Text by Hanna Grauert (Freie University Berlin)
© Pablo Dohms
Mrs. K is a refugee from Syria, starting a psychotherapy in Germany. For my anthropological fieldwork I was able to accompany Mrs. K during her therapy sessions. I observed that apart from the communicative therapy sessions, several assessment test and reports were conducted. On the one hand, these reports serve to ensure the stability of the case because of consistent and systematic documentation (diagnosis, test and assessment, script of the therapist). On the other hand, it can lead to uncertainty if the client has insufficient knowledge about the process and its consequences as the example of the diagnosis of Mrs. K’s neurologist showed:
Among other documents the final report of the neurologist played a vital role in the construction of Mrs. K’s case. Following the request of the therapist, Mrs. K had to visit a neurologist with a special document the therapist gave her, called “Konsiliarbericht”, which is needed by the health insurance in order to cover the cost of the therapy. The neurologist and Mrs. K had one single appointment, where he filled in the report with no more than two sentences and his signature. None of the other main participants of the therapy (therapist, translator, social worker or myself as anthropologist) attended this meeting. His diagnosis was “Depression and insomnia, chronic pain syndrome (Depression mit Schlafstörungen, chronisches Schmerzsyndrom)”. In the therapy itself the social consequence of this diagnosis for the future development of the therapy became clear. Mrs. K was asking through her translator what the doctor has written on the paper she was supposed to bring back to the therapy. Her question on what the neurologist wrote implies, that Mrs. K was not aware of the diagnosis the neurologist made and its meaning. The therapist comments that the written diagnosis actually correlates with what Mrs. K told him. While Mrs. K had no further time to ask another question to clarify the meaning of the diagnosis, the therapist went on in her professional role, asking questions about her phone number and other contact information. Instead of creating possible explanations for the client, the therapist remained in the role of the professional and took the next free turn (actually the turn of the client) in order to change the subject.
Living a full, happy and satisfying life - what does it mean to you? Everyone has different ideas concerning their well-being in the world - there cannot be only one, clear definition of the concept being or feeling well. We live our lives individually and with different worldviews that are shaped and shared by the people who surround us. What happens, though, if we suddenly suffer mentally and feel ‘ill’ in our own body or in our environment? Like Mrs. K we search for the help of others or, depending on the urgency, the help of ‘professionals’ like doctors, psychologists and psychotherapists. Not knowing where mental pain is coming from, we often expect a clear answer from professional health care workers, a simple explanation why we are not feeling well, hoping that ‘professionals’ know more about us than we do ourselves. Similar to other clinical settings, in psychotherapy, diagnosis and assessment tests are made in order to administer appropriate treatment. However, this essay outlines with the help of the illness case of Mrs. K., that diagnostic methods reflect only a partial truth of a person’s mental illness experience. Before analyzing Mrs. K illness case, I want draw attention to the standardized methods in psychotherapy and present a different, ethnomethodological approach to psychotherapy. This ethnomethodological approach will help to see Mrs. K illness case from a different angle and will underline my argument that other social interpretive methodologies have to be deeper incorporated in the field of psychotherapy.
The Problem of Institutionalized Construction of Illness
Formal assessments and diagnostic testing methods are a main and vital element in professional practice of psychotherapy. In this standardized procedure, psychological testing is considered to be just as any other medical test: If you have a severe stomachache, a doctor might order X-rays or MRIs in order to understand where and what is causing those symptoms. According to the American Psychological Association (Eabon and Abrahamson 2019), the same process is executed with mental illness. The American Psychological Association is the largest scientific organization of psychologists. Through their publications they shape psychological science and knowledge discourse to a large extent. Through their understanding, psychologists apply these assessment tests like “tools” to measure their clients’ mental condition, to diagnose and to administer therapy. Moreover the American Psychological Association sees only a ‘professional’ qualified enough to make a diagnosis with the help of different psychological tests and assessments, questionnaires or checklists in order to find the source of the problem and subsequently, the proper treatment (what kind of therapy, is any medication needed ?, etc.). The American Psychological Association came to four general conclusions, supporting those quantified and quantifying methods:
(a) psychological test validity is strong and compelling (b) psychological test validity is comparable to medical test validity (c) distinct assessment methods provide unique sources of information (d) clinicians who rely exclusively on interviews are prone to incomplete understandings (Meyer et al. 2001, p.1).
