One of the oldest names given to psychotherapy is “talk therapy.” Conversations during which the patient narrates his problems, and the therapist interacts with them, constitute the foundation of this form of relationship. Through words – and beyond words – the relationship takes root and grows, carrying infinite therapeutic possibilities.
It is important for practitioners to be conscious of the type of language they use, with all of its limitations and various effects. Just as language can build a strong connection, it can also be an impenetrable barrier, or a swamp of misunderstanding.
In this article, I will address two linguistic aspects that shape therapeutic conversations and contribute to determining their outcomes:
First – Description of psychological problems:
Diagnostic language versus subjective experience (depression as a model).
Second – Using narration in psychotherapy:
- Narration as a way to understand humans.
- Case formulation, the scientific model for storytelling.
- The narrative approach, an introduction to a more ethical practice.
Describing Psychological Problems: Diagnostic Language Versus Subjective Experience
It was necessary for researchers in the psychological field to standardize the linguistic description of psychological phenomena; to build a stable reference that helps psychologists find a common ground for understanding and organizing the process of producing scientific knowledge. Due to the correlation between physical illnesses and psychological problems, research studies aimed to uncover any biological signs that may precede or accompany psychological symptoms and explain their presence. Regardless of the results of these research studies – as this is not the subject of the current article – this concept added a medical layer to the language used, and this is clearly evident in the diagnostic language based on diagnostic evidence, such as: the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The existence of this language – in itself – does not represent a problem, and its presence may be useful in many cases. The problem lies in the way it is circulated and used in its rigid and stereotyped form by practitioners as if it were the only unified framework for understanding and dealing with psychological experiences.
“You have depression.” From the experience of most, this may be the most prominent thing someone hears in their first treatment session. These simple words are uttered as if they explain everything!
Giving mysterious symptoms a known name may create a degree of comfort or reassurance for some, and it may also be necessary and lifesaving for others. Naming is a must, the discussion here is that it is merely not sufficiently accurate nor expressive in its description of psychological phenomena. Many patients use metaphors in an attempt to navigate through psychological pain. Each metaphor tells a special kind of pain. In depression, for example, even if the apparent symptoms are similar, each case has its own unique characteristics, and here are some metaphors from people describing their experience:
- “I live in a desolate space, my voice cannot be heard, and my place cannot be seen.”
- “I feel stuck in a terrifying dream. I exhausted all my efforts to wake up from it, but I am still asleep.”
- “I feel as if I am freefalling forever into a bottomless pit.”
I must also mention here the metaphor of “Darkness Visible,” chosen by writer William Styron as the title of his book, which he wrote after his depression symptoms increased in his early sixties. He wrote this book as an attempt to express and understand his internal conflict, stemming from the ambiguity of the symptoms and the difficulty of putting them into words. He wrote:
“Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode, although the gloom, “the blues” which people go through occasionally and associate with the general hassle of everyday existence are of such prevalence that they do give many individuals a hint of the illness in its catastrophic form.”(1)
The book was a stark linguistic protest against the limitations of the word “depression.” Styron argues that the word “melancholia” is the most accurate description of the darkness of this disorder, and that is probably because it was not often overused in other contexts, as happened with the word “depression”!
The meaning of the word “Depression” has slipped dangerously from the central focus of its original purpose, and it has become colloquial, diluted, and misleading, to the point that it is no longer sufficient to indicate what it is supposed to indicate. This is true to many diagnostic labels that have been subjected to semantic inflation, through their overuse and promotion as a specific package of symptoms.
Metaphors are important figures of speech used to express the abstract in a tangible way, and their use has been discussed by many therapeutic theories and research studies that are concerned with the relationship between language and the self. Among them is the Acceptance and Commitment Therapy approach (ACT), which is based on the idea that language contributes to the formation of the problem in the first place, and through language we can also make a difference and adopt a new, more flexible view of our reality.(2)
With their linguistic and imaginative richness, metaphors convey some of what depression means to different people, who may experience similar feelings regarding the ambiguity of the future and helplessness in the face of a situation from which one cannot escape – yet they are different, as each suffering takes on its own form and meaning. The details of this specificity are what should be present in therapeutic conversations.
