Do I need a diagnosis?

Do I need a diagnosis?The latest version of an influential psychiatric diagnostic manual is coming out this year – version 5 of the DSM (Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association).   This event has supercharged a long-standing conflict between those for and against the use of standardised diagnoses for mental health issues.  For a UK-based discussion see this recent article on the BBC website: 


Such disagreements among mental health professionals can be very confusing for someone trying to deal with their own issues and wondering where to turn for help.  Here are some pros and cons of getting a diagnosis, written from my personal perspective.


  • Access to NHS psychiatric services.  This is important if you believe medication will help you, as part of your route to getting well.  And particularly if you are experiencing ‘out of control’ moments when you may take risks or put yourself /others in danger.
  • Some people feel relieved to have a diagnosis: they stop worrying and start taking action.  This is particularly true for people who prefer to be well-organised and structured.
  • Many sources of support are diagnosis-specific (e.g. voluntary organisations, support groups) so you can find and connect with people who experience similar issues.


  • A diagnosis doesn’t always lead to a clear ‘treatment plan’.  When we have a medical diagnosis, e.g. gallstones, it is useful because then we know (or the doctor knows) what treatment is needed.  Mental health issues don’t really fit this medical model.  You can get a diagnosis, but then you still need to choose, from the very many options available, what kind of help to go for.
  • Sometimes a diagnosis can be a sticky label.  Even when someone is feeling well again, a part of them may think the label still applies. It can limit their aspirations and expectations. (Taking this a step further – occasionally people may use a diagnosis as way to get people to look after them, or avoid taking responsibility for themselves.)
  • Diagnosis of mental health issues is not as robust or accurate as most medical diagnoses: you can’t have a blood test for OCD!  It relies very much on the subjective experience and perception of both the patient and the mental health professional.
  • Diagnosis systems such as DSM and ICD do not capture you as a whole  unique person, but as a collection of symptoms and behaviours.  This can rub off on you and the professionals treating you.

The most common route to get a diagnosis is via your GP who may refer you to a psychiatrist.  What if you want to understand your symptoms but don’t want a formal diagnosis?  Psychotherapists with a UKCP-recognised qualification will be familiar with psychiatric diagnosis systems, and understand the range of diagnoses available (this is not a requirement in counselling qualifications).  However most psychotherapists will be very mindful of the potential downsides of psychiatric labelling, and will focus on you as a whole person.

Decades of research have consistently shown that the most important predictor of successful therapy is the quality of the relationship between client and therapist.  Being seen and accepted for who we really are is central to the work of therapy.  A diagnosis can be like a filter between you and the therapist – distorting or limiting what can be explored.  But in some cases it might be like a safety harness as you take your first steps to make sense of yourself.  The one sure thing is that you can talk about it in therapy!


For new parents: attachment and bonding talk

This post is a summary of the talk I gave on attachment and bonding at the Ethical Mums coffee morning 24th May 2012.

To be completely in tune with your baby, understand their cries and be able to respond to them – this is what new mums often strive for, or expect of themselves.  This kind of ‘perfect bond’ is idealised in our society.  It is a myth of course, although when we have a good day we are tempted to believe it’s possible!    But the reality is that being responsible for a new baby is hard work, and ‘mis-attunements’ happen all the time.  We can’t always soothe our baby’s crying straight away.  We sometimes feel angry and frustrated, or useless and ashamed.

‘Mis-attunement’ is a word that describes situations when mother and baby are not ‘on the same page’.   You can try everything: feeding, putting down for a nap, changing the nappy, cuddling, winding, more clothes, fewer clothes – and feel as though you have no clue what baby is trying to tell you.  Newborns have no concept of themselves as separate people, separate from you the mother.  It is by the repeated process of mis-attunement and re-attunement that your baby develops into a separate person, with their own sense of self.  The really important thing is how we manage the mis-attunements.  It is how we as parents manage ourselves and relate with baby in these situations that counts.  And how we ‘make friends’ or re-establish attunement afterwards.  Can we be accepting of our imperfections, recover (after a cry or a few deep breaths or counting to 100!) and approach baby in a loving, calm manner?

As parents we need to be able to contain our feelings of inadequacy, anger, frustration or anxiety, and put them aside – at least during baby’s waking hours.  To do this day after day after day, we need support.   Without plentiful and regular support from family, friends, other new mums and professionals, our capacity to do all this containing can get stretched to breaking point.  In the Ethical Mums coffee morning we talked about how we cope when those difficult days come along, shared tips and listened to each other’s experiences.  Being listened to and knowing that it is not just you makes a huge difference.  I’d like to thank all the mums that came and wish them all the best with their new families!

Esther is a UKCP-registered psychotherapist, counsellor and mother of two based in South Ealing.  07932 116171

Are your mind and body the same thing?

This piece is prompted by Oliver Burkeman’s column in Saturday’s Guardian (28th April 2012) which divides people into ‘dualists’ and  ‘physicalists’.  The underlying philosophical assumption of a ‘dualist’ is that their mind is a separate entity from their body, and ‘physicalists’ believe that:

“everything that happens in the mind must arise from the spongy grey tissues of the brain”.

He reported research findings which indicate that ‘physicalists’ are more likely to take care of their bodies by eating healthily, whereas ‘dualists’ are prone to treat their bodies less respectfully.  Whether we think our body is ourself or just a container for it makes a difference to how we behave.  He goes on to say that if you believe that physicalism is correct, instead of turning to psychotherapy for problems of the mind, physical intervention is the way to go: “FIRST, GO FOR A SWIM”, he recommends.

I am a physicalist – I wonder if there are many people who have studied neuroscience who are not? – and I agree with the swimming part, or walking, cycling….  But I think Oliver Burkeman has missed out an important point.  If the mind and the body are essentially the same thing, connected through the nervous system, then the influencing can go both ways.

