We Need to Rethink Diagnostic Criteria and Psychological Research

In this blog I am going to explore the reasons why I think the biomedical model of mental illness largely fails us and the history behind what set us on that path. Lastly, I will offer an alternate way of working with mental health challenges that I believe is more appropriate, more useful and more respectful of those we are working with.

My issue is not that client’s distress or what we term “mental illness” does not exist; it absolutely does. I take issue with how our distress is described, labelled and categorised in medical terms, something frequently perpetuated by psychologists, psychiatrists and doctors (as a result of their training). I’ll explain how what sounds credible and has come to be considered “fact” in our culture, largely has no basis in reality and at the very least is up for debate.

"Western psychiatry is based on the idea that the various forms of distress that people can suffer from… are best understood as medical illnesses with mainly biological causes in our genes and biochemistry. But in fact, there has never been any evidence for the so-called biomedical model of mental distress"1. – Dr Lucy Johnstone (Clinical Psychologist).

“There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it”- DSM IV Chairman Allen Frances.

Why I came to Question Psychology, Psychiatry and Diagnosis

“Psychiatric diagnosis is not a valid or evidence-based way of understanding difficulties and distresses that people experience” (bold font added) – Lucy Johnstone, Clinical Psychologist

For a while now I have been skeptical of the medical model of mental illness despite it being broadly accepted in mental health fields and research. In the last six months or more I have read several books that have confirmed and cemented my questioning nature. It has also caused me to reconsider what I learnt in my psychology degree; information I used to accept as fact.

I’ve since learned that much of the research and diagnostic categories are up for debate, but they don’t explain that to you during the course of your psychology degree (I suspect fields like psychiatry and psychology would become far less appealing if this was more widely understood).

Take for example the replicability crisis in psychology from a few years ago:( Replication Crisis | Psychology Today New Zealand) or the many books questioning diagnostic criteria some of which I will cite in this blog. I encourage you to google about the replicability crisis in psychology and make your own mind up but I’ll offer my thoughts here.

Part of the reason I started to question what I learned in psychology was the success my clients have experienced with me using a non-pathologising approach called Solution Focused Brief Therapy. I’ve used SFBT for 8 years now, since the beginning my Master of Counselling degree.

SFBT works in a vastly different way to traditional models of therapy and yet I have found it to be highly effective, provided you have a thorough and nuanced understanding of the approach. However, if you were to place SFBT within the framework of the medical model with all its assumptions and “rules”, SFBT shouldn’t work; and yet it does.

When I first learnt the approach, this caused me much confusion (given my background in psychology) because of the very medicalised and rigid way the field of psychology approaches human suffering (partly by necessity given it’s using the scientific method).

I came to my Masters of Counselling degree with a very solid set of ideas and assumptions I had gained during my Masters of Psychology degree that made SFBT difficult to “compute”. Unlike everything else I had learned, SFBT wasn’t focusing on mental illness, pathology, symptomology or medicalisation exclusively, it focused on wellness, hope and the outcomes a client hoped to achieve from therapy. In coming from such a narrow focus in psychology SFBT seemed totally counterintuitive and struggled to see how I was doing any therapy at all with this approach!

Since finishing my Master of Counselling degree in 2018 I have a more thorough and nuanced understanding of Solution Focused Brief Therapy because I have been committed to further training and reading on the approach. This has meant the differences between pathologizing models of therapy and SFBT has become even more highlighted for me. I can separate the two as distinctly different while acknowledging they can still both work, they just come at problems from different perspectives.

In particular, I made an effort to understand the perspective of SFBT’s founders: Steve deShazer and Insoo Kim Berg. SFBT made me curious enough during my counselling training that while I was in disbelief as to why it would work and frankly confused as to why it did, I was curious enough to be persistent, keep learning, reading and practicing because of the results my clients were getting. I figured there must something to this, even if I don’t fully understand it.

I realise now that SFBT just follows a different set of “rules” and assumptions than the medical model, yet reaches the same outcomes (rules isn’t quite the right term in either case but I can’t think of a better word). If the medical model is about what is wrong with you and what you’d like to get away from, SFBT is about what is right with you and what you’d like to have more of. Both work; they just go about it in different ways.

This experience caused me to question what I thought I knew about what caused mental health issues and how I believed clients became well. The medical model (although widely used and widely accepted) is not fact, it’s just one of the ways of looking at mental health problems (albeit a very popular one) and the research is far from settled. If it were settled, we would know roughly how to “fix” mental health problems and we would go in for treatment much like we go in for surgery or to visit the doctor for our medical issues.

There would be tests to confirm we have a particular “mental disorder” much like there is with our physical body with blood tests and scans.

There wouldn’t be so much debate about what causes mental illness and there wouldn’t be over 400 different models of therapy at the time of writing this blog (I googled to get this figure). We don’t have 400 ways of treating diabetes, cancer, heart disease or a broken leg because there is a much more linear and effective way of treating these issues, therefore we don’t need to keep “searching” for the answer like psychology does.

We know what works and it’s quite consistent across patients and cultures. This isn’t the case for mental illness. There are numerous theories as to why we become unwell and as I’ve mentioned 400 methods as to how you might treat it. Then throw in how vastly different we are as people as individuals and across cultures and I wonder how far we have actually come in our understanding in the last 100 years.

Human nature has a subjective element to it that our physical health does not. There’s something uniquely human about this subjective element. I would argue it’s this subjectivity, our thoughts, feelings, unique perspective and desires that makes us human.

However, this subjectivity leaves room for many interpretations, assumptions and varying ideas of how to “fix” mental health problems also.

Unsurprisingly, we have never found a definitive answer to what causes mental illness. We haven’t come as far in our knowledge of “mental illness” as we have medical illnesses or illnesses of the body. Unlike our physical health there is nothing to be observed, examined, healed or removed like there might be with a tumour for example.

We are simply left dealing with the subjectivity of thoughts, feelings, worldviews, cultures and opinions and that’s not just from our clients! That’s from the so called “experts” in our field also, yet they talk as if their findings are fact. How can we be as objective with people as we are in our studies of the natural world? You have one subjective being (the researcher) studying another subjective being (the research participant) studying something that is highly subjective and not tangible (the human mind).