Diagnostic language is a language that details and classifies psychological disorders, but it is detached from the individual psychological experience. When we use diagnostic language as a synonym for subjective experience, use its terms mechanically, and base therapeutic interventions on it, we overlook the most important aspect that we must pay attention to: The uniqueness of the individual experience, personal meanings, and the contributing cultural and social contexts. Total reliance on this language weakens the ability to access and understand the nooks and crannies of people’s stories, the dark corners where difficulties initially rose, weighing heavily on one’s identity, taking over the soul. Disorder-oriented clinical efforts, linguistically and mechanically, do not explore the depth of the person’s actual suffering, and are unable to alleviate it.
Narration As a Way to Understand Humans
Within every human plays a constant internal monologue that gives them an almost stable sense of identity. Storytelling stands against meaninglessness, absurdity, alienation, emptiness, and annihilation. The need to materialize those internal narratives increases in times of crisis when identity faces the risk of fragmentation amidst harsh circumstances. This can be seen in the case of prisoners, warriors, and patients, who often experience a dire need to write during their struggle.(3) They tell stories to solidify their purpose, values, and everything that can give them strength in the face of despair. They encapsulate within their stories what they fear losing, or perhaps they come alive through their writings, as the language genius Wittgenstein said, “The recounting of personal experience in the narrative mode is a basic form of life.”(4)
In the past two decades, the concept of narration has smoothly seeped into the academic and clinical psychological sphere. In this quote, Theodore Sabrin affirms the centrality of narration in his scientific and professional life, as an academic professor of psychopathology and a clinical practitioner: “In my teaching of abnormal psychology, I had found it more useful to report on and analyze life histories, that is, stories about concrete individuals, than to review the experiments done on nameless, faceless subjects, the results of which were expressed as probabilities. Further, in my role as clinician, I could not carry out my work unless I located the clients and their significant others in a narrative plot.”(5)
Narration plays a pivotal role in psychotherapy. People often visit the psychiatric clinic with broken, illogical stories, and perhaps what drives them to seek treatment is that these stories have become unbearably painful. Self-narrative serves as a target in almost any psychotherapy approach. In one form or another, psychotherapy theories referred to this, with different names. Part of psychological suffering lies in the nature of the self-narrative through which the individual defines himself. An important part of psychotherapy is understanding this individual narrative and reconstructing it in an effective way.
Case Formulation: The Scientific Model for Storytelling
“Case Formulation” emerges as a bridge that connects the objective scientific perspective with the subjective perspective of psychological suffering, as an attempt to balance the solidity of objectivity and the fluidity of relativism, the scientific language found in books and the narrative language through which people tell their stories, where every letter carries a unique set of meanings, feelings, and ideas. Case formulation is a collaborative process in which the therapist and patient participate to form a comprehensive conception of the patient’s psychological problems. There are multiple types of case formulation, all of which are based on a solid scientific foundation, derived from theories, psychological principles, and the results of scientific research. Despite its many orientations and methods, it aims to reach a common understanding. Outlining the aspects of a given problem includes identifying the biological, social, cultural, and personal factors that contributed to its formation and continuity. This includes the strategies that the person used to confront this problem and his strength points. Based on this, the goals and treatment plan are determined.(6)
Case formulation is resistant to fragmentation and reduction, and this is what gives it its value, as it works to recombine the sharp and scattered angles of the story into a single form, centered around the person as a whole, not just his problem. This paints the story in a more realistic, unbiased, and clear light. When a person captures these panoramic dimensions of his problem, he can understand where he stands, gaining the ability to look at the problem lightly, as well as think about it effectively.
