 6