 In my opinion, psychology is far more philosophy with the scientific method applied to it than it is a genuine science. It sits somewhere between philosophy and the natural sciences but does a bad job of both. In saying that, I studied it to Masters level, enjoyed and do find the broader themes useful to my work as well as the broad background knowledge of human behaviour.

Why did we Medicalise Mental Illness?

“Mental health problems don’t define who you are. They are something you experience. You walk in the rain and you feel the rain but you are not the rain” – Matt Haig

In short, the reason we favour the medical model is largely due to the early success that was seen in curing physical diseases. Diseases of the body could be isolated and cured which lead to the idea that the same was likely possible for “diseases of the mind”.

If the medical model worked so well for curing our physical ailments it was thought the same was likely true for “mental illness”. All we needed to do was find “the root cause” (which I’m sure you’ve heard before from many psychologists) apply an intervention, and then the client would become well. Better still, it was thought that genetics, brain function or biology were involved, so if we could just examine the body and find the cause like we do in medicine, we could “cure” mental illness.

I don’t blame the experts of that era for thinking this way, it was the logical next step after the advancements seen in modern medicine. It’s just that to this day nothing definitive has ever been found to confirm this hypothesis. There is no known biological or genetic cause for “mental illness” unless it’s a neurological disease such as Alzheimer’s, in which case it’s disease of an organ in the body (the brain), and can’t be a disease of something that is only conceptual “the mind”.

There has been a concentrated effort over centuries to find a physical, genetic or biological “root” causes for our mental distress. However, at the time of writing there are still no biomarkers or tests that can be done to provide evidence of a mental disorder. There is no physical cause we can point to and say “that causes mental illness”. At best we can point to symptoms and correlations or possible contributing factors, but nothing definitive. There are a range of theories and models that hypothesise about what is happening, but these only provide reasons we think mental disorders might be happening. There are no definitive answers, at least not yet anyway.

In aligning themselves with the medical model and using terms like formulations, assessment, diagnosis and treatment, psychology and psychiatry could “hitch a ride” on the credibility of the emerging medical model and its success. As a result, I believe they received an “uptick” in each discipline’s credibility. They couldn’t lay claim to the same definitive answers that medical science could, but that didn’t seem to matter, the perception was created all the same due to the medicalisation of “mental illness”.

Interestingly, psychology and psychiatry started as branches of philosophy. They started off being very interested in ideas, theories and reason until the scientific method was applied. “Struggles of living” were originally the domain of philosophers and their mark on our culture is still evident today, not because what they were saying was “scientific fact” but because their ideas held such a profound, personal meaning for each of us that they still hold true to today.

It's quite remarkable that even with all our advancements in medical fields and science; and even though famous philosophers lived vastly different lives to our own, their ideas are still influential in our culture to this day. When did this last happen in Psychology? Psychiatry?

You could argue that what philosophers had to say is almost “truer” than anything the humanities have ever produced. I’ve noticed psychologists that have remained most prominent, for example Carl Jung had a philosophical “bent” to their work. Is it possible that the scientific method isn’t the best way to go about describing/studying human nature? What is as uniquely human as human suffering or human potential? Is the scientific method too rigid, too restrictive? When we control variables do we lose the essence of what it means to be human?

I find what philosophers have to say far more profound, meaningful, interesting and significant than any modern-day Clinical Psychologist. In my view Clinical Psychologists seem good at regurgitating the research they have learned about with very little independent thought.

Just to be clear I’m not just knocking psychologists, I think there are problems in the entire health field. There are many Counsellors I believe were poorly trained (especially in the past) and have given Counselling a bad name and for good reason.

The regulation of the field is getting better but is in need of continued improvement. I do see evidence of more independent thought amongst Counsellors and Psychotherapists, it’s just sometimes it’s well-meaning but poorly informed. So, in all these fields it depends on the individual in my experience. That’s just my view of what I’ve seen in both fields (remember I have a Masters of Counselling and a Masters in Psychology so I know both fields quite well which is why I feel ok to pass judgement on both, Psychotherapists I know less about).

Interestingly, those psychologists that have become more famous in modern times such as a Jordan Peterson, show evidence of independent thought (regardless of whether you agree with him or not) rather than the siloed thinking in psychology today. I would argue he also leans far more into the philosophical side than the scientific, even though he backs up what he is saying with a thorough knowledge of the scientific literature.

In addition, Sigmund Freud, Carl Jung, Viktor Frankl and many more of those influential in the field tended to be far more philosophical in their thinking than scientific in my opinion, due to the deep and meaningful topics they “wrestled with”. They seemed more interested in meaning than our quite reductionist view of what is considered “fact” these days.  What they had to say still hold a prominent place in our culture decades later. Funny that.

Sigmund Freud and his Influence on Therapy….

“Words were originally magic, and the word retains much of its old magical power even today. With words one man can make another blessed, or drive him to despair; by words the teacher transfers his knowledge to the pupil; by words the speaker sweeps his audience with him and determines its judgements and decisions. Words call forth effects and are the universal means of influencing human beings”. – Sigmund Freud

Sigmund Freud often referred to as “the father of modern psychology” first gave lectures on his work in the United States in 1909 but it was during World War II that his work really became prominent (despite his passing in 1939) as recruits were being screened for their fitness in order to go to war. During this same period and especially after the World War II, psychiatry and psychology gained more prominence as the effects of war were wanted to be better understood.

Sigmund Freud’s style was seen as quite compelling and remarkable at the time and he came up with plausible theories (for the era) as to why certain phenomena were observed among his patients. He championed the idea that what we saw on the surface (symptoms, behaviours, language, physical expressions etc) were not quite as they seemed. There was therefore some other force (in this case the unconscious) that was driving our particular urges and behaviours.

Interestingly, there is no evidence to suggest this is true (that an unconscious exists), they were just compelling theories and concepts with no better explanations at the time. The unconscious is only a man made (or person made if you prefer) construct. We can’t quantify the unconscious or see it, or measure it in any way, yet the idea is compelling. Like sitting down to watch a murder mystery; as humans we seem to be very drawn to the idea that “not everything is as it seems”.

