Can There Be a Recovery-Oriented Diagnostic Practice?

Abstract

Despite the prevalence of the DSM in mental health practice, research, and the public imagination, it remains the target of criticism. With the publication of another volume in the DSM series, we have seen increased dialogue regarding the necessity of viable alternatives that do not succumb to the pitfalls of a descriptive diagnostic system. In this article, we explore a framework for a recovery-oriented and person-centered diagnostic practice along with an example based in Experiential Constructivism. We discuss 10 principles of a recovery-oriented approach founded on our requirements that diagnosis should be collaborative, future-oriented, and facilitative of meaning making. We argue for diagnosis that goes beyond labeling people’s mental health conditions, enhances provider–consumer relationships, and supports recovery-oriented practices. We then provide one example of this approach from a study that explored client and therapist understandings of DSM and Experiential Constructivist diagnoses. We conclude by briefly discussing the implications of developing and applying new diagnostic practices in mental health care, specifically the practices that would also need to be in place to sustain any alternative diagnostic approach to the DSM.

Keywords

collaboration constructivism diagnosis dialogue existential psychology mental illness person-centered approach recovery relational

As has been the case for much of humanistic psychology, some proponents of the so-called “recovery movement” find the very notion of diagnosis antithetical to its core values. Because traditional models of diagnosis have focused on observable deficits at the expense of considerations of subjectivity, context, and meaning, DSM diagnoses have not had much to offer humanistic and recovery-oriented practitioners. As the recovery movement arose in reaction to dehumanizing practices in, and more recently outside of, psychiatric hospitals (e.g., Chamberlin, 1978; Deegan, 1992), such a rejection by recipients of these diagnoses carries a considerable amount of weight. This rejection has been further supported by the controversies over the recent release of the DSM-5, which many stakeholders view as having pathologized normal human reactions primarily to the benefit of the pharmaceutical industry and the profession of psychiatry it supports (British Psychological Society, 2011; Caplan & Cosgrove, 2004; Cosgrove & Bursztajn, 2009; Cosgrove, Bursztajn, Krimsky, Anaya, & Walker, 2009; Cosgrove & Krimsky, 2012; Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006; Demazeux & Singy, 2015; Frances, 2013; Kamens, 2010; Kamens, Elkins, & Robbins, 2017; Whitaker, 2011; Zisman-Ilani, Roe, Flanagan, Rudnick, & Davidson, 2013). Given the history of the DSM series and its problematic use in clinical psychiatry and psychology in labeling people rather than mental health conditions (despite its claim, since the DSM-III, not to be doing so; Flanagan & Davidson, 2007; Honos-Webb & Leitner, 2001), we have ample reason to be skeptical of any diagnostic framework that claims to categorize people in terms of their mental health conditions.

Do diagnostic frameworks necessarily have to categorize people, however? Apart from the crude application of diagnostic labels in lower quality, depersonalized versions of medical practice—such as “the broken leg” in Room No. 303 or “the diabetic” who has poor glycemic control—it is hard to imagine the effective provision of medical care without diagnosis playing a central role. To the degree to which mental health conditions can be considered health care conditions like any other (a basic premise both of recovery and of the parity legislation finally passed in the United States in 2008; cf. Davidson, O’Connell, Tondora, Styron, & Kangas, 2006), might the same not be true in mental health? That is, if we could truly diagnose difficulties people have or face without resorting to dehumanizing, deficit-based, and stigmatizing labels, might diagnosis not play a similarly central role in provision of effective mental health care? If so, what might such a diagnostic system look like and how might it be applied in practice (Zisman-Ilani et al., 2013)?

The following report offers one example of how such a diagnostic practice might be conducted based in Experiential Constructivism (Leitner, 1985, 1988; Leitner & Faidley, 2002; Leitner, Faidley, & Celentana, 2000). The diagnosis we will provide came from a study exploring clients’ and their therapists’ experiences of Experiential Constructivist and DSM diagnoses (Pavlo, 2008, 2014). Before exploring its application, we propose a number of requirements and principles with which we suggest any approach to diagnosis would have to be consistent in order for it to be considered “recovery-oriented.” These include both principles of what diagnoses should not be (the easy part) as well as principles of what diagnoses should be (the more controversial part). We offer these principles and their illustration not as a definitive solution or approach to this issue, but as a starting point for further discussion.

