A Holistic Model of Wisdom in Psychological Diagnosis

By Dorit Netzer, M.A. ATR-BC, LCAT

The scope of this paper permits a preliminary delineation of a holistic approach to diagnosis, which I follow in my practice as an art therapist. I juxtapose, what might be, a standard approach to psychological diagnosis (based on the DSM-IV-TR) with the alternative model I present. The latter is my own integration of wisdom approaches to viewing the condition of suffering (pathology) with an understanding of its unique manifestations, potentialities, and extensions; accepting its existence and transcending its persistence. This process of diagnosis requires the client’s participation beyond the report of symptoms and complaints. It is an invitation to truly review one’s present condition as a potential springboard to a new level of relationship with one’s own Self and the world.

As an art therapist, my approach to diagnosis is creative and intuitive. I see each person as a work of art in the process of creating itself. Just as I notice the infinite shades and tones in a given color, I know that there is no single blend or combination one must choose. Rather, I believe that color choices are infinite and that each carries its influence on the experience of both the creative process and the emerging object de art. Additionally, each choice is unique to a given being in time, place, and in relationships to other beings and non beings. Choices are fluid and dynamic and the canvas can be worked, reworked, and appreciated through all the stages of its production. To me, diagnosis cannot end with a fixed label as, I believe, it is detrimental to the creative process for the artist to identify with a finite analysis of his/her artwork.
Accordingly, I understand health and ill-health, ease and dis-ease, as an on going creative process of balance and imbalance within the individual. As the reasons for the artist choice of one color over another are mysterious even when we can rationalize them, so are one’s life choices and their outcomes, which may present as pain and suffering as well as joy and ease. As the artists of our lives we may look for rational reasons for our suffering, sometimes not acknowledging our participation in this creative process. In result, we may seek to avoid pain or extinguish it as soon as it emerges, moving away from its roots and thus away from the possibility of true healing. To truly heal, I believe, is to be whole, which includes all aspects of being, the infinite colors within the spectrum we can each perceive in a given state of being, all the shades – dark and light.
Like a dream, which contains multiple layers of symbols and metaphors, suffering can be approached on many levels. If we accept the authorship of our life, it becomes an allegory, filled with signals and signposts. Both pain and joy become guidelines on the map of our lif’s journey. We can then transform and recreate this journey, so we can move in a life enhancing direction, rather than feel lost or stuck. 
In conjunction with this fluid approach toward the continuum of balance and imbalance, through my clinical experience as a creative therapist, I begin to notice analogical forms and patterns, which allow me to enter the process of diagnosis with a frame of references and a foundation for each unique instance. This foundation is the recognition of a human typology deriving from wisdom traditions such as Greek Humoral medicine, European Complexico, the Indian Ayurveda, and the Chinese Five Elements medicine. These systems are not deductive in nature as are the guidelines for diagnosis given by the DSM. Rather than looking at the parts (i.e. symptoms), these models of typology had been shaped through generations of observing the whole. Out of an understanding of what constitutes balance in each human temperament or constitution, any single manifestation is seen in the context of the whole as either manifesting greater or lesser balance.

