Exploring Diagnosis and Normalization

What Brings People to Therapy?

Asking this question today, I’m thinking very broadly about the impulse, or emotion, or need which brings people into therapy. I’m not thinking about what’s the most common problem in therapy, or anything like that, but more like what are the ordinary common denominators. And I’m hoping this will lead to insights for helping.   

Two things are grounding this inquiry. It’s quite shocking to me that over 80% of visits to a primary care physician don’t involve a health issue. The second is my recent reading of Marcel Proust’s In Search of Time Lost, a famously sensitive and introspective novel written 100 years ago (or so) about life in France. The thread which connects these two disparate stories from science and from fiction is this: that there is a massive diversity of human experience, much of which can feel intensely bad, but which does not represent there being anything at all wrong with us.

We see doctors when we feel both uncomfortable and insecure about it: we aren’t sure if this fatigue is simply some tiredness, or the precursor to leukemia. So, we want to get an expert to have a look on our behalf. I think many visits to the counselling therapist have the same motive in mind. Except, writing in 2023, I’m aware that nearly every bit of human experience is now up for grabs as being potentially problematic or pathological. We have all learned to navigate our internal worlds with the same uncertainty that we often navigate our bodies: our bodily health is opaque, and frightening. I can’t see inside myself, I can’t personally tell if I have bronchitis or emphysema, and if I get it wrong I could lose everything, even my life. Our bodies are an easy source of insecurity, it makes sense that we so much enjoy the viewpoint of experts, to reassure us that a cough is just a cough.

But when did our emotional and psychological life become so fraught? Reading Proust, I am struck by his delightful insights into the curiosities and idiosyncrasies of everyday people. He writes of affliction, and desire, and moral hazard, of trying and failing, of immaturity and growing up, of idiocy and brilliance, of deep self-awareness and the hilarious gaps of our views on the self. And nowhere in this astonishing, humane treatment of persons does he invoke the language of psychologized helping. The giants of psychotherapy had not yet come along and invented languages of pathology and healing, and so Proust was still free in the 1920s to speak of our differences, for good or for ill, as just the normal, ordinary parts of human life.

Consider some of these non-psychologized gems and think of how these simple realities would give so much fodder to today’s psych-professionals:

“Facts do not find their way into the world in which our beliefs reside, they did not produce our beliefs, they do not destroy them.”

“Perhaps there exists no one, however virtuous he may be, who may not be left, one day, by the complexity of his circumstances to live on familiar terms with the vice he condemns most expressly…”

“He diverted the conversation to other subjects, precisely because they interested him less…”

There are 4000 pages of these kinds of remarks in Proust, gentle, observational, humanizing and empathetic. I’ve selected this smattering because I know that when these things are said in therapy, there is a sense that one has done wrong, cognitively, morally, socially… And just like when we feel uncertain of our cough and go to the doctor, in 2022 we now have a place to go with every uncertain experience of our inner life too.

Now, of course, I am a therapist, and I believe strongly in the work we can do for people: but I want to say here that we created a double-edged sword in making popular these insights into the pathways of disease and maladaptation that exist for people. Now, just like with our bodies, where we know of incomprehensible modes of death and dying that leaves us with insecurity, we now also know that there are dangers lurking everywhere in our psychosocial lives. While it provides pathways to safety, it also exposes us to this meta-neurosis of being worried about Who I Am and What I’m Like.

In 1982 Ivan Illich wrote: “Medical procedures turn into black magic when, instead of mobilizing his self-healing powers, they transform the sick man into a limp and mystified voyeur of his own treatment. Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation of the sick on science and its functionaries instead of encouraging them to seek a poetic interpretation of their predicament or find an admirable example in some person—long dead or next door — who learned to suffer.” 

Working with the Double Edged Sword of Therapy

It’s important to say that this feeling of being worried about Who I Am is a completely valid reason to come to therapy. It is a product, perhaps of being human, but certainly of being human in our current time. Modern, western, urban – we worry now about who we are. There is an important part of this that dates all the way back to early Christianity in which sin was transformed from the Judaic sin of bad behaviour to the Christian sin of ill intention. One must become the monitor of their very thoughts, and dreams, and perceptions instead of merely behaving well. What a challenge!