Principles for Recovery-Oriented Diagnosis

For the easy part, we suggest that diagnostic systems that offer deficit-based, static, and detached labels for peoples’ struggles not only have little to offer humanistic and recovery-oriented practitioners but also lead to the aforementioned issue of mistaking categories for people (Flanagan & Davidson, 2007). This issue is detrimental for both clients and providers and the effects of which have been well documented (Flanagan, Miller, & Davidson, 2009; Schulze, 2007; Yanos, Roe, & Lysaker, 2010). For providers, there is the danger that they miss or neglect the parts of people that do not fit into these narrow and deficit-based labels. For clients, these labels and the negative stereotypes that accompany them may be mistaken for intrinsic aspects of themselves, thwarting attempts to construct and elaborate narratives that feel correct for them (Honos-Webb & Leitner, 2001).

As humanistic and recovery-oriented practitioners are well aware, a central component of recovery-oriented mental health care is accessing the parts of the person that are not well captured by DSM diagnoses (e.g., strengths, potential, agency, desire for relationships, among others). To facilitate this vision of mental health care, we propose three basic requirements of a recovery-oriented diagnostic system. First, diagnosis should be collaborative. Second, diagnosis should be future-oriented. Last, recovery-oriented diagnostic systems should treat symptoms in ways that help clients and providers ascribe meaning to these often disturbing and confusing experiences. As a result, successful diagnoses will then result in stronger therapeutic relationships and higher levels of engagement, as people will find these understandings useful in making sense of their own experiences. To meet these three basic requirements, we put forward 10 principles of recovery-oriented diagnosis. Before turning to an illustration of such a diagnosis, we will describe these requirements and principles in greater detail. But first a word about the term diagnosis itself.

Despite the problems with the term diagnosis, we continue to use it in this discussion to highlight that it constitutes a common practice in mental health care, but one that often goes unnoticed or unexamined. We believe that this process can be done in more transparent and respectful ways consistent with the values of the recovery movement and humanistic psychology. We use diagnosis to mean the identification and description of the difficulties that bring people to mental health care. Unfortunately, diagnosis has been conflated with the approach of the DSM, largely a result of the promotion of the possibility of an atheoretical diagnostic system that is strongly rooted in the medical model. Rather, mental health professionals make diagnoses based on a variety of factors, including theoretical orientation, discipline of training, and personal values. Take psychotherapy as an example. Therapists of all orientations make some decision about the nature of the difficulties that bring people to therapy and then develop a conceptualization or clinical formulation (see Johnstone & Dallos, 2013, for a thorough discussion of formulation in clinical psychology) based on this diagnosis. For instance, a psychodynamic therapist using an attachment orientation would be interested in the nature of one’s attachment to others (secure, anxious, disorganized). A cognitive therapist using schema therapy may identify maladaptive schemas. A Rogerian therapist would be interested in a client’s conditions of worth (see also Leitner & Phillips, 2003). After such a process takes place, these therapists construct conceptualizations of the work to be done in psychotherapy. The ethical nature of this act—making a judgment about another person’s way of being—cannot be overestimated and careful attention should be paid to this process. We believe that the following 10 principles begin to address these concerns.

Collaboration, Dialogue, and Agency

Principle 1: Diagnosis should be idiographic and from the client’s perspective, incorporating both objective and subjective data from the point of view of the person’s agency.

Principle 2: The diagnostic process should be collaborative and the resulting diagnoses should be useful in helping the client and provider work together.

Principle 3: The clinical interview should be the primary source of data and everything the client says should be taken seriously.

Principle 4: When presented to clients, diagnoses should stay close to the person’s experience, primarily relying on everyday language rather than professional jargon. Additionally, diagnoses should be written using tentative rather than definitive language.

Principle 5: Diagnoses should incorporate a client’s concerns in the present moment.

These first five principles aim to make diagnosis a collaborative practice as well as foster collaboration within the therapeutic relationship. We view collaboration between clients and providers to be a cornerstone of recovery-oriented practice. Collaboration, in this sense, involves providers viewing clients as active participants in their care rather than passive recipients of treatment. A collaborative stance necessitates respecting clients’ subjective experience as well as preferences, values, and goals for mental health care. Thus, diagnosis also should incorporate clients’ lived experience along with wishes and goals. Additionally, diagnosis should not provide privileged information that is helpful to providers about clients (Honos-Webb & Leitner, 2001); both clients and providers should find diagnosis useful to the task at hand.