As the American Psychological Association aims for biological and cognitive reasons for suffering, they ignore that experiences of illness are not only a quantified fact but rather an interpretive processes: Whereas test and assessment procedures might gain access to the biological and cognitive processes of an illness, they cannot offer findings to the social interpretative process of illness experience, because they are mainly part of the procedure itself. Therefore, the social interpretative experience of mental suffering is missing in pathological approach in general. Through an anthropological perspective it can be fruitful to provoke social interpretative questions on an illness case: Are assessment tests and diagnosis really the most important “source” of information? Are interviews, which rely on the personal experience of an illness narrative, truly incomplete if distinct assessment methods have not been applied? Are questionnaires and assessments the most effective methodology in order to diagnose or identify mental illness?
In this essay I will argue that it is vital to consider other perspectives on how mental illness and its narratives are continually produced. Thus, a phenomenological methodological perspective will show that the diagnostic methods the American Psychological Association support, hardly reflect an illness, but deeply shape the process of a person`s experience of his/her illness to a large extent. Institutionalized procedures can lead to (mis)diagnosis and to misunderstandings of the therapy process itself, especially in transcultural settings if basic processes and expectations of therapy are not negotiated or communicated with all participants.
Phenomenology and the Construction of Illness
One issue regarding the four general assumptions on psychological testing and assessment as proposed by the American Psychological Association is that one internal, biological reason for suffering is presumed by taking patients’ personal experience out of the context and reducing it to a checklist of symptoms (Kirmayer 2015, p. 624). Phenomenology, in contrast, is the study of human experience, which should be an important methodological perspective in the process of psychotherapy: Phenomenology will not offer causal explanations or tools to measure the severity of a mental illness, like questionnaires and diagnostic assessment tests. Phenomenology, in general, is the study of our lived experiences, which includes a reflexive and dynamic observation how individuals engage with their social and physical world. In other words, there is no “objective” world, independently existing from our experience, but rather a world that is constantly shaped and constituted within our environment. One field of study concerning anthropological themes is the experience and meaning of illness, suffering and healing as well as communication practices and communication in institutionalized settings as a psychotherapy (Desjarlais and Throop 2011, p.88). Insofar phenomenological approach to illness incorporates a patient’s experiences on multiple levels, which might be accessed by biological, cognitive as well as social interpretative processes (Kirmayer 2015, p. 625 f.). Furthermore, the sociological phenomenology, based on the everyday experience of individuals, has influenced sociologists such as Harold Garfinkel and Harvey Sacks with their ethnomethodological approach (Garfinkel 1984).
The Case of Mrs. K: An Ethnomethodological Approach
Ethnomethodology, founded by Harold Garfinkel (1984), deals with the fundamental phenomenological question how social reality can be perceived. Ethnomethodology developed from the phenomenological idea that meaning and social reality are constitutionally constructed and are constituted by the narratives that we have incorporated in our self-descriptions and imaginations. It is, at the same time, locally produced in an interaction with other humans and social institutions in our environment (Kirmayer 2015, p. 648). Therefore, Garfinkel assumes that social order is not something static but is continually produced, especially in social interactions. More specifically, the production of social reality as an “ongoing accomplishment of the converted activities of daily life "(Garfinkel 1984, vii). This process stays stable as long as all participants are conscious about the interaction itself and have therefore the possibility to continually negotiate the production of knowledge and meaning. It is the unchallenged assumption of a common and unchallenged knowledge base where all participants have equal interactions parts. Therefore interaction and the production of social order struggles, when there is too much effort in explaining each other perspectives and if existing asymmetries in an interaction are predominating (Garfinkel 1984). This ethnomethodological perspective on therapy is relevant, as psychotherapy is mainly an interaction between therapists and their clients. Thus, mental illness, diagnosis and ways of therapy cannot only be reduced to testifying, as the American Psychological Association so generally claims, but must rather be seen as a process, the analysis of which is based on an ongoing negotiation of subsequent documentation of experience (like assessment test, diagnosis, scripts etc.) and the interaction between client and therapist. With this ethnomethodological approach the conversation in therapy of Mrs. K, which was mentioned in the beginning, can now be seen from a different angle. Due to the fact that her original words are always translated by the interpreter or abstracted by the expert knowledge and medical language of a professional (e.g.: by terms like "depression"), Mrs. K is subject to the constant challenge that people are just talking about her but not with her. This is problematic and does not lead to an equal interaction between all parties. Instead, documentation and diagnosis assessment predominate the constitution and the narrative of Mrs. Ks case, leaving her passively outside the communicative process. In the extract of the therapy session mentioned in the beginning, social facts ( e.g. terms like depression) and insofar a social reality is created on Mrs. K. Unfortunately Mrs. K. is passively left behind in this very important moment due to standardized processes. This example shows that testing and diagnosis can lead to misunderstandings, if basic processes (like diagnosis and assessment tests) are not negotiated together with the patients or clients - especially in transcultural settings where language barriers and institutionalized practices cannot be expected to become automatically harmonized. An ethnomethodological approach conveys that from a therapist perspective there is no need to requesting standardized processes in order to proceed the therapy. However, for the patient it is vital not only to be an active part of the conversation but moreover to be conscious about the professional and standardized work in psychotherapy, about documents and diagnosis in their meaning. Therefore, additional time is needed to explain basic therapeutic work to the client and to negotiate meanings and expectation concerning the therapy itself. This form of negotiation will help to weaken uncertainties about the therapy process and to find a common knowledge base.