As clients, we come to the right place when we bring these worries and anxieties to our counsellors. But as therapists, we need to be aware of the double-edged sword we carry. In our capacity for helping, we have also changed the landscape of what it means to be a person, and made it just a little scarier.

Given these circumstances, there are three interlocking tools which are absolutely critical that therapists keep top of mind: 1) diagnostics, 2) pathologization, and 3) normalization (acknowledgement and acceptance).

Diagnostics in Medicine and in Counselling

Consider again the metaphor of the patient going to the doctor with a scary cough and let us map this onto the client coming to therapy with a scary feeling. The doctor cannot simply say — “You’re fine”, or they will lose credibility as an expert. They must run some diagnostics. The same is true in therapy. However, there are special challenges in counselling. Primarily, we are talking about invisible phenomena. There is no way to look and see if something is or isn’t “broken”.

There are also issues with more formalized assessments and battery tests: these tend to find what they are designed to find regardless of whether it is there or not (e.g. false positive bias).

In formal biomedicine, there is a primary ethical duty to not commit a false negative – that is to say, not to miss something that is, in fact, there. In counselling, we do not have the same ethical duty (which makes sense because it’s impossible to determine if “something” is actually there when it’s an invisible psychosocial dynamic!). Doctors will trade false positives to prevent false negatives. Counsellors should not be so willing.

Pathologization and Nonpathologization

Pathology is a fancy word for sick, ill, diseased. It means something is definitely wrong. And to be nonpathologizing is to emphasise that things are alright. The doctor who investigates your cough only to tell you “it’s just a cough” is performing a “nonpathologizing” task for you – it relieves your anxiety and insecurity. The cough itself remains uncomfortable, but stops being very distressing. So there is tremendous relief in accurately nonpathologizing our experiences. We can very often suffer the primary thing if we know that it’s not representing something terrible.

The doctor who wrongly nonpathologized, and misses the bronchitis or pneumonia or whatever, is making a huge mistake, so nonpathologizing should be accurate. In counselling therapy, you see the word “nonpathologizing approach” everywhere, for better or worse.

One reason for this was stated above, that we do not have the same imperative against false negatives that biomedical clinicians have. There are two more reasons that counsellors should emphasize nonpathologizing approaches. The second, which I’ll discuss below, is because of the “looping effect”. But the first is that, based on a distribution of probabilities, it is most likely true that there is nothing wrong with the person who’s emotional and psychosocial distress has brought them to counselling. What we call “mental health problems’’ should be restricted to very extreme and intense occurrences — massive psychosis, the abyss of melancholia, etc. But in everyday life there are always hints of these afflictions amidst our ordinary experience.

Keeping track of the stairs as you go up doesn’t mean you have OCD. Someone who feels mixed emotions about their partner does not have Borderline Personality Disorder. The person who harbors a grudge does not have psychopathy. Those who want distance in their relationship do not have Avoidant Attachment Style. The person who experiences a period of collapsed energy does not have Major Depressive Disorder. At least not necessarily. All of us experience these diverse human experiences, all of which have by now been categorized, at least in their extremes, as being a scary disorder. (And when that occasional person comes through, we catch it. The extremes are pretty obvious in their intensity and, even more visible, the deleterious impact on the lives of those afflicted.)

In counselling, we should think of our labels as “diagnosis of exclusion”. That is to say, that a diagnosis becomes so when there are no better explanations for what’s happening, when all the better explanations have been sufficiently excluded as options. This means that we ought to explore the experience itself, with an expectation that there will be a good reason for this psycho-social phenomena. And in fact, our use of pathologizing labels like Anxiety Disorder should be reserved for, as an example, experiences of anxiety when there are no compelling reasons for anxiety at all. I have literally never encountered this, by the way.