Dialogue is central to recovery-oriented diagnosis. It is hard to imagine a collaborative approach to diagnosis that neglects the dialogue between clients and providers. As preferences and goals for treatment may not be readily accessible for clients, we envision the clinical interview as an open, transparent, and egalitarian dialogue between clients and providers. In the example that follows, we used a very unstructured approach to the interview. After being informed about the study, participants were told that the first few interviews would be used to develop two different diagnoses. Then, the interviewer invited clients to share what the interviewer would need to know to understand them. The interviewer then followed the participants’ lead and provided minimal additional structure to the interview. In this manner, participants shared what was most important to them in the present within the context of their life histories. This approach allowed participants to get to know the interviewer and share information at a pace that felt correct for them. When something did not make sense to the interviewer, he would simply state his confusion and state his misunderstanding of the participant’s intended meaning and/or simply ask for more information. The interviewer took the approach that everything said by the client was significant and meaningful (see Leitner & Celentana, 1997). In this manner, we gained both an understanding of current and past struggles in the context of the persons’ lived experience (rather than a list of objective “facts” for the person).

Transparency is an important aspect of recovery-oriented diagnosis. As we would neither assume that clients have the same goals as their providers nor forgo gaining a client’s consent before entering into the diagnostic process, we believe that the resulting diagnoses should be relevant, useful, and understandable by clients (or, any nonprovider). Thus, diagnosis should be written in the everyday language of the client and stay as experience-near as possible. In the following example, we relied on Fischer’s (1994) individualized assessment practices and wrote the diagnoses using the client’s language as much as possible. We also wrote them in the second person to highlight their idiographic nature and the intersubjective nature of creating a diagnosis for another in line with our belief that diagnostic process should transparent.

Diagnoses also were written using tentative rather than definitive language. As definitive language implies a static condition that may never change, we assume that client change at the outset and, as a result, diagnoses will be different at various times in one’s life. Tentative language also allows for the possibility that the diagnosis is incorrect for the client, as we believe that it is inappropriate to assume that our theoretical understanding of clients is more accurate than their experience of themselves. Clients should have the opportunity to invalidate diagnoses if they do not fit their experience of themselves.

Hope and Relevancy

Principle 6: Diagnoses should be future-oriented and be useful for both parties in goal setting and care planning (tied in with recovery plan). In the same vein, diagnoses should foster hope for clients and providers. Diagnoses should not be static labels; rather, they should provide avenues for growth.

Principle 7: Diagnosis should be relevant to the task at hand (e.g., psychotherapy, medication management, skills training).

These two principles aim to make diagnosis a practice that fosters hope through future-oriented and relevant diagnoses. Diagnosis should be a bridge between the present and the future. Thus, diagnosis should help clients and providers not only identify but also achieve mutually agreed-upon goals. Diagnoses that provide a description of the person’s current life in the context of what they want for themselves allow clients and providers identify specific and mutually agreed-upon issues to resolve in therapy. When diagnosis provides a static description of issues in the present, it becomes all too easy to define the person by the issues or difficulties that bring him or her to therapy.

We also have found that relevancy is another way to increase levels of hope in the therapeutic relationship in that a diagnosis should be relevant to the task at hand. For example, psychotherapy, skills training, and medication management have different purposes and require diagnoses that are relevant to the demands of each. While we do not imagine these diagnoses to be drastically different from one another, we do believe that the diagnosis should fit the work being done by clients and providers to move toward those mutually agreed-upon goals. For example, the example we will describe was developed for the purposes of psychotherapy and the diagnostic system focuses on the experience of intimacy and the relationships in persons’ lives. While the experience of intimacy may be important for any therapeutic relationship, it is conceivable that a diagnosis for medication management would require different information including how one experiences various medications, preferences for types of medication, and the desired duration of being treated pharmaceutically. When the diagnosis is relevant to the task at hand, they are seen as more useful and, in turn, allow for greater hope within the therapeutic relationship. When diagnoses are not perceived as relevant, the diagnosis itself may foster a sense of despair, as it may be more difficult to see a way to achieving one’s goals. Furthermore, we hope this underscores the notion that diagnoses are one of many possible constructions not some objective truth.

Symptoms, Strengths, and Pain

Principle 8: “Symptoms” are understood as meaningful efforts at survival and communication, based on life history, and inclusive of the effects of overt and subtle trauma. In other words, behaviors are meaningful when viewed in context.