Towards a Negotiation of Methods in Psychotherapy
The ethnomethodological approach conveys, that the diagnostic methods mostly do not fully reflect an illness, but truly shape the process of a person’s illness experience to a large extent and can under certain circumstances even leave the client passively behind in the process of a psychotherapy. Following the ontological turn, human beings and their state of suffering or well-being cannot be reduced to social, cultural, psychological, historical or biological characteristics (Jackson and Piette 2015, p. 25). It is rather a question of understanding how human beings interact directly with their world or how social realties are created. Psychotherapy builds a research field that links many disciplines and their methods. As this essay shows, it is fruitful if interdisciplinary answers can be found in this field, because here many anthropological, sociological, philosophical, linguistic and psychological questions meet and might better be addressed in conjunction. As a more integrated proposal, let me suggest a rephrasing of the APA’s initially mentioned general conclusions:
a) psychological test validity is only one method among many and is only fruitful in combination with others b) psychological tests can structure the process of therapy but must be negotiated with the patient with regard to its meaning and its outcome c) distinct assessment methods will only give access to a partial truth and will have consequences on the illness narrative and experience of the patient d) clinicians and psychologist must rely on interviews and negotiate the process of therapy in order to diminish misunderstandings.
Desjarlais, Robert, and C. Jason Throop. 2011. “Phenomenological approaches in anthropology.”Annual review of anthropology 40: 87-102.
Eabon, Michelle F. and Dan Abrahamson. 2019. “Understanding psychological testing and assessment”. Accessed May 27, 2019. https://www.apa.org/helpcenter/assessment.
Garfinkel, Harold. 1984. Studies in Ethnomethodology. Cambridge: Polity Press.
Günthner, Susanne, and Thomas Luckmann. 2002. „Wissensasymmetrien in interkultureller Kommunikation.“ In Kultur(en) im Gespräch, edited by Helga Kotthoff, 213-243. Tübingen: Gunter Narr.
Grauert, Hanna. 2018. “Verstehen und verstanden werden. Eine ethnographische Analyse zur Konstitution eines Falles in der psychotherapeutischen Versorgung von Geflüchteten“ thesis, University of Konstanz.
Jackson, Michael, and Albert Piette. 2015. “Introduction. Anthropology and the Existential Turn.” In What Is Existential Anthropology?, edited by Michael Jackson and Albert Piette, 1–29. New York: Berghahn Books.
Katz, Jack, and Thomas J. Csordas. 2003. “Phenomenological ethnography in sociology and anthropology.” Ethnography 4(3): 275-288.
Kirmayer, Laurence J. 2015. “Re-Visioning Psychiatry.” In Re-Visioning Psychiatry Cultural Phenomenology, Critical Neuroscience, and Global Mental Health. edited
by Laurence J. Kirmayer, Robert Lemelson and Constance A. Cummings, 622-660.
Cambridge, Cambridge University Press.
Meyer, Gregory J., Stephen E Finn, Lorraine D. Eyde, Gary G. Kay, Kevin L. Moreland, Robert R. Dies, Elena J. Eisman, Thomas Kubiszyn, Geoffrey M. Reed. 2001. “Psychological testing and psychological assessment: A review of evidence and issues.” American psychologist 56(2): 128.
Schütz, Alfred, and Thomas Luckmann. 1979. Strukturen der Lebenswelt. Frankfurt am Main: Suhrkamp.