The ‘stickiness’ of labels…..

When we’re looking at anxiety or low mood, low self-worth or depression there is a wide range of so-called ‘disorders’ that can be found when searching the internet to try to self-diagnose, as many people will do. DSM 5 - the American Psychological Association (APA) diagnostic reference manual - lists a very long list of disorders and this list has grown with each update to the DSM over the decades, as more issues become classified or re-classified.

For some, getting a diagnosis of a specific disorder is key for opening up treatment and resolution, for example it may confirm something they have long wondered about. But for others, labelling something as a disorder can be a barrier to resolution, because it can be something to latch on to as a reason for why they are like they are (and implicit in that is that there is nothing they can do about it, which may not be true). Labels become ‘sticky’. It also assumes that a diagnosis based on a set of criteria determined by symptoms is a purely objective test. But even simple checklists of symptoms to determine levels of anxiety and depression are not clear and objective - they require interpretation. Such checklists or questionnaires may be helpful, but they can also be easily ‘gamed’ - it is not difficult for example to achieve a diagnosis of moderate anxiety on the basis of filling in a GAD-7 questionnaire (a common questionnaire to check for anxiety symptoms used by GPs and therapists). That doesn’t mean such a form isn’t useful, just that it is only one piece of information on which to base an understanding of what is going on.

You may be suffering from anxiety, but that doesn’t necessarily mean it is a disorder in the sense often understood (i.e. as in the dictionary definition of ‘an abnormal physical or mental condition’). In fact, anxiety is a very normal response and experience, but in excess - for example when combined with excessive negative thinking - becomes unhelpful.

Nor is there universal agreement among professionals or academics as to the validity of labelling many ‘disorders’. There is, for example, significant critique of the label of ‘post-traumatic stress disorder’ or PTSD (e.g. by Richard McNally; 2012), a label which has now been expanded enormously beyond its original meaning. Now a huge range of issues appear to meet the criteria for PTSD, even though they are so different it can risk undermining the severity of the original meaning of PTSD. Being bullied at school, for example, is unlikely except in the most extreme circumstances to equate to the trauma of killing and people around you being killed in a war zone. So should they really be labelled the same thing? Do we over-medicalise symptoms by labelling, so adopting the labels as something we identify with, as someone with a ‘disorder’, implicitly that it is a condition you have (and part of you, your self) rather than something that you experience and maybe can be resolved? There is of course an important distinction to be made between psychoses and neuroses, where labels may be especially helpful for psychoses (living in a state of unreality) in order to access specialist psychiatric expertise. But neuroses, by definition, relate to chronic distress, rather than a loss of reality (or presence of alternative realities or identities) and care is needed as to the value to the client of a seemingly hard and fast label.

There is increasing interest (e.g. Hoffmann et al 2019, Hayes et al, 2019) in moving away from syndrome-based therapy (based on research relating to group studies) to more individualised process-based therapy, recognising the importance of personal context for how an individual responds to circumstances and how they respond to treatment. Using labels for individuals, based on common symptoms across a large cohort of people in a research study (or many studies) effectively tries to shoehorn an individual into a predefined category. Is that helpful?

The benefit of a CBH approach…..

My own view is that we should be cautious in applying a simple label to something that may be quite complex. A label can help in directing treatment, but It can also distort the direction of travel, focusing perhaps on specific symptoms or diagnosis and missing underlying causes that are maintaining those symptoms. And it can take us away from the individual and the need to treat ‘what is in the room'.

Cognitive Behavioural Hypnotherapy (CBH) is known as a transdiagnostic therapy that seeks to treat the individual and their presenting issues. It focuses on the core underlying maladaptive processes - cognitive, behavioural, emotional and interpersonal - and targets treatment on those rather than using more prescriptive disorder-specific protocols. Patterns of unhelpful coping strategies, for example, that might be common to a number of ‘disorders’ (e.g. over-thinking/worry) can be addressed rather than focusing so much on a ‘sticky’ label. In this way CBH has naturally been following the more individualised process-based therapy approach identified by Hoffmann and Hayes above. An illustration of this can be seen with ‘eco-anxiety’ (relating to a fear of environmental doom in the context of climate change, for example). Eco-anxiety is not a disorder - it is a specific contextualisation of anxiety, a manifestation of a normal human emotion (anxiety) where the focus of attention is on a situation that may be interpreted as being hopeless, but it doesn’t have to be. And it is often characterised by a number of maladaptive processes that have become unhelpful, e.g. worry.

The take-home message is not to self-diagnose via internet searches! It is so easy to recognise symptoms and diagnose yourself as having any number of disorders when they may not be helpful labels at all. If concerned, book a 90-minute assessment and conceptualisation session with me (no obligation for further sessions), to find out what might be going on and we can then look to see, if you wish to, whether CBH might be helpful for you.

Bill Sheate, May 2022

References

1. APA (2013) - DSM 5 - The Diagnostic and Statistical Manual of Mental Disorders 5th Edition.

2. McNally, R (2012) What is Mental Illness? Harvard University Press

2. Hofmann SG, Hayes SC. (2019) The Future of Intervention Science: Process-Based Therapy. Clinical Psychological Science, 7(1):37-50. doi:10.1177/2167702618772296

3. Steven C. Hayes, Stefan G. Hofmann, Cory E. Stanton, Joseph K. Carpenter, Brandon T. Sanford, Joshua E. Curtiss, Joseph Ciarrochi (2019) The role of the individual in the coming era of process-based therapy, Behaviour Research and Therapy, 117: 40-53.