Principle 9: Diagnosis should not only focus on the problems that bring people to therapy but also highlight strengths and assets.

Principle 10: Diagnosis should help the client and provider understand painful and darker aspects of human experience rather than provide a way to distance clients and providers from psychological pain (as is often the case in DSM diagnoses).

Rather than viewing symptoms as observable signs of underlying illness, we view symptoms as meaningful efforts at survival and communication based on one’s life history. Diagnosis should aim to help clients and providers understand often frightening and confusing symptoms. Put differently, we believe that all behaviors are meaningful when viewed in context. We believe that diagnosis should aid in assisting clients and therapists ascertain and create meaning of any experience. In this process, providers should not only focus on the issues that bring people to mental health care but also highlight strengths and assets. These strengths often are the ways providers and therapists can find ways to help persons achieve their goals. Often, symptoms themselves may be strengths, as they may signify meaningful ways the person has survived in the face of hardship.

Last, we believe that diagnoses should not shield or distance persons from painful, frightening, and dark experiences, such as past trauma or frightening symptoms. When providers find ways (often through diagnosis) to distance themselves from darker, painful experiences, they run the risk of ignoring crucial aspects of the client’s experience. Generally, diagnosis should make difficult to understand experiences comprehensible to clients and providers.

Illustrative Case Example

As mentioned previously, the following example of a recovery-oriented diagnosis comes from a study focused on understanding the utility of Experiential Constructivist diagnoses. In this qualitative study, we interviewed eight participants (four clients and their therapists) on multiple occasions to construct Experiential Constructivist diagnoses, confirm the DSM diagnoses taken from their records, and explore their experiences of each diagnosis. The participants were recruited from a state psychiatric hospital. Client-participants were considered to have serious and persistent mental illnesses and were given DSM diagnoses of schizophrenia (paranoid type), borderline personality disorder, schizoaffective disorder, and avoidant personality disorder. Client-participants had experienced multiple hospitalizations and their current hospitalization had lasted anywhere from a couple of weeks to 3 years.

For the purposes of this article, we will focus on one participant. Simon (a pseudonym) was a 33-year-old, African American male who had spent the past 15 years homeless or in and out of a variety of inpatient facilities. Simon spent the past 3 years at the facility in which we met, originally admitted due to concern over his potential to do harm to others. According to Simon, this current hospitalization was prompted by physical altercations with two different correctional officers. According to his chart, Simon was experiencing terrifying auditory and visual hallucinations that had religious themes and was considered to be physically aggressive on intake to the hospital. He was given a DSM diagnosis of schizophrenia, paranoid type. Staff considered his spiritual and existential concerns signs of his illness, and his preference for talk therapy, specifically psychoanalytic therapy, was seen as one aspect of his delusions. Staff often expressed how amazed they were at Simon’s progress, as they did not seem to have much hope for Simon when he entered the hospital.

In the first 2 years of Simon’s hospitalization, most of the staff were too afraid to enter his room or engage with him in a meaningful way. The one therapist brave enough to enter his room, sit in close proximity to him, and discuss his concerns remained an important person for Simon throughout his hospitalization. He was prescribed high doses of antipsychotic medication and muscle relaxants to control his violent behavior and symptoms. When we had met, however, Simon had been progressing through the hospital’s program successfully and was preparing to be discharged.

After an unsuccessful year in college, Simon moved out of his parents’ house and spent much of the past 15 years homeless and in mental health care. At the time of our interviews, Simon was preparing to be discharged and was planning on living with his parents for the first time in these 15 years. Simon described a traumatic upbringing, characterized by emotional abuse and neglect. He often intimated other abuse and relational injuries but did not discuss these with the interviewer directly. As his discharge from the hospital approached, Simon became anxious about moving back to his parents’ home and he said that the hallucinations were more intense. However, he was coping well and seemed hopeful about the next stage in his life.

In the first few moments of our initial interview, Simon described his experience as a child living in a neighborhood characterized by drugs and violence. While he could not engage in such activities, these events left a lasting impression on Simon. Simon began the interview by describing the violence, loss, and death around his childhood home. He began the interview:

Uhm, I don’t know . . . Hmm, I don’t know . . . I guess, I’m 33, been in college, I’ve been sleepin’ on the streets, you know, so, I don’t know. I’ve seen a lot. I kinda grew up pretty much middle class, you know. My family, we probably were above the poverty line, but we stayed in the inner city, so, I’ve seen, I’ve seen federal agents raidin’ my neighbor’s house for drugs. You know, I’ve seen that. I’ve been friends with people that’s been friends with people, known people, that’s got killed, no one really myself. But, I’ve had a few of my neighbors, a girl I used to talk to, her boyfriend got killed. Had a cousin that I didn’t know too well—he got killed.

