The process by which
counselor attempt to reach out and to understand has been the subject of great
controversy and not a little confusion and misunderstanding over the years. The
earliest attempt to describe the process was termed, perhaps unfortunately, “diagnosis”
(Williamson, 1939).
The term was borrowed
largely from medicine and came to process connotations and meanings that were
quite foreign, and in some instances, repugnant to counselor. In any event, the
process of diagnosis and its role within the total intervention process is quite
different in counseling from what it is in medicine.
Traditionally, the
process of diagnosis in medicine has been concerned primarily with the presence
of disease entity within the patient.
Measles, mumps, chicken pox, polio, pneumonia, and influenza are disease
entities. They present distinct symptoms, are caused by specific infectious
agents, and have known differential treatments associated with them. Much of
the progress of medical science has involved the identification of disease entities,
the discovery of their causes, and the formulation of specific remedies. In
this sense, diagnosis typically involves the study of symptoms, the use of
laboratory tests, and finally a prescribed course of specific treatment. Within
this model diagnosis necessarily precedes treatment and represents a distinct
stage in the total process of treatment.
However, even in
medical settings attempts to apply this type of process to so-called “mental
illnesses” have not been notably successful. The nature of presumed disease entities
in the “functional mental illnesses” has proved to be different from those
types of pathology for which specific organic causes can be established
(Eysenck, 1961).
Evidence about the
relatively low reliability and limited utility of traditional psychiatric
diagnoses led Eysenck to suggest that the whole notion of disease entities
should be banished from modern psychology. Nonetheless, despite this
controversy, work on the medical model of diagnosis in psychopathology has
proceeded.
The American Psychiatric
Association has published three editions of its Diagnostic and Statistical Manual of Mental Disorders. The Third Diagnostic Manual (DSM III)
designed to be a more reliable system for diagnosing mental disorders within a
medical, disease entity model (American Psychiatric Association, 1980),
includes somewhat more specific and operationally defined criteria than were
found in the first two manuals. However, it should be understood that for most
of the categories the criteria are still based upon clinical judgment and have
not been fully validated.
The DSM III is considerably
more comprehensive than earlier editions and marks a clear attempt to bring a
wider range of human concerns, including developmental, educational and
vocational, problems under the rubric of “mental disease.” In this sense, it is
as much a political document, staking out the territory of organized
psychiatry, as it is an attempt to provide a scientifically defensible system
of classification (McReynolds, 1979).
In previous chapters we
have discussed the philosophical and professional limitation of the intra
psychic disease entity models. Many counselors have reacted negatively to the
medical model of diagnosis and for very good reasons. The risk of stigmatizing
clients with labels that are both vague and frightening, the possibilities of
creating “person blame” approaches that solve social problems by scapegoating
powerless people, and the erosion of personal responsibility by translating all
sorts of human concerns into sicknesses have caused many counselors and
counseling theories to shun traditional models of diagnosis and to regard the
term itself as anathema.
We should note that not
even all psychiatrics diagnosis support disease entity models. Benjamin (1981) reviewed
the history of psychiatric diagnosis and deplored attempts at “remedicalizing”
psychiatric diagnosis. Menninger (1963) proposed that unitary models of
diagnosis be developed to enable clinicians to conceptualize levels of client
functioning without involving notions of specific disease entities with all of
the untested assumptions that these entail. He noted that disease entity models
totally fail to describe upper levels of human functioning, or what he called
being “weller than well.” Prugh (1973) has proposed a unitary model that
develops a diagnostic system based on the departures from the optimal personal
and family functioning of children at specific age levels.
Such unitary models
seem useful in evaluating efforts both at preventing obstacles to optimal
functioning and at enhaching personal
growth. One advantage of unitary models is that they can consider both the
assets and resources available to individuals as well as the obstacles. What
follow is a unitary diagnostic model to describe levels of functioning in
relation to human effectiveness.