Normalization

When we have used diagnosis of exclusion and then depathologized an experience, the last piece of the puzzle is normalization. It is helping shift our clients’ understanding of this phenomenon from scary and not-normal, to just a part of everyday human experience.

Normalization is not just saying “that’s normal”. Normalization is the work of helping people to enfold their experience into the wonderful, humanizing diversity of ways of being in the world. Normalization lets a cough be a cough – sometimes we are gallant and sometimes catty, sometimes we are sensitive and other times bullheaded, and so on. We are inconsistent and idiosyncratic creatures. The stable base of our evolving identity is capricious, it is an organism in an ecosystem which sways and tilts and morphs with its environment. We are who we are, on some path towards who we want to be.

Good normalization work requires skillfulness and expertise in language. Proust is a master normalizer. He does not have the doctors tools of saying “You have no disease, therefore you are normal”, and neither do therapists, so the job is not so easy for us. We have to empathize and deeply understand not just our client, but all the vagaries of human existence so that we can help put language and feeling to experience in such a way as to prove that it is normal.

Our intellect and our imagination help to shape our perceptions of the world and ourselves. When we understand we are normal, there is a positive looping effect. When we believe we may be damaged, broken, or sick, there is a negative looping effect. That is, in the ephemeral world of our inner life and experience, unlike the concrete physical world of our bodies, what we believe about the state of things interacts — directly — with the state of things! If I believe my crooked knee is healthy, it remains crooked. But, if I believe my tendency to explore my relationships in deep thought is normal, then I can enjoy it, lean into it or out of it, and generally feel secure and non-anxious about our personal tendencies this way or that. But, if I believe I am an anxious overthinker, then the suffering will double upon itself.

I alluded to this above as one consideration in our diagnostic and nonpathologizing process. Whereas doctors make their biggest mistake when they miss something that is there (a false negative), I believe counsellors make their biggest mistake when they name something that isn’t there (a false positive). We will live and interact with these labels to our detriment. The wicked son acts bad. The sick person stays in bed.

Conclusion

The Roman poet Terence wrote “nothing human is alien to me”, many centuries ago. Human experience is so varied, and we have learned reasons to feel insecurity about so many parts of our life, that many people come to therapy unsure if their thoughts and feelings are “okay”.

And they probably are. One job of good counselling is to look and make sure this isn’t an unlikely case of extremes, and if it’s not, to show, skillfully, that all is well in one’s inner world. That the extraordinary diversity of your experiences can be enjoyed, can be surfed, and can be changed if that is the desire. Depathologizing and normalizing work is deep, humanistic, empathetic work that requires a sincere acceptance of human beings as they are and as they have perhaps always been.

This normalizing work is a crucial aspect to doing good helping work. Because if counsellors aren’t careful, they can use their double edged sword in a way which simultaneously helps and harms clients. We provide some relief to what ails, but perhaps we deepen the sense that this affliction is a genuine and serious risk to the person. So we have to be very careful with our words and our tactics. The first signs of a Disorder are present everywhere: they have literally no meaning. I would not be surprised to learn one day that many animals on our planet feel anxiety – that does not mean they have Disorders. As clients, we should be open to exploring our experience beyond the language of diagnosis and prevention. We should let ourselves be open to discovering that we might be weird, and quirky, and doubtful, and often kind and sometimes not, and that all of this is just how it’s supposed to be. Every tick and quirk of ours does not lead down dark and horrifying corridors, despite whatever the WebMD of mental health would have us believe. And as clients, we should be absolutely sure that we understand the difference between what is a Disorder and what is yes another problem with living.

Problems with living deserve care too. Working on these problems-in-living is a mark of evolution, and growth, and maturity. But let us not take it too far. Let us both accept what is, and want to work for something more, and let us get some help in that task, without reaching for languages of illness, and brokenness, or “mental health issues”. It is enough to say I have low motivation for work these days, it is enough to say I find my partners dinner conversation boring lately, without reaching for depression or ADHD as a means of getting help. It is the job of counsellors to normalize what is not a pathology: and most of our lived experience is just that – normal.