As the interviewer was a White man a few years younger than Simon, Simon may have felt their backgrounds were too divergent and wanted to be sure they were on the same page. As will hopefully become clear, Simon was a very intelligent and sensitive person, who appreciated how context (class, race, etc.) affected behavior, identity, and relationships. It is noteworthy that Simon chose to tell the interviewer about loss, death, and violence in the first moments of the interview, as it seemed difficult for Simon to experience himself as present and permanent.

He then described how he felt his family was a “mystery.” He reported that both his parents came from tumultuous backgrounds and, as a result, aimed to construct the image of a perfect family. Simon’s mother was diagnosed with bipolar disorder when Simon was a young child. As a result, she was often hospitalized during her manic periods. Simon said that in his childhood, he “always secretly wished that she would get stuck in the manic cycle . . . ’cause I felt like that was her true self.” At these times, he described his mother as “alive. She wasn’t just, you know, a ghost, you know. Just born to work and come home and cook. She had opinions and she had ideas and she had likes and dislikes.” Unfortunately, she also was frequently hospitalized during these times and was unable to care for Simon. Of these times, he said, “we [Simon, his father and sibling] would kinda be hurtin’ . . . if she was out of whack, if she wasn’t in the picture, we were out of whack.”

There were three main themes of Simon’s interviews that are illustrated in this brief description of the first few minutes of the interview. At the present time, Simon was very invested in understanding his family, as he was to live with them for the first time in 15 years. As Simon described his upbringing as often painful, confusing, and lonely, his attempt to understand it was a difficult yet courageous undertaking. The second theme had to do with the ghosts Simon discussed in the interviews. He described being raised by these ghosts, as he was unable to learn from his parents directly. He said,

I think they were busy trying to keep like images of the perfect family. They were trying to hold it together, so they didn’t have time with the kids, you know, ‘cause it was a full job for them just to keep their image going. So, they’d be beat by the time it came to deal with us. I mean we had the four walls of the house to protect us from the negative elements outside, but, maybe ghosts, or something, you know, became my friends or my leaders, you know. And, these ghosts, you know, they were already in house, you know, so, I don’t know. I think that is where I got most of my discipline—from these ghosts, I guess.

The third theme had to do with Simon feeling “fractured” and unable to combine his parents and his own worldviews in meaningful ways. For example, after describing his mother’s hospitalizations, he said,

. . . I mean, you’ve got Hindu gods . . . that had a lot of faces, you know what I’m sayin’, Hindu deities and . . . when these things were happening you’d get to see other faces, your faces. So, instead of just being Simon the son . . . it’d be like, Simon the son of Susan [his mother, a pseudonym]. You and it would be another, I’d be able to look at myself, from a different angle . . . I think we kinda were pushed in these little conforming boxes that never seemed to fit us. So, when these episodes would come up we would get to see other sides of our universe. . . . I always enjoyed that . . . ’cause I never really knew who I was . . . in relationship to my family or to my community.

At the time of the interview, Simon was very focused on understanding his relationship to his family and the greater community. It seemed to be a difficult undertaking, often leaving him confused and hurt. During his hospitalization, he spent much of his time reading about philosophy, politics, and religion. However, he struggled to incorporate different perspectives into a personal narrative that felt satisfying. Specifically, Simon described having difficulty incorporating his parents’ perspectives into his own worldview. As these issues appeared to be most important to Simon at the moment, we focused on these issues in his Experiential Constructivist diagnosis. Before providing the diagnosis, I will briefly describe the Experiential Constructivist diagnostic system.

Experiential Constructivist Diagnosis

Experiential Constructivism is a relational and existential elaboration of Kelly’s (1955) theory of personal constructs. In many respects, Experiential Constructivism is interested in the experience of intimacy and the ways people negotiate threat and risk in relationships (Leitner, 1985, 1988). Because deepening a relationship necessitates being open to both validation and invalidation, it often feels too risky to engage others in this manner (Leitner & Faidley, 1995). However, retreating from such risk altogether often fosters emptiness and isolation (Leitner, 1999b). Intimacy may feel significantly more risky when one has experienced past relational injuries (traumas), as safety may feel preferable to being hurt again (Leitner, 1999a). Thus, the goal of psychotherapy from this perspective would be to assist clients and providers in negotiating this tension between threat and emptiness through the development of an intimate therapeutic relationship characterized by mutuality and trust.