The Narrative Approach: An Introduction to a More Ethical Practice
The concept of narration became more well-known and popular after Michael White and David Epston developed a therapeutic approach with philosophical groundwork and interventions based on narration. This approach emerged from family therapy and drew from social constructivist theory and postmodernism.(7) This therapeutic approach added a new dimension, as it sheds light on the influence of dominant discourses on the lives of individuals, the formation of their identities, and their self-narrative; what is said and what is not said. This approach therefore sees how discourses and narratives within mental health institutions are connected with what is outside them, and how these discourses and narratives influence and are affected by each other in a dynamic process of exchange.
The ethical role of the practitioner is evident when it comes to engaging with these narratives. Dealing with the oppressed voice of marginalized groups represents the most difficult ethical challenge that psychological practitioners face. The position of neutrality here could be nothing but implicit support for oppressive discourses!
Regarding the claim of absolute neutrality in psychotherapy, Michael White believes in the absence of neutral stories, and that stories cannot be listened to with neutrality, influenced by Michel Foucault’s view of knowledge and power. The language through which we tell stories to help us organize and understand our experiences is derived from society and culture. Therefore, the meanings that these stories carry are not individual and subjective, but rather shared and do not deviate from the framework of the society within which we exist. If therapists wish to challenge injustice, they must challenge those narratives that are rooted in dominant oppressive discourses.(8)
“I should have preferred to be enveloped by speech, and carried away well beyond all possible beginnings, rather than have to begin it myself […] I should be at the mercy of its chance unfolding, a slender gap, the point of its possible disappearance.” – Michel Foucault(9)
A forty-year-old woman was exposed to various forms of oppression and neglect during her upbringing, and she got married at a young age to a violent and abusive husband. She underwent therapeutic treatment for years: psychological medications and therapy sessions. From these experiences, she clearly remembers the diagnoses she received more than anything else: During her mental health journey, she received three different diagnoses: depression, post-traumatic stress disorder, and generalized anxiety disorder. She knows nothing except that she is the weak, helpless, (and ill) person prone to break with an inevitable fate of sorrow. Burdened by this self-narrative and loaded with feelings of helplessness and inadequacy, she came to the psychiatric clinic after reaching a point where she had lost the ability to feel life, or the desire to live. She wonders: What happened to me? The medications and psychotherapy sessions she underwent may have helped alleviate the severity of the symptoms she suffers from, but what I would like to point out here is how the individual diagnosis-oriented medical discourse kept her stuck in the same ropes from which her suffering was woven. Instead of dismantling this narrative, a new one was added. Here, the practitioner also agreed with the narrative that brought her to the clinic. “Yes, the problem is with you. There is a defect in your psychological composition, in your personality traits, in your thinking patterns!”
The psychological practitioner does not have to be a social reformer, or a revolutionary in the face of injustice, but there is a minimum requirement, which is not to implicitly stand with injustice. Employing diagnoses and therapeutic interventions in mechanical, reductive language often adds salt to the wound, supports oppressive discourses, and deepens a person’s feelings of powerlessness over their personal reality.
The narrative approach and many systemic approaches are able to avoid this ethical trap, by accommodating the complexity of psychological phenomena and the multiplicity of forces and factors contributing to them. This happens through the practitioner adopting a more holistic thinking about psychological difficulties and a more flexible conception of identity; as he does not assert that there is one absolute and fixed truth, nor does he put a definitive stamp on the stories he hears. This position leaves a vast linguistic scope for retelling the stories. Narration is interpretive, and as many narrative therapists are able to observe, the value of interpretation does not lie in its correctness and accuracy, as much as it lies in its ability to open new horizons and possibilities for leading a healthier life. The more sensitive and expansive the language is, the more likely it is to get to what really matters.
In Conclusion
I rephrase the question that prompted me – initially – to write this article: Could an extent of psychological suffering result from a severe linguistic flaw in the mental health narrative?
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