We relish in trying to figure out who the “villain” really is. Likewise, we seem to gain a certain pleasure trying to figure out the answer to why we do what we do (or why others do what they do even more so) and coming up with a range of explanations or theories as to why. We don’t sit all that well with the “unknown” so we come up with explanations or “theories” to explain the “why” and “how” of life. I believe these explanations comfort us as they make the world (and ourselves) seem less complex and more easily understood.

Today, now that we all have the internet at our fingertips, there seems to be a lot of self-diagnoses or a proclivity to want to diagnose a friend or family member. I don’t know why this is so compelling, but there’s something innately satisfying about making the “unknowable” known. That is, until it is known; then it becomes boring and we move onto something else.

I suppose it’s part of what makes life interesting and makes life worth living. Imagine if we had all the answers? I think life would become incredibly boring. One of the fascinating things about people is we can never really be sure we have arrived at the right answer, we can only ever make an interpretation or guess. Maybe that is why, as a species we find ourselves and others so endlessly fascinating. It’s like an endless puzzle and if you add to that the questions we have about our existence and our purpose, you arrive at questions that have troubled us for generations. Anyway, I digress.

 So, Freud popularised this idea, that if we just look hard enough and deep enough, we will find the answer to human problems and it seems to have had a huge influence on psychology and psychiatry in particular. They very much apply a “Freudian-like” approach in their problem-focused way of thinking and in doing therapy and research. They love a good “root cause” and a theory to go with it. Yet it would be the development of a certain manual, the DSM, that would cement this type of thinking even further, something I explain in the next section.

The Influence of The Diagnostic Statistical Manual

“They have this big book called the DSM IV, you know, that is supposedly written about crazy people, but I think it is a book written by crazy people!” – William Glasser (American Psychiatrist)

Firstly, the medical model for mental illness rests on the idea that there is something that we can’t see that is driving or causing “mental illness”, similar to the cause of our physical illnesses.

Sound familiar? It might use different terms but it’s fundamentally the same idea as Freud’s. It’s just that instead of the unconscious, this time it’s your genetics, biology, a “predisposition” or physical abnormality that is “causing” mental illness. Still no evidence for this, but we persist with this theory believing one day we will find the answer; that one day there will be biomarkers or tests to confirm a “mental illness”.

The belief is that symptoms are "clues" as to what’s really going on under the surface (with the unconscious, our biology or our genetics for example). Psychiatrists (and psychologists/ psychology bought into this idea) decided that if we just group clusters of symptoms together and give them different categories (disorders) that will give us a standardised way of diagnosing clients. Certain symptoms would then become “evidence” of a particular disorder (or at least point us towards one).

They also interview the client and sometimes do psychometric testing but this was the fundamental idea of the DSM.  Roughly speaking: identify the cluster of symptoms and roughly work your way to a particular disorder/ diagnosis, then confirm it through interviews and psychometric testing, then decide on an “intervention”. I doubt they would ever claim outright that you “have” a particular disorder but it is often inferred by the language they use. I don’t think many people come away from a psychologist and say “it’s possible I have this disorder but they can never be entirely sure and it’s just an arbitrary label”. Most clients come away saying “I have (insert disorder here)”. That’s certainly the attitude of doctors and psychiatrists too, who prescribe medication based on this diagnosis.

You’ll often hear psychologists gladly point out the “failings” of psychiatry (on sites such as LinkedIn) but conveniently leave out the fact that they used these same diagnostic criteria for years (it’s part of the training in Clinical Psychology) and still do. Yet they point the finger at psychiatrists which seems like a cunning diversion. Use diagnostic criteria when it suits you (and makes you money) but as soon as it gets bad press point the finger in the other direction!

In summary, all the DSM does is cluster symptoms together into categories they call disorders, yet many of these symptoms overlap and the diagnostic criteria is not particularly reliable (Francis, 2016, Johnstone, 2022).

The first Diagnostic Statistical Manual (DSM) was published in 1952. However, it was DSM III (published in 1980) that really expanded diagnostic criteria and aimed to provide a more “standardised” approach to diagnosing “mental illness”, rather than the more diverse and inconsistent approach previously provided by psychoanalytic theories.

However, these categories are influenced by the time period and social context from which they are created. You might be surprised to know that homosexuality featured in the DSM as a disorder for many years until it was removed in 1973. This decision to include homosexuality as a disorder would not be made today of course, which speaks to the subjectivity of the labels used and the influence of culture, time and place.

In his book “Saving Normal” Allen Francis (2016) a psychiatrist involved with the making of DSM IV, refers to what he calls “Fads of the Past”, the ways in which we used to view mental illness and treatment which have since either been disproven or fallen out of favour. He explains:

“People don’t really change much, but labels do. Humanity’s symptoms and behaviours may oscillate a bit but probably remain basically stable over time. In contrast, the way we characterise them can fluctuate as wildly as changing fashions in music or hemlines. The symptoms and suffering are real – but sometimes we get trapped by explanations and labels that are just plain wrong and far too convincing (Francis, 2016, p. 118)”

You might also be interested to know that these categories are not defined based on scientific evidence, they are done by committee. James Davies upon interviewing DSM committee members is quoted in his book “Cracked” as saying:

“What I saw happening on these committees was not scientific – it more resembled a group of friends trying to decide where they would go for dinner. One person says ‘I feel like Chinese food’, and another person says ‘No, no I’m really more in the mood for Indian food’ and finally, after some discussion, they all decide to go have Italian” (Quoted in Davies, 2014, p. 30).

Lucy Johnstone (2022) quite rightly points out the subjective nature of these diagnoses but also the circular arguments that come from them. She uses these examples: “why do you hear voices? Because you have schizophrenia. Why do you have schizophrenia? Because you hear voices.” She contrasts this with the medical model in medicine: “Why does this person have headaches? Because they have a brain tumour. How do we know they have a brain tumour? Because it shows up on the X-ray/ blood test etc”.

In this way a diagnosis explains nothing, unless there is a cause we can actually point to and test, otherwise it’s purely subjective and guesswork (Johnstone, 2022, Szasz, 1974). Diagnostic criteria are nothing more than a classification system, but we are no closer to understanding “why” these “disorders” happen. We still don’t know the elusive “root cause” psychologists frequently refer to. This is concerning when you think a lot of psychologist’s assessments and diagnostic labels are based on these categories and likely influence medical, judicial and more broadly with population health and public service decisions.