Experiential Constructivist diagnosis aims to provide an understanding of the client’s experience of intimacy in the service of deepening the therapeutic relationship. The Experiential Constructivist diagnostic system may be considered one form of Kelly’s notion of “transitive diagnosis.” Kelly (1955) wrote,

The term [transitive diagnosis] suggests that we are concerned with transitions in the client’s life, that we are looking for bridges between the client’s present and his future. Moreover, we expect to take an active part in helping the client select or build bridges to be used and in helping him cross them safely. The client does not ordinarily sit cooped up in a nosological pigeonhole; he proceeds along his way. If the psychologist expects to help him he must get up off his chair and start moving along with him. (p. 775)

Diagnosis, from this perspective, aims to open possibilities for the future via the therapeutic relationship.

To this end, Experiential Constructivist uses 16 diagnostic concepts (see Table 1) that focus on three related aspects of a person’s meaning-making system: the experience of self and other, the ways in which one approaches relationships, and the experiential dimension of relating to others (Leitner & Faidley, 2002; Leitner et al., 2000; Leitner & Pfenninger, 1994). In this manner, clients and providers can use this diagnosis to help navigate the therapeutic relationship. Using these three components, we aim to describe how a person negotiates the aforementioned tensions to aid in the development of helpful therapeutic relationships.

Table 1.

Experiential Constructivist Diagnostic System.

Developmental–structural issues	Interpersonal components	Experiential components
Construct of self versus otherSelf–other permanenceSelf–other constancy	Underdispersing dependenciesOverdispersing dependenciesAvoiding dependenciesPhysically distancing selfPsychologically distancing self	Discrimination
		FlexibilityOpennessCreativityCommitmentCourageForgivenessResponsibility

		Reverence

Simon’s Diagnosis

We used self–other permanence, dependency avoidance, discrimination, flexibility, forgiveness, courage, creativity, and reverence as the basis for our description of the Experiential Constructivist diagnosis, as we believed that these were the most relevant to Simon as he prepared to be discharged from the hospital. The following is the description of the diagnosis we presented to Simon:

The intense struggles you have described in defining who you are may be understood in relation to frequent injuries you experienced at an early age. These injuries affect your struggle to form a solid and stable sense of self—a self that you could use to engage others and the world. For all of us, early understandings of the self are fragile and tenuous. However, with reliable and consistent nurturing, these understandings become more solid and stable. Unfortunately, those people closest to you early in life came and went in unpredictable ways, making it difficult for you to develop a stable sense of self. One example of this struggle may be the two ways you describe your mother. On the one hand, your mother was low, depressed and focused on fulfilling the roles she chose for herself. At these times, your mother did not feel very present to you and it may have even felt as though she had disappeared. On the other hand, during her “manic” periods, you describe your mother as vibrant, opinionated, and present. At these times she felt most alive and was most your mother. In other words, you felt your mother as very present at certain times, and, at other times, she was gone for you. This is further complicated by the chaos that followed your mother’s manic periods; chaos that often led to hospitalization. Paradoxically, your mother was psychologically present and physically absent.

At an early age, you describe feeling as though you could see yourself from different perspectives, but the inconsistencies you mentioned did not allow for a foundation to build these perspectives upon. For example, you described seeing yourself from different perspectives (Simon my mother’s son, Simon the student), but integrating these roles seemed to be difficult. In order to exist and continue to create ourselves, we need a foundation, a stable sense of sense from which we can experience the world and create a sense of self that feels correct for us. However, we require help from others and this help comes in form of consistency and attention. Otherwise, as you have experienced, we are left feeling fractured and fragmented, as there is no foundation for these perspectives to be built upon.

