Chapter draft for F. Kaslow (Ed.) Relational Diagnosis, Wiley, 1996.
       Is Diagnosis a Disaster?: A Constructionist Trialogue
       click here for original paper

       by
       Kenneth J. Gergen, PhD 
       Lynn Hoffman, MSW 
       Harlene Anderson, PhD 
 

This paper is really  conversation between Ken Gergen, Lynn Hoffman and Harlene Anderson.  Each of them speaks three times in turn: Gergen, Hoffman, Anderson.  The conversation is apparently going to be in a book that evaluates the usefulness of "relational diagnoses."  All three authors have many misgivings about traditional diagnoses.  They all think of themselves as social constructionists and believe that DSM categories do not just label reality.  They shape reality.  The question is whether relational diagnoses are any better. 

What is a relational diagnosis?  It is something like "co-dependent."  That is, it is a classification that suggests that  a problem is a disorder but that the disorder is not contained in the individual.  It is contained in the relationship.  This means, for example, once you break up the co-dependent couple the co-dependence stops.  Or, if the problem doesn't go away,  then it is truly a "relational diagnosis." 

Below is my summary and abbreviation of the conversation.  Think of it as a kind of abstract.  I hope it invites you to read the original, but if not, then at least it might help you get a framework on some of the issues being discussed.  These are just my notes.  I think they represent the conversation satisfactorily, as these abbreviated versions go, but I may well have left out something, or even misrepresented something, that others can point out.  I would be happy to supplement or modify this version.
 

1. Kenneth Gergen
It seems over the years we get more and more diagnostic categories.  I call this endless production of diagnostic categories the "cycle of progressive infirmary." 

2. Lynn Hoffman
We have this problem as a profession that we think if you can name something (e.g., hysteric) then you know what to do about it.  It is as though naming something makes it real.  But to me, growing up in a leftwing artist community, it doesn't seem that way.  I think that "every time you build a world of ideas or join one, it is like a screening device that limits you from seeing other worlds."  But this is the way things are.  We name problems.  "It takes an earthquake that strikes at a deep structure level, like finances, to mark historic change."  Otherwise, we keep doing things the same way.  Now, family therapists want to use diagnoses.  In some ways that will be good in that it will make the profession more financially secure.  On the other hand, it seems like a negative thing.  Right now we are the only health industry that does not give labels.  I kind of like that.  I hate for the family industry profession to lose that edge. 

3 Harlene Anderson 
To me, anytime we give a diagnosis we commit ourselves to a framework that assumes stability of a problem.  It creates a kind of self-fulfilling prophecy so that we end up stabilizing the problems we are trying to resolve.  I don't think that the move to provide relational diagnosis results in a change that makes diagnosis any better.  Instead of shifting to a relational diagnostic system, I think we should be asking different kinds of questions.  Like, what should we therapists do with our professional knowledge and past experience.  We are trained in an antiquated system.  How can we communicate with professional colleagues (that do not see things our way)?  And how do we resolve the ethical problems we have in using diagnostic categories? 

4 Kenneth Gergen 
When I consider diagnoses, I am struck by the problem these diagnoses do not point to anything that exists.  We might all use the same terms (e.g., schizophrenia) but we use the terms differently.  It gives us a false sense of security.  Do we really want to freeze the frame on the complexity of life by using diagnoses that simplify everything?  I think this is especially a problem when the diagnoses become a part of people's permanent records. 

5 Lynn Hoffman 
Let me be a devil's advocate. The attempt to turn to relational diagnoses is not the first attempt to improve diagnoses.  Both Wynne and Tomm, for example, have tried to improve them, and in fact have improved them.  Also, there is some merit to the idea that we need to work within the system that is already in place.  On the other hand, I must admit part of me wants to show that the rendering of a diagnosis is a political event, that is, it is not merely a neutral description. 

6 Harlene Anderson
I am not inclined to try to patch up the diagnostic practice by improving the categories.  All the litigation suits that are happening show me that the practice of giving diagnoses gives practitioners a false sense of security.  I believe we need to stay closer to the narrative and the client's ability to narrate their lives in a co-collaborative way. 

7 Kenneth Gergen 
First, I want to point out that "[b]ecause there is so much agreement among us, the discussion hasn't blossomed to its fullest degree."  So, let me try to find the areas in which we might disagree.  Here is one:  I realize that you two are clinicians.  I'm not.  But to me, trying to work within the existing framework as Lynn was suggesting just supports the status quo.  I realize that I dont have to use clinical work to support myself, but I can't see any other reason to continue using diagnoses.  Don't we have an obligation to our clients to show them the patrachal nature of our diagnostic labels?  Doesn't respecting them require this of us?  Although we might agree that the diagnosis is not always injurious, we are basically in agreement that it is not essential, at least, to the process of therapy.  The problem goes back to clinicians needing to be paid and insurance only paying when we give diagnoses.  I have a suggestion: Maybe insurance companies could offer non-fault insurance so that we did not need to prove that the client needed therapy in order for them to pay.  Every person with a certain policy would have access to a certain number of sessions at a certain rate of coverage, and the insured would decide for themselves whether they wanted to utilize that part of their policy. 

8 Harlene Anderson 
A long description about a case of young woman who was anorexic.  The point was that people believed in the diagnosis and made presumptions about this woman on the grounds that she was anorexic, not on the basis of anything else about her.  Then, when the clinician looked past the diagnosis it was more possible to see through the mystification and get a more realistic grip on the problem and the possibilities for resolution. 

9 Lynn Hoffman 
"It does seem that the conversation is now taking us into new spaces. The question I  have is whether the shift would have happened if I had not "joined the opposition" or if    Ken had not chosen to "disagree"?  But now I am back to the original postiion.  I think the cutting edge of therapy is moving away from diagnoses and problems and their causes towards some more discursive understanding [paralogy] of what is happening in the session.  We have come a long way to get to this point and now, to me, even a "cursory look at the DSM IV shows it to be built on cobwebs."  I think it is interesting to think about what it would be like to get rid of the whole extended family: psychology, psychiatry and psychotherapy.  Could we set up something better?