Physical activities – exercise, breathing – have an impact on our state of mind.  With almost every client, I enquire about diet and exercise.  But in the opposite direction, our thoughts or mindset can have an impact on our bodily wellbeing.  For example, practising mindfulness can reduce physical symptoms of anxiety such as racing heartrate, sweating, muscle tension.  Years of research under the Positive Psychology banner has demonstrated the link between optimism and general wellbeing.

And making-sense-of, understanding something (a mind-based activity) enables us to make different choices.  Recently I ran some workshops on resilience, which included this information: that the body doesn’t distinguish between the kind of stress it’s under.  Mental stress, being too cold, blood sugar being too ‘spiky’, it’s all the same to our adrenal glands which have to  deal with the stress regardless of the cause.   A week later I received a text from a group I trained, to say they had swapped their sweets and biscuits for nuts and fruit in meetings, and were feeling the benefits.  Knowledge is power to choose how we behave  – one of the ways our mind influences our body.

As usual (although it doesn’t make for pithy newspaper articles) the answer is not ‘either/or’ but both.


Lop-sided leadership

A short excerpt from my first blog in case you haven’t been following from the very beginning 😉

“Professor Cary Cooper tweeted recently that when senior managers hear about the solid evidence linking improved employee well-being to better performance at the bottom line, they nod their heads but don’t take any action.”

That is an example of the problem I’ve spent 15 years grappling with:  how to get leaders and managers to understand and value subjective ways of looking at organisations, as well as the traditional objective ways.  So this post is the story of an uphill struggle and what I’ve learned along the way.

I started out as an organisational psychologist in the ‘People and Organisational Change’ practice of a management consultancy firm.  We rejected all accusations of being ‘pink and fluffy’ and invested a great deal of time and energy into translating psychological concepts into tangible, objective tools and techniques.  One particular task of mine was to develop our ‘culture shaping’ offering.  Our challenge was to take the nebulous concept of corporate culture and make it something that could be defined and measured.  Then we set about listing all the ‘levers’ that leaders could pull to change their organisation’s culture and align it with their strategy.   We produced a fabulous set of Powerpoint slides but it didn’t win us much business.

A few years later I embraced the subjective and trained as a psychotherapist.  A simple sentence to write but actually a life-sentence – it’s not just what I do for a living, it’s what I am.  The training gave me a whole new perspective on the organisational work I continued to do.  In collaboration with a former colleague (Jeff Wolfin at Humanicity) I set out once more to articulate my way of understanding organisations and what that means for leaders and managers.  We came up with the phrase ‘dual-paradigm manager’:  managers need to be skilled in both the objective paradigm of ‘organisation as machine’:

  • delivering against targets
  • project / task / resource management
  • process improvement (etc..)

and the subjective paradigm of ‘organisation as social system’:

  • building trusted relationships
  • leading and inspiring people and teams
  • fostering well-being, engagement and creativity
  • having those ‘difficult’ conversations.

Managers’ skills are typically well developed in the first list, but much less support is given to the development of skills in the second list – leaving us with ‘lop-sided’ managers.  I picture them with one very strong arm and one weak arm – how much more effective they would be if they could use both arms together.

One problem as a provider of training, consulting and coaching in this field is how to point directly to the financial value of building strength in the other arm. What will be the return on investment?  There are various ways of estimating ROI for this kind of work but they are unfamiliar to most organisations.  Also because they require a belief in the power of people’s subjectivity, they are easily dismissed by those who don’t ‘get it’ or choose not to.  For example, you might establish a chain of impact whereby increasing ‘engagement’ by x% leads to y% more productivity and z% less absence, delivering a £huge impact at the bottom line – but if the CEO switches off at the word ‘engagement’ then you don’t stand a chance.

Even when a serious amount of high-quality research has been done to demonstrate clearly and powerfully the link between the subjective, in this case employee well-being, and objective financial performance (ref: “Well-being – Productivity and Happiness at Work” by Ivan Robertson and Cary Cooper 2011) it is still difficult to persuade organisations to take action, as Prof. Cooper and many others have observed. Why?

I remember meeting a friend and former colleague, talking about my plans to facilitate workshops based on the ‘social system’ paradigm – for example, “How to improve the quality of conversations in your organisation” using Transactional Analysis approaches. She said to me, “It will never work – you’ll never get people to trust each other enough”.  This is the nub of why it is so difficult to introduce the subjective paradigm, to get people to explicitly commit to strengthen up their weaker arms.  It asks people to be much more of their ‘whole self’ at work, to show some of what is usually hidden.  It is safer to pretend that as we walk through the door of our workplace, we can leave our vulnerable bits behind.

Luckily I have had opportunities to work with teams where sufficient trust is present.  In future posts I will write about what has worked well so far, in my quest to bridge the gap between the  ‘organisation as machine’ objective paradigm that permeates business, and the subjective world we really live in.

Introduction to my blog

Here I will be writing about some of the subjects I am passionate and curious about:

I want to explore how the world of business can connect with the world of psychology – how to bridge the chasm between those markedly different paradigms. Professor Cary Cooper tweeted recently that when senior managers hear about the solid evidence linking improved employee well-being to better performance at the bottom line, they nod their heads but don’t take any action.  I’m interested in why that happens.

The other subject I’m likely to write about – won’t be able to help myself – is about brains, babies, relationships and society.  We understand much more concretely now the impact of the baby’s interaction with his or her parents in those early months.  This has major ramifications for social policy.

As a psychotherapist I take very seriously the issue of client confidentiality.  I won’t be writing about my 1-2-1 client work.

I invite you to comment if you feel moved to do so!