This may affect the struggles you have had in constructing a solid sense of self (by solid sense of self I mean a self that feels permanent, stable and consistent). It is clear you have begun to have a solid sense of who you are, but these understandings are not solid enough. Put differently, you have great success in intellectually beginning to understand yourself, but you still feel confused. You describe setting off on a journey to understand yourself and have wrestled with life’s major questions. Through contemplation and study, you seem to have been able to put words to experiences that remained hidden. Some pieces, however, do not make sense and seem to leave you confused. For instance, the pain that accompanies these inconsistencies in your early development is difficult to intellectually understand. In order to feel solid, our intellectual and emotional understandings of the world should overlap. One could say that you are struggling with creating a sense of self that feels correct for you. A better way to put it may be that you are creatively struggling to create such a self.

You discuss trying to integrate two different perspectives of the world. You describe a sense of discontent with the way materialism and traditional religious views get in the way of people living meaningful lives. You also describe learning from Eastern philosophies and religions. You said that it is difficult to let either one go, as they both have equal weight in the universe. This may be true—different perspectives have importance, relevance and validity. It may be good to “cut your losses,” as you discussed, and choose one to base your reality on. Then, you can understand the other perspective and integrate the parts that are relevant. Choosing the aspects of each perspective that feel correct for you, instead of trying to take in an entire perspective, may be something to explore. This may allow you to not only gain a more of a solid sense of self, but also have a sense of growing. There is great strength in understanding that life’s mysteries are just that: mysteries.

As hard as we try, we can never make sense of all the incompatible views of the universe. An example of this struggle is the way you describe your father. While your musical and philosophical interests are in line with his, he was not able to affect you directly and, instead, you learned important lessons from the ghosts. This had lead to a feeling of discomfort as you had “to steal” these lessons instead of him giving them to you. It may be important to realize that you can have these perspectives and have feelings about the way they were given to you.

Due to these struggles with defining yourself in relation to others, it seems difficult for you to depend upon others. Because you were not able to reliably depend upon your parents, it is difficult for you to put yourself in a position to depend on others. Because you have struggled to make sense of them not being reliable enough to depend on, it is difficult to move beyond your parents and explore meaningful relationships with others. Relationships can be awe-inspiring experiences, as others can confirm us in profound ways. At the same time, relationships can be terrifying, as others have the ability to reject and invalidate us as they become closer to us.

Managing this tension seems difficult. All relationships have the potential to injure us. Discriminating between those where that risk of injury is too high versus those where the risk feels more acceptable can be a struggle. At times, this seems to manifest when you think about sitting down with your parents and talking with them about your past. You are correct in saying that dialoguing with your parents will be an important part of your growth, but it seems as though you have forgiven them before the conversation you want to have with them has ever taken place. This may be dangerous. If your parents are unable to provide the information and answers you are seeking, you may be left feeling hurt again. To put it differently, if the conversations do not meet your expectations, you may end up feeling hurt and invalidated again. Understanding how past injuries have affected your current understandings of others is crucial here.

It is important to remember that people change and your parents are not exactly as they were in the years past. Approaching your parents as though they are as they were when you were young may be setting yourself up for getting hurt. People are constantly changing and re-inventing themselves, and, if we cannot accommodate these changes by letting ourselves change, it is difficult to grow with another person. Alternatively, using these newfound understandings of others and ourselves, we can continue to engage with the people in our lives. This ability to grow in the context of relationships is especially important in our attempts to understand ourselves. It seems difficult for you to experiment with others and the world, if all the different perspectives that you are trying to integrate keep you somewhat confused about your own sense of self. You described feeling as though you are better able to allow others to exist as they are and you described an emerging sense of respect for each person’s position. For example, allowing yourself to take in these positions and be changed by them, without losing your self, may be useful.

While it is crucial to understand your past, it is also important to understand that you choose how you engage the world in the present. There is a tension here. In order to feel free enough to make choices in the present understanding our past is important. But, as you progress through life, your understandings of your past will change. Thus, a final explanation of yourself may always be just out reach.

Returning to our requirements for recovery-oriented diagnosis, we believe that this diagnosis is collaborative, future-oriented, and presents symptoms as experiences to be understood in the context of the person’s life. We organized the diagnosis in terms of Simon’s current and most pressing concerns. We used the constructs of the diagnostic system to understand and organize Simon’s experience, but, rather than providing Simon with a detached and abstract description, we used Simon’s own words and tried to stay as close as possible to his experience. When constructing the diagnosis, we wanted to incorporate Simon’s lived experience in ways that were respectful. Thus, we aimed to take Simon’s concerns seriously and did not treat these concerns or his understandings of himself as signs of a “mental illness.” If collaborative therapeutic relationships are a goal of mental health care, we believe our approach to diagnosis is one way to realize this ambition.