An exception as I’ve said is, neurological disorders such as Alzheimer’s disease but in these cases, there is a physical explanation such as degenerating brain tissue we can point to as evidence or a cause, so in that case it’s not purely subjective, it’s biological.  We can identify an issue with the organ the brain itself. It’ a problem of the body not “the mind”.

There’s a big difference between the brain malfunctioning as an organ and problems of “the “mind” given “the mind” is just a concept.

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A Very Brief History of Categorising Mental Illness

Given these fluctuations in “disorders” I thought it might be interesting to see how mental illness has been categorised (albeit not in a fancy book) over the centuries so I will give you an incredibly brief and simplistic overview and if you want to know more you can do further reading. I used Francis (2016) to assist me with this paraphrasing to make it briefer for the reader.

The earliest written documents used to refer to “mental illness” saw demonic possession as the primary explanation where the “devil” would have to be exercised out of a client in order to return them to health.

In 1300-1700 there were “Dance Manias” where the cure was “frenetically rapid” dancing. There was “Vampire Hysteria” 1720-1770, “Werther Fever” in 1774. Then came the dawn of Neuroscience, the new “biology of the brain” that could explain our ills that had been previously accounted for through theology and religion.

Symptoms were now not the result of demonic possession, sin or vampires. Now mental illness could be explained as malfunctions in the wiring of the brain. Symptoms were thought to be due to lesions of the brain and this was the explanation for confusing non-specific human suffering. However, this theory although plausible and convincing to the smartest doctors of the day proved to be completely wrong (Francis, 2016). Then came Neurasthenia 1800s-1900s. Essentially this meant “weak nerves”. Allen Francis (2016) explains:

“Neurasthenia was a vague and non-descript diagnosis with vague, non-descript and useless treatments. That this did not reduce its enormous world-wide popularity should tell us a great deal about the seductiveness of clinical confabulations. We have an intellectual need to find an elephant in the cloud. The label we create, however inaccurate, provides a comforting explanation………It is a metaphor of distress appropriate to the technology and worldview of a particular time and place” (Francis, 2016 p. 126-127)

“Today’s psychiatrist can describe schizophrenia, but can’t begin to explain it (Franci, 2016, p.118)”

Then came Hysteria/Conversion Disorder 1800s-1900s, Multiple Personality Disorder in the 1990s to where we are today. According to Google, the most up to date DSM contains 297 disorders. We haven’t exactly found the “root cause” yet have we? To me it seems we do nothing more than rearrange categories when new information comes along but we are still no further to the answer. We just become more elaborate with our explanations as to why we “think” mental illness happens.

A more modern example is the “chemical imbalance theory” popular in the 1990s up until very recently. This has now been shown to be false, yet still filters through “conventional wisdom” in the helping professions.

In the current system a diagnostic label can be useful in gaining access to certain treatments, medications, services and funding so to some extent we are stuck with it. However, it’s important to remember it’s just a label.

“There are some advantages to acquiring a diagnostic label, including being able to access services and claim benefits. However, there is evidence that the overall effect is unhelpful, and sometimes very damaging” – Lucy Johnstone, Clinical Psychologist (Johnstone, 2022 p.18)

“In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise which we have anticipated since the 1970s, remains disappointingly distant”. (Kupfer cited in Belluck and Carey, 2013). See Johnstone (2022) p.32.

“The Myth of Mental Illness” – Thomas Szasz

“Mental illness, of course, is not literally a 'thing' - or physical object - and hence it can 'exist' only in the same sort of way in which other theoretical concepts exist” – Thomas Szasz

In 1974 Thomas Szasz a psychiatrist, wrote a classic book “The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, a book I have recently read, criticising psychiatry for labelling people as “mentally ill”. He argued this shift to labelling people as “mentally ill” was incorrect and merely a way to control people’s behaviour that didn’t fit with the cultural norms of the day. He explained “mental illness” is only a label, a metaphor we use to describe troubles of living which means terms like: diagnosis and treatment are incorrect as these are terms from medicine and therefore only apply to the physical body.

He even goes on to say that calling mental troubles an illness implies there is something wrong with the functioning of the body or brain, however when clients are observed this is not the case. The exception would be as I’ve said, a degenerative disease such as Alzheimer’s, but Szasz (1974) would argue the fact that you can find signs of this degeneration in the body indicates a “physical illness” not a mental illness.

This means it ceases to be a “mental illness” as there is evidence of illness in the body, given the organs are not functioning as we would typically expect them to. Lastly, he makes the claim that Mental illness” doesn’t exist at all since it’s merely a concept I’m not sure if I would go quite that far but I can see why he arrived at that conclusion.  I also think a quote by Carl Jung fits in well here in regards to troubles of the mind and their subjectivity:

“We don’t really heal anything we simply let it go” - Carl Jung

If you think of troubles in your own life, did you ever really “heal” anything? or was it simply a change in perspective that helped?

The Rosenhan Experiment 1973

Another example of the shaky evidence for diagnostic criteria is the Rosenhan Experiment also known as “On Being Sane in Insane Places” from 1973. A psychologist, David Rosenhan set up an experiment where Rosenhan and seven mentally healthy associates became “pseudo patients”.

They pretended to have schizophrenia in order to be admitted to a psychiatric hospital. None of the “pseudo patients” had a history of mental illness. Participants included a psychology graduate, psychologists, a psychiatrist, a painter and a housewife. During their assessment they claimed to hear voices and faked symptoms of schizophrenia during their psychiatric assessment.

Amazingly, all participants were admitted to psychiatric hospitals, 12 different hospitals across the United States. They were instructed to “act normal” once admitted and explain they no longer heard voices. Despite acting “normal” their stays ranged from 7 to 52 days and all but one was discharged with schizophrenia “in remission”. Rosenhan concluded mental illness is perceived as an irreversible condition creating lifelong stigma rather than a curable illness.

“It’s not difficult to be misdiagnosed as being mentally ill, but it is very difficult to get rid of that diagnosis” - David Rosenhan

“The facts of the matter are we have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them. We now know that we cannot distinguish insanity from sanity” – David Rosenhan

As noted in Johnstone (2022) in referencing two independent research projects (called Hi-TOP and RDoC) she explains in the researchers view there is no clear cut-off between normal and abnormal; rather we all have broad tendencies in the ways we react to experiences.