Reconsidering Diagnosis in light of Treatment
To further the merit of reconsidering the DSM approach to psychopathology and diagnosis, I would like to place my work in the context of recent research and anecdotal report of case studies in the field of psychology. The latter reveal that clinicians question the current format and diagnostic guidelines of the DSM-IV-TR. The limitations of the categorical guidelines of the DSM-IV-TR have been acknowledged (e.g. Fauman, 2000; Wideger, 2005). A categorical diagnostic system does not account for the range and degree in which most psychological phenomena present themselves. The overlapping nature of the description of disorders makes the focus on symptoms rather than the etiology of a given condition problematic (Fauman, 2000).
Wideger (2005) advocates a dimensional model of psychopathology. Although I agree that a dimensional model is more qualitative in nature and suggests that there is a continuum to pathological process, thus placing order and disorder at the edges of a range of psychological phenomena, it, nevertheless, aims at classification and distinct labeling. I believe that the focus on discerning whether a client fulfills predetermined set of criteria for a given diagnosis (i.e. having a readymade template into which the client must fit) impinges upon the clinician’s direct attunement with the client as a unique person in relationships within a given time and place. Without such attunement the clinician is more likely to resort to a generic prescription rather than a distinct intervention. Additionally, it places the clinician in authority rather than giving tools for the client to gain knowledge and mastery of oneself.
 In addition to the dimensional model, other alternatives to the current DSM-IV-TR formulation are offered by researchers such as Ivey and Ivey (1998) and Lopez, Edwards, Pedrotti, Prosser, LaRue, Spalitto, and Ulven (2006). Some of the raised issues have to do with the distinction between mental disorder and developmental manifestations, suggesting that the focus on behavioral, psychological, or biological dysfunction rather than etiology, including cultural considerations, may prove detrimental to the process of discerning beneficial interventions and long term treatment. A more positive approach is thus suggested, in which the client’s strengths are also emphasized. In addition, according to Ivey and Ivey, many psychological responses, for example depression, indicate an appropriate (logical) response to a given condition in the context of a developmental and familial history and should not be defined as the individual’s deficient adaptive response. As such, Ivey and Ivey’s developmental model of diagnosis is clearly more empathic of the client and is oriented toward the roots of the condition as well as treatment.
Lopez et al. (2006) further challenge the DSM-IV assumptions regarding the definition of mental illness. They point to the misconception that by reading a diagnostic record of an individual (since the diagnostic code is used for communication among primary and adjunctive clinicians as well as health care agencies) the reader gets the whole picture of the client. In this process, they correctly indicate that the cluster of symptoms is erroneously presented as factual, clearly defined and named entity and thus classified as a type of disorder (e.g. personality disorder). History shows that the changes in societal beliefs and perceptions have altered what was once defined as mental disorder, undermining the authority with which each succeeding version of the DSM is presented. In light of the increasingly growing body of research regarding the limitation of the DSM model, I join the clinicians who seek to replace the definitive tone adapted by the American Psychiatric Association with an open stance of understanding human struggle to cope with the many intrinsic and extrinsic factors of life through one’s lifespan.

Positive Psychology and Wisdom in Diagnosis
Duckworth, Steen, and Seligman (2005) review and expand upon the field of Positive Psychology. This approach to clinical psychology focuses on well being, the individual’s strength, meaning-making process, and happiness. A diagnostic method inspired by this model is guided by the view that in the face of suffering, a focus on positive emotions regarding the past, present, and future in addition to the person’s strengths and potentials alleviates the suffering, changes one’s perception of the root causes of suffering, and builds character and coping skills for future challenges. One distinctive element in this approach in comparison to the DSM approach is the participatory quality of the client in the process of understanding his/her state as unique to the amalgam of one’s character and circumstances. In addition, this model springs from an essential trust in human innate capacity and desire for well being and happiness. Duckworth et al. define it as the flow toward the pleasant life, the engaged life, and the meaningful life.
Similarly, Hutchins (2002) offers a diagnostic model that is inclusive of both gifts and challenges. Here, too, the individual’s unique being in the world is considered. Hutchins considers the person’s calling and direction in life, the mental and physical gifts, and the psycho-social environment within which the individual lives and works. Both elements of support and challenges are considered to create a full image of the person’s condition in a given time and place and in relationship to others. Thus the person is seen as a whole, whose desire to overcome the challenges he/she undergoes becomes an aspect of the choice of treatment.
 
