Experiential Psychopathology - Dr John Howells

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II - Family Psychology & Family Psychiatry - Diagnosis

General

A farmer, driving to the nearby town, thinks he discerns a red flush on his field of barley; the event provokes an urgent systematic enquiry. Is it a fact? What caused it? What is the responsible fungus? At the end of the afternoon a small plane trailing a cloud of insecticide delivers the exact remedy. So, diagnosis (dia-gnosis, through knowledge) has led to correct therapy.

Yet, in psychiatry, diagnosis is eschewed. The fashionable vogue is to plunge into therapy. It is as if in surgery, at the signal of abdominal pain, we plunged in with no knowledge of the anatomy of the abdominal organs, no understanding of their function and no systematic enquiry to discern the focus of the pain. In psychiatry, the sign of emotional anguish is enough. We plunge in.

But this behaviour is not calculated perversity. It is presumably our defence against the admission of ignorance. The anatomy of the personality has yet to be worked out, the functioning of the psyche is obscure, and the understanding of psychopathology is at a rudimentary stage. Dependant on, and ruled by, the fertile but illogical and uninformed imagination of a number of well-intentioned clinicians over the last 70 years, we hesitate to start afresh – such is the daunting influence of what has become established opinion. Better the wrong landmarks than no landmarks. But lost we are.

To help is a laudable aspiration. But to plunge into the abdomen with no prior examination and no knowledge of anatomy and physiology is not help. It is a hazardous impulse fraught with danger for the patient. In that situation, masterly inactivity and reliance on nature’s own defence measures might well be more effective.

To turn to systematic enquiry is the sure road to knowledge. The resources now available make this possible. One fruitful field for garnering knowledge is the pathological. It behoves us therefore to be systematic in the clinical field, to enquire, to understand, to build on understanding and to intervene with knowledge. Diagnosis must come before therapy, not only for the good of a particular family, but also for the future of psychiatry.

Developments in a field depend on a number of factors, but probably none so retards progress in psychiatry today as the confusions of its nosology and, linked with it, the lack of agreement on criteria for defining syndromes together with the imprecision of nomenclature. Ignorance is a matter to be overcome by time and endeavour; the lack of order in known phenomena is something to be righted now. An aetiological classification is a paramount need because accurate delineation of dysfunction leads to logical investigation, and so to the meeting of the central obligation of psychiatry – effective treatment.

The following matters are discussed here. The family psychiatric service accepts referred patients, individual, couple, or family. Thus the referral procedures must be described. From it arises the intriguing question: What dictates the referral of a particular family member at one moment in the life history of this family?

Having accepted an individual or family, it is necessary to explore the presenting symptomatology, the complaint, that particular organism’s subjective reason for seeking help. Investigation then moves to an assessment of all the indicators, going from a presenting individual’s symptomatology to a complete assessment of all the family’s indicators. These procedures allow of a diagnosis in terms of organic, psychic, or mixed syndromes.

To make a diagnosis is not to elucidate the psychopathological process that set up the indicators. The informant may be clear about his symptomatology and the clinician understand the nature of it, but neither has any notion of the cause of it. Thus exploration now moves to the area of the psychopathology of the disordered family. The understanding of the process leads to effective, deliberate therapy.

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