This makes sense. How do we distinguish normal from abnormal? What is interpreted as normal in one culture would be considered abnormal in another. Who gets to decide what is normal and abnormal? and where is the cut off?

None of this is clear despite all the research conducted over the years. Contrast this with markers of physical illness such as diabetes or cancer. These are broadly speaking the same regardless of which culture you come from. If mental illness is “real”, shouldn’t it be consistent cross culturally much like our physical illnesses?

Lucy Johnstone (2022) points out that with mental illness you can literally be “cured” as soon as you step off the plane in a different country.

So, where to from here? I believe we need to change the current system and the way we view and treat “mental illness”. A system that more accurately reflects what we know. The public should be made aware of the very subjective nature of diagnosis in the mental health fields (particularly psychiatry and psychology) and maybe we should revise how we assess what is made available in terms of treatment, services and funding based on this revision of the research.

I will not go into how to do that as it’s beyond the scope of this blog (maybe in a future one) but we certainly need to raise the question. The same with the research in psychology. We need to be very clear about what it tells us and what it doesn’t tell us. The history of diagnosis is a great example of where we took liberties on what the research concluded when the reality was very different.

We have been doing the same old thing for years and we are still in the midst of a mental health epidemic, so surely, it’s worth trying something new and for psychiatry and psychologists to be more transparent about what they know for sure and what they don’t know. They get paid far too much to only be giving you a “best guess” as to what is “wrong” with you.

If a client takes comfort in having a diagnosis and it’s helpful, great, but either way the consumer deserves transparency in what they are getting and what their options are based on accurate information. Afterall it’s their body and their life. Of course, if there are safety concerns, we need to address that, but if a client is deemed “safe” to be in the community (sometimes due to a psychologist’s report) they deserve freedom of choice and transparency around the information they receive.

It’s about the public being well-informed and having choice. If there comes a time where we do have biomarkers that confirm mental illness then maybe we can have a different conversation but as it stands there is no evidence for this way of working.

As I see it diagnosis mostly benefits psychiatrists, psychologists and the pharmaceutical companies as it is them that gain renumeration in the current system. If they benefit from the medical model, where’s the incentive to stop doing it? They make a lot of extra income diagnosing and writing reports.

From what I’ve seen and read so far (and the topic is vast) Thomas Szasz, David Rosenhan, Allen Francis, Lucy Johnstone and Steve deShazer (who I will introduce in the next section) are the exception not the rule in the mental health fields. Good on them for being brave enough to speak out and go “against the grain” of the status quo. In the case of Lucy, Thomas and Steve good on them for also offering a different way of working (I’m not as familiar with the others work in this area so can’t comment).

The Importance of Language, Meaning and Context in “Talk Therapy”

“If we could begin to see much illness not as a cruel twist of fate or some nefarious mystery but rather as an expected and therefore normal consequence of abnormal, unnatural circumstances, it would have revolutionary implications for how we approach everything health related – Gabor Mate (2022)

As I’ve described at the beginning of this blog, symptoms and human suffering are very real. A client’s reactions to traumatic events are very real, but the categories we have created and classed as “mental illness”, as well as concepts of what are “normal” and “abnormal” are purely arbitrary and often different cross-culturally. We don’t have the data yet to define any of this with any accuracy, it’s highly subjective. So how then should we go about helping people in therapy?

If we put aside medication for a moment, which I believe does have its place but is probably overused, the main tool that psychologists, counsellors, social workers and other mental health professionals use is talk therapy. Yes, psychologists and other health professionals often give what they call “tools” or “interventions” or they might give you “homework” but the vast majority of the time you see them they are using what we refer to “in the trade” as “talk therapy”.

 You would think then there would have been much focus and study into the use of language in therapy and on the therapy conversation itself, however this doesn’t seem to have been very well studied. I know psychology in particular has focused heavily on what is “wrong” with people or their “pathology” as they call it.

Unlike psychology where a theory is formulated (or hypothesised) and then “tested” via an experiment, the creators of Solution Focused Therapy (Steve deShazer. Insoo Kim Berg and their team) went about things in a very different way (deShazer, 1985 & 1988). They started with no hypothesis and simply wanted to understand the nature of problems.

They wanted to observe real therapy sessions (behind a one-way mirror and through video recordings) to see what the therapist did that worked well and what the therapist did that didn’t work. They produced transcripts of therapy sessions and studied the language very carefully. What was happening between client and therapist during a therapy session became an increased focus of their study over time.

Through their careful observation deShazer and the team established language patterns that were consistent with problems and then mapped these patterns out and labelled them as “problem talk”. This included repetitive “loops” of thinking their clients would engage in and a very “either or” style of thinking that they discovered helped to continue a problem pattern rather than help clients “solve” their problems (deShazer, 1985). In other words, they got “stuck” in their problems through the language they used to talk about their problems and this resulted in them continuing to use the same ineffective strategies repeatedly.

To their surprise however something happened organically. They noticed that within this “problem talk” there were “exceptions”, times when the problem was absent, less or times when clients would go against the rule of “problem”. They discovered that if they encouraged the client to talk about, and therefore focus on these exceptions their clients would get better outcomes and become well more quickly. They also discovered clients actually had their own “solutions” that were often far more effective than anything the therapist could dream up. Often a “solution” was found within this talk of exceptions, it’s just that the client was so focused on problem they didn’t see it. They labelled this type of conversation “solution talk”.

 Over decades they kept studying and noticing that patterns and language around problems tended to lead to more problems, while talk of exceptions and focusing on what a client wanted lead towards change.

Given most therapies of the time (in the 70’s and 80s) required a theory to explain how they worked, the founders eventually worked their way backwards to a theory for Solution Focused Brief Therapy. They decided on the theory of social constructionism.

They made an existing theory fit a therapy style, rather than a theory going on to produce a therapy modality, which is more typical of how many therapy modalities have been created. In using social constructionism to explain what they were observing in their therapy sessions they came to the conclusion that language creates our reality (our subjective reality rather than our objective reality in my opinion) and it is the “gap” between what the client says and what the therapist replies that helps create a new “agreed upon” meaning for the client. In this way they are said to be creating or “constructing” a new reality; going from “problem talk” to “solution talk” or from problem story to solution story if you prefer.