The Traditions and Science of Human Morphology as a Diagnostic Model
The many traditions of human morphology consider, in essence, the body’s expression of the mind. Historically, morphology as a system of diagnosis and therapeutics is found in Eastern and Western traditions (Epstein, 1997). One such tradition is Indian Ayurvedic medicine, which considers three doshas or constitutions (Vata, Pitta, and Kapha) and their combinations. Ayurvedic medicine considers both inherent morphology (Prakruti) and present changing lifestyle choices (Vikruti). Ayurveda says that health comes from balancing the doshas from a given Vikruti regaining the inherent balance given to one at conception based on one’s Prakruti (Lad, 1998).
Another morphological tradition is the Chinese Five Elements system (Wu Hsing). The elements are Wood, Fire, Earth, Metal, and Water, which according to this ancient tradition govern the physical, emotional, and spiritual existence of human beings just as they regulate the cycles of growth and change in nature. In this system, like in Ayurveda, a person is born with constitutional affinity, which distinguishes him/her from other types. The predominant element in each person must be kept in balance with all other elements through recognition of a natural cycle of building and breakdown in result of balance versus imbalance (Elias & Ketcham, 1998).
Both the Indian and the Chinese systems of diagnosis and treatment are holistic in the deepest sense of this term. They consider the constant flow of multiple aspects of being in an inter-connected dynamic of creative participation. In addition to an appraisal of the given symptoms or manifestations of imbalance, the individual is seen in the context of his/her morphological type, which inherently guides the clinician in assisting the individual to take actions toward re-harmonizing the self in alignment with one’s True self. Additionally it provides guidelines for ongoing health practices, which honor the unique needs of each morphological type.
The Western world cultivated its own version of Morphology. The Egyptians portrayed the Sphinx as a creature comprised of a human face, the body of an ox, a lion’s tail, and an eagle’s wings and claws to symbolize the four elements of man, the mind (a man’s reason), the body (an Ox’s strength and endurance), the soul (a lion’s courage), and spirit (the eagle’s flight or inspiration). These facets are further represent four temperaments, namely, Bilious (man), Lymphatic (ox), Sanguine (lion), and Nervous (eagle) (Epstein, 1997). 
Similarly, the Greeks recognized the four humors as governing the Choleric, Sanguine, Phlegmatic, and Melancholic temperaments. Over time, as this tradition lost its honorable position to an allopathic model of medicine, the use of these terms became static, stigmatic, and inaccurate means of labeling a person as bad tempered (Choleric), optimistic (Sanguine), impassive (Phlegmatic), or dejected (melancholic) (Child, 1995). A phenomenological system has thus been converted into a form of passing judgment; from a holistic view of energetic balance to a dualistic view of positives and negatives.
It is not within the scope of this paper to describe the various morphological types in any one of these models. The reader is welcome to refer to the references for further study of any of the above mentioned systems. It will suffice to say that when an individual experiences an imbalance state the governing temperament exhibits itself ever so strongly. However, careful study of any morphological system gives a distinct image to each type to the extent that a learned practitioner of any of these diagnostic models can assess the general governing type of a person on first sight. The human form is thus a mirror to inner character in the stature of the person, complexion, weight and muscle tone, facial characteristic (profile and front face), and general demeanor. It is paramount that no judgment in the form of authoritarian knowledge is passed in this process of encountering the individual. A spiritually derived premise in all of these systems is that the individual has tacit knowledge of his/her true nature and innately seek to align with it as means to harmonious life. The clinician’s role is to assist the individual to gain conscious awareness, if such has not been acquired thus far, in order to enable the individual to act in alignment of his/her true nature.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Fourth edition, text revision (DSM-IV-TR). Arlington, VA: American Psychiatric Association.

Child, G. (1995). Understanding your temperament. London: Sophia Press.

Duckworth, A. L., Steen, T. A., & Seligman, M. E. P. (2005). Positive psychology in clinical practice. Annual Reviews of Clinical Psychology, 1, 629-651.

Elias, J., & Ketcham, K. (1998). The five elements of self-healing: Using Chinese medicine for maximum immunity, wellness, and health. New York: Harmony Books.

Epstein, G. (1997). The science of face reading: A practitioner’s guide to morphology. Advances, The Journal of Mind-Body Health, 13(3). Retrieved April 28, 2006, from http://www.drjerryepstein.org/morpholo.html

Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.

Hutchins, R. L. R. (2002). Gnosis: Beyond disease and disorder to a diagnosis inclusive of gifts and challenges. The Journal of Transpersonal Psychology, 34(2), 101-114.

Ivey, A. E., & Ivey M. B. (1998). Reframing DSM-IV: Positive strategies from developmental counseling and therapy. Journal of Counseling & Development, 76, 334-349.

Lad, V. (1998). The complete book of Ayurvedic home remedies. New York: Harmony Books.

Lopez, S. J., Edwards, L. M., Pedrotti, J. T., Prosser, E. C., LaRue, S., Spalitto, S. V., & Ulven, J. C. (2006). Beyond the DSM-IV: Assumptions, alternatives, and alterations. Journal of Counseling & Development, 84, 259-267.

Widiger, T. A. (2005). A dimensional model of psychopathology. Psychopathology, 38, 211-214.