This diagnosis also fulfills our requirements that recovery-oriented diagnoses inspire hope by being future-oriented and relevant to the demands of psychotherapy. Throughout the diagnosis, we aimed to offer Simon suggestions for areas to work on in psychotherapy without being overly or narrowly prescriptive. For example, we were concerned that Simon may feel disappointed if the conversations he hoped to have with his parents did not go as he hoped. Thus, rather than telling him how to have these conversations, we offered our concerns along with some issues Simon may want to consider with his therapist.

The diagnosis also provided a way to understand Simon’s symptoms as meaningful experiences. We wanted to describe some of the anxieties Simon was experiencing in the present in ways that allowed him to explore them in more depth. As mentioned previously, we also wanted to respect his experiences by not reducing his concerns to signs of “mental illness.” For example, we described Simon’s feelings of fragmentation in terms of his description of seeing himself from different perspectives but not feeling like he had a solid foundation. Often, others, including staff, construed Simon’s discussion of spiritual or religious matters as signs of mental illness, or “triggers.” Thus, we wanted to take Simon’s perspective seriously by incorporating these aspects into the diagnosis. We also wanted to point out Simon’s strengths and ways he could continue to build on them as he moved forward toward his desired future. In other words, we believed his assessment that his anxiety had to do with his relationships with his parents, rather than a manifestation of mental illness via stress.

If we used the diagnosis in psychotherapy, we would have offered the diagnosis as one possible way among many to understand Simon’s current life. We also would have asked Simon if our suggestions for areas to work on in psychotherapy made sense to him and were consistent with his own priorities. Through such a dialogue, the diagnosis could be used to set the stage for a collaborative psychotherapeutic relationship. While we did not use the diagnosis in this way, we did have the opportunity to discuss this diagnosis (as well as the DSM diagnosis) with Simon. A detailed discussion of Simon’s reactions to each component of the diagnosis, as well as the findings of studies using this approach to diagnosis, are beyond the scope of this article. However, we have preliminary evidence that these 10 principles were perceived as useful and attainable by the client- and therapist-participants and having benefits, such as increased levels of hope and agency.

Conclusion

While a dialogue about alternative diagnostic systems is crucial, we believe that it is equally important to consider how any new diagnostic system would be incorporated into routine mental health care. Despite long-standing criticisms about the validity and utility of the DSM, its diagnoses are inescapable in mental health care and research and often occupy a taken-for-granted place in the professional and public imagination. Thus, one part of the answer must contend with the issue of the impression the DSM has made on the mental health field and how to undo this damage. While the answer in part lies in how we choose to conceptualize diagnosis, other tasks include continuing to provide evidence for the utility of person-centered models of care and collaborative relationships while dispelling the stigma prevalent among both the public and mental health professionals, especially those beliefs that result in pessimistic attitudes toward what types of dialogue those diagnosed with serious mental illness can engage in and their potentials for recovery.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anthony J. Pavlo

Author Biographies

Anthony J. Pavlo, PhD, is an associate research scientist at the Yale University Program for Recovery and Community Health. His research focuses on recovery-oriented and person-centered practices in mental health care and utilizes a relational approach based in humanistic psychology to understand and elaborate concepts and practices in health care.

Elizabeth H. Flanagan, PhD, is an assistant professor in the Yale Program for Recovery and Community Health, Department of Psychiatry, at the Yale School of Medicine. She has been researching and writing about diagnosis and the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the past 20 years. Recent research has focused on the subjective experience of mental illness and the validity of the DSM. She argues that the validity of the DSM could be improved if the DSM development process included people with lived experience in important roles in diagnosis development workgroups and if diagnostic categories became more aligned with the experience of mental illness rather than how they appear to clinicians. Past research focused on clinicians’ natural taxonomies that develop as a result of clinical experience and the relationship between these taxonomies and the DSM.

Larry M. Leitner, PhD, is an emeritus professor at Miami University. He has been involved with experiential constructivism throughout his career.

Larry Davidson, PhD, is a professor of Psychology at the Yale University School of Medicine, where he founded and directs the Program for Recovery and Community Health. He also serves as the Senior Policy Advisor for the Connecticut Department of Mental Health and Addiction Services, and from 2009-2014 served as the national director of the Recovery to Practice initiative of the U.S. Substance Abuse and Mental Health Services Administration.

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