As the client views themselves and the world around them differently, through a new reality (or perspective or lens) they start to see their objective world differently also. The lens through which they view the world changes. Objective reality doesn’t change, their perspective changes. For example, they still might go back to work the next day in a job they hate but they may view the job differently, in such a way that it makes it the job easier to cope with.

They may later decide to leave that job or stay now that they view the job differently than before. They might see more options available to them whether they choose to leave, stay or adapt to their current job circumstances. As their perspective changes there’s a flow on effect for how they view themselves, important others in their life and what life means to them more broadly. This is all we can change as a talk therapist in my view, as ultimately, it’s the client that has to go out into the real world and live their lives. However, a perspective change leads to different choices.

Subjective vs Objective Reality

“Subjective truth is feathers in a wind tunnel, blowing anywhere and everywhere. Objective truth is an anvil bolted to the floor of the wind tunnel” – Ron Brackin

“Where you stand determines what you see, and what you do not see; it determines also the angle you see it from; a change of position may be the most effective form of change” - Steve deShazer.

As I’ve continued to mention, I think one of the problems psychology has as a discipline is the very subjective nature of ourselves as humans. There’s a certain “essence” to what makes us humans such as our feelings, hopes, dreams, thoughts, sense of self, perspectives, worldviews, that just can’t be measured in any objective way. They are by their very nature subjective and unique to all of us.

We are studying something that isn’t tangible which is quite different to fields like medicine where the body can often be observed, such as with MRIs or CAT scans or measured with things like blood tests or genetic tests. The body is the objective reality upon which our theories and hypotheses can be tested. We can observe whether we are correct or incorrect and this is the same for all of the “natural sciences”.

As I’ve mentioned there are no such tests for “mental illness” so the accuracy of the findings in psychology are compromised. Findings often (simply because of the subject: Human beings) are reliant on interpretations of results and self-reports which ironically are not particularly reliable (Johnstone, 2022).

The conclusions that can be made from such research findings are always limited by that fact. There is nothing objective to be observed. At best I think psychology shows us patterns of behaviour and probable outcomes, but that is as far it goes. It can’t really claim much more than that unless it’s a neurological disease as far as I can tell, but that is fine as long as that limitation is made transparent to the public. How many of us believed the chemical imbalance theory despite there being no evidence for it?

 If you add to this the replicability crisis in recent years (Replication Crisis | Psychology Today New Zealand) or the revelation that the chemical imbalance theory was wrong despite it being a dominant explanation for decades (Analysis: Depression is probably not caused by a chemical imbalance in the brain – new study | UCL News – UCL – University College London) the evidence for the characterisation of “mental illness” is actually quite flimsy in my opinion.

This is quite different to the medical field where theory frequently is consistent with objective reality (in this case a physical illness of some kind in the body) that can be diagnosed and then cured. Psychologists due to the nature of the subjects they are studying (human beings) by contrast remain in the realm of subjectivity as we don’t yet have any objective evidence to hold onto.

This may change in the future, but we are not there yet. Add to this that a very subjective being (a human) is making an interpretation of another human being or the research data and you add a further layer of subjectivity. How can we expect them to be truly objective despite their best efforts to control all the variables? In the end a research article is still the authors subjective interpretation of the results. Unlike medicine where we can confirm our hypothesis by observation and testing on the body, psychology cannot lay such a claim apart from with neurological diseases.

Which then begs the question why classify mental illness at all? Why call it mental illness? Why pay hundreds of dollars for a psychologist’s report that in reality is really just an “educated guess or opinion”? If it wasn’t, if it was far more accurate than that, we wouldn’t have the quite frequent occurrence that a psychologist makes one prediction and the person from which they observed acts completely the opposite.

Take the example of a violent criminal deemed safe to go back into the community that goes on to commit the same crime. There’s an element to human nature that can’t be predicted as much as psychologists would like to think they can. I think within psychology and among many psychologists there’s a certain amount of arrogance and to be fair they’ve probably been led to believe their therapy and their research is far more ground breaking and influential than it is for the reasons I’ve stated.

You can’t argue with objective reality because it’s there to be tested and observed. In the medical field the physical body serves as the objective reality to test a hypothesis against. I can think I can fly all I want, but if I jump out of a tree (despite how many times I flap my arms) I’m still going to hit the ground. There’s a limit to our subjectivity and its impact because as soon as it gets met by objective reality it gets found out.

However, because fields like psychology and academia are obsessed with finding the “root cause” of mental illness we keep traveling down the same path despite it being more than 120 years since Freud, with all our advances in technology and all we come up with are more theories, new fads of modalities and no explanations. We are still largely in the dark. “Theories” might have become more “scientific” than the mythical explanations of the past, but in the end, they are still just theories, we are no closer to the truth.

Working Alongside Clients instead of Against Them

“Resistance is not an objective quality of a client, but rather a metaphor used by therapists to describe certain patterns of behaviour” – Steve deShazer

As you can imagine if you want to help someone change their worldview you are better to work alongside them rather than against them. If I were to say to you “you have to think this way and here’s why” I think we all have a visceral reaction to this. Something along the lines of “get stuffed” comes to mind. Or take the “culture wars” of the last 10 years or so.

One side says “you have to think this way” the other side say “no we are the ones who are correct, you need to think this way”. Both sides end up resenting being told what to think and say “get stuffed”. As a result, it creates disharmony as there is no “universal truth” (broadly speaking) that we can all agree on.

Then add to this the extremes of both sides who tend to be quite noisy and things get very messy.

Yet that is essentially what psychologists and psychiatrists do when they give you “tools” or medication in the case of psychiatry. Here’s the research, here’s (what we think) works. So, if you just go off and do it, you’ll be well. If you don’t do it that’s because you are “resistant” to treatment. I’m spelling out their possible thoughts but they are unlikely to articulate it that clearly, not to the client anyway. They are more likely to say they don’t think you are the right “fit” for their therapy and this can be true at times for a range of reasons but not because of “resistance” in my view.

It seems unsurprising then that psychologists came up with the concept of resistance. What a luxury. It’s not that their therapy doesn’t work or their research is poor. It must be the client’s fault! And they are not imaginative enough to come up with any other explanation. Our research says it works, so it must!

Interestingly, Steve deShazer and Insoo kim Berg (the founders of SFBT) did away with the concept of resistance (17. The Death Of Resistance: what is it and why it’s so important in Solution Focus).

Instead, they chose to work alongside the client deciding that if a client is “resistant” they often have very good reasons for it. This makes a lot more logical sense to me. In my experience, if clients turn up to therapy, they rarely make all that effort to book an appointment, arrive on time, sit in my office, only to be “difficult”. If there is “resistance” there’s usually quite a valid reason why. The other therapy I am trained in is Motivational Interviewing and they also came up with the concept of “rolling with resistance” for those with alcohol addiction possibly for similar reasons: it worked.

 So, how does Solution Focused Therapy work alongside clients rather than against them? By inviting clients to answer questions about where they want to go rather than focusing on where they don’t want to be. By focusing on outcomes instead of problems. The therapists focus on what the client wants from therapy. They use the client’s words and the client’s worldview by asking them what they want from their own unique perspective.

The therapist does not impose their “expert” view on the client. They are not telling a client what they need to do like a psychologist might (psychologists are often far more directive than counsellors but I can’t speak for everyone).  As much as being “the expert” might be tempting to the ego, I’ve found It’s much easier to help a client head in a direction they want to go. It’s much easier to move to what you do want than to try and move away from what you don’t want. In fact, working in this way limits the so called “resistance” dramatically.

When you think about it; are you in therapy to know more about what you don’t want (what psychologists and psychiatrists’ study) or are you there to do something different and head in a direction of what you do want? I think we all know we are there for change yet this isn’t where the focus of traditional therapy lays with its focus on problems and pathology.

 Another important aspect of SFBT is the therapist does not consider themselves an expert (unlike psychologists and psychiatrists that naturally assume this position with their diagnostic labels, reports and assessments) because they understand they can never be an expert on a client’s life. The client is the only person that can be a real expert on their life which if you think about it is quite obvious. Who knows your life better than you do?

SFBT therapists are experts in how to conduct a therapeutic conversation that leads towards change, nothing more. It takes great skill to get good at this as given how we are conditioned to solve problems, the temptation is always to go back to traditional modes of therapy and “problem solving”.

Personally, I think you have to have a certain amount of arrogance to think you can read another person’s mind and tell them what is best for them. On some level we all know this, yet in reality that is what problem-focused therapy is all about. No wonder we are in 2025 and still haven’t made much progress, we’ve been pointing our efforts in the wrong direction! Traditional methods of problem-solving work well in our objective reality and the natural world. It doesn’t work so well in the world of subjective reality of which most of us as humans spend much of our time.

The Dominance of Structualist Thinking and Meaning Derived through Dialogue

“As far as we can discern, the sole purpose of human existence is to kindle a light in the darkness of mere being” – Carl Jung

I’ve become fascinated with Steve de Shazer’s writings over the last six months particularly their intersection with philosophy, the study of language / discourse in therapy and his ideas about how and why we change.

In his book: “Words Were Originally Magic” (deShazer, 1994), Steve deShazer explains why much conventional thinking today follows a scientific model or structuralist way of thinking. He explains that to the structuralist, what we observe in human behaviour is not as it seems and that this way of thinking stemmed from the natural sciences (where we observe the real world) but particularly from advances in medicine where previously unexplainable phenomena could be explained and observed by examination and then confirmed by biomarker such as a blood test.

He explains that due to the excitement around the advances in the medical sciences it was assumed the same advances could be made with mental illnesses. Then came Freud who had great influence on modern psychology where he linked mental disorders to a “cause” namely the unconscious, and since then there have been many attempts at explaining the causes of mental disorder from cybernetics, to family systems, to biological causes, genetics and chemical imbalances. However, despite the promises of advancement this unifying “cause” has never been found.

All that seems to have happened is the many reasons for why psychologists and psychiatrists “think” we have mental illness has expanded and with it so has the wide range of therapies to address these problems. Currently there are many “reasons” thought to explain mental illness yet the “cause” remains elusive.

I would argue that the reason for this is the subjective nature of the subjects being studied: human beings. However, interestingly, deShazer (1994) highlights this same ambiguity within language itself. He explains that within language and conversation the structuralist viewpoint would claim that what we say, do and the symptoms we display, all have a deeper meaning than what is first seen, heard, observed on the surface. That there is a simple structure or what we see on the surface (words, descriptions, narratives, symptoms & feelings described) and a deep structure that holds the “real meaning”.

You could call this “deep structure” the unconscious in Freudian terms, or in Cognitive Behavioural Therapy it might be “maladaptive” beliefs or Negative Automatic Thoughts (NATS) “causing” the unwanted symptoms. In Trauma informed care it might be the unprocessed trauma, in somatic therapies it might be the inability to engage with your feelings or be “present” with them. I believe most traditional therapies function in this way, as does the scientific method in psychology with its leanings towards pathology and quantitative research methods (which are less interested in details and more interested in averages and bell curves) that have been more dominant over the years, however this might be changing.

 In this way, in my view a psychotherapist or psychologist that works with a problem-focused modality serves as something of an interpreter. They take what you say or what they see (body language) on the surface, comparing it to their academic knowledge or their framework (type of therapy they are using) and then translate what your symptoms, words, actions, behaviours etc really mean based on their preconceived assumptions (their “expert” knowledge).

On the surface it sounds logical enough because it follows the pattern of something we are very familiar with: conventional problem solving and logic used for problem solving in the real world. The problem is that something found in the real world (such as an oil leak in the engine of your car) functions in a more “static” way than “human problems” with their subjective component. In the case of a car we find the problem, fix it and then the car is fixed. Yet a problem with your car is static. That is, the oil leak isn’t going to change, it’s always there to be discovered. It also doesn’t wake up one morning and decide on second thoughts it would rather have a puncture.

This is entirely different with human beings BECAUSE of our subjective nature. The “problem” can change from one day to the next based on changing feelings and perceptions. It can’t be isolated like a “real world” problem can. In this way it is ever changing and remains quite elusive. It can’t be measured or confirmed so how does the psychologist or psychiatrist know what they are looking for? How do they know when to stop looking? It has to be based on their perception.

How can anyone else other than yourself truly know what you mean; when we typically find it difficult to articulate what we mean to ourselves?

When I zoom out a bit the whole exercise seems absurd, arrogant even. In what other arena would we expect someone could understand what we think and feel and then predict what we were likely to do? We can’t even do this with our intimate partners who we often know better than anyone. Yet this what the psychologist and psychiatrist effectively aim to do (In the case of reports and assessments for example). Based on their research they decide what they believe is right for you.

 A common saying upon not knowing what another person feels or thinks is: “Hey, I’m not a mind reader!” Yet somehow, we have decided psychologists have this magical ability? Based on research that as I’ve mentioned is highly subjective, unproven (as we can’t prove anything psychology) and unsurprisingly hard to replicate.

In that case what distinguishes a psychologist from a fortune teller? (I admit I'm being a bit cheeky with this one), or a trusted friend that knows you well? How can a psychologist know you BETTER than you know yourself?  

I suspect despite all the study (of which I too have done roughly 80% of what Clinical Psychologists train in by having a Masters in Psychology) a close friend would likely be able to make equally profound assumptions about you and they often do. I quite frequently see change in clients and when I ask how? It’s because they spoke with a trusted friend, family member or colleague that helped them expand their thinking or gain insight. No training in therapy, no knowledge of the research. Sometimes I wonder if the research actually narrows a psychologist’s thinking.

Remember all that a psychologist can give us is their “best guess”, sure, it’s better than going in blind but it’s still a bit “hit and miss”. If it wasn’t, psychologists should be effective with every client. They have all the research, they claim to know the “root cause”. Why aren’t they more effective then?

Research in psychology is based on very broad data across a population that tells us nothing about the individual. Yet it’s the individual, not the collective, that walks into a therapist’s office and wants change. Their perspective on the world, their past and who they are as a person is entirely unique to them. There might be similarities across cases but nothing will match 1:1.

The research in psychology in my view, at best, gives us broad patterns about human behaviour. The research is useful in my experience because it makes you aware of certain trends in human behaviour, but it’s limited in its applicability to the person sitting in front of you. Therapy is a far more organic process, and the client is the expert.

Sometimes the research is useful and sometimes it’s not. As there are no tests for mental illness the fact the research can only make broad sweeping generalisations is entirely appropriate and when applied to the population as a whole at least tells us something.

Also, often they use first year psychology students in their research because research is expensive to conduct and it’s difficult to recruit participants. How representative, especially historically do you think this population is of the general population?

Not everyone can afford or chooses to go to university. What bold claims they make from their research given these limitations. Generalizations are all we should expect of psychologists, psychiatrists and the psychology field at the moment and to be honest many counsellors and psychotherapists as well,, as they often follow the same research. I think at times rather than enlighten us, the research has held us back as we seem be stuck looking at human suffering in the same old tired ways that bring about the same often unsatisfactory results.

Then there’s the function of language that frequently leads to misunderstandings. When I say something, I cannot control how you interpret it not matter how beautifully and carefully worded I make my sentence. How you interpret it is entirely dependent on the receiver, their life experiences and how they choose to interpret what I say.

As deShazer (1994) I believe rightly points out, when we search for the “ultimate truth” we keep digging around in the “deep structure” or “unconscious”; yet how do we know when to stop digging? How do we know what we are looking for?

 Frequently, once we start digging, we simply find more and more “signifiers” or words that basically describe the same thing just in a slightly different way. How many different ways can I explain my pain? And even then, it quite often doesn’t get close enough to grasp the truth of what I mean. We just don’t have the language to articulate some our most deep and meaningful experiences. Similarly, when dealing with problems, the more we dig, the more problems we seem to uncover, and it becomes never ending cycle.

deShazer in contrast to traditional therapists, decided to simply view a therapeutic conversation as it is, to see what was on the surface (the surface structure) and not read anything else into it. Afterall, to read more into it than that would only be the interpretation of the observer. How could it be anything more than a cheap imitation of what was meant? Instead, he did his best to stay as close to what the client was saying as possible. He believed the only “data” we needed was the content of the clients’ utterances, EVERYTHING we needed to see was on the surface (deShazer, 1994).

This practice he coined “text-focused reading” and contrasted it with “reader-focused reading” which is closer to what psychologists do. In reader-focused reading the reader comes with their own preconceived ideas and assumptions about what a person is saying and meaning and interprets it based on their own assumptions or their “research knowledge”. In text-focused reading there is nothing to be interpreted, everything we need to know is available to us on the surface through the words a client uses.

Instead of making interpretations (or assessments) as psychologists do, deShazer believed meaning was crucial to change in therapy and that this meaning was constructed through the conversations we have with clients. As I mentioned earlier, in his view, meaning was created in “the gap” between what one person says and how the other person responds. Often, we misunderstand each other more than we understand each other but through a series of verbal exchanges we arrive at an agreed upon meaning.

It is this new “meaning” constructed in therapy that shapes our experiences and our perspective on the world and that ultimately leads towards change. At this time that’s the best way I can explain what’s happening in Solution Focused Brief Therapy.

How we experience the world and ourselves is shaped by the meaning we give our experiences. Therapy is a chance to change the meaning we have often been “given” (by our parents, family, teachers, early life experiences, significant others and society) and never reconsidered from our adult perspective.

In my opinion as we create a meaning that is more accurate and closer to what we authentically want out of life our experience of life changes as a result. Solution Focused Brief Therapy, I believe, quite unapologetically (unlike psychology or psychiatry), acknowledges it is dealing with our subjective reality/ perspective on the world. It is through working with this subjectivity and “constructing” new meanings together (between therapist and client) that a change in meaning occurs and therefore thoughts, beliefs and behaviour change as a result. deShazer and his team worked this out through observing therapy sessions and essentially seeing what emerged from the data.

They simply observed what they could see on the surface (deShazer, 1994, 1988, 1985). I think this is likely to be far more accurate than a hypothesis “cooked up” in academic circles and then artificially tested in a lab but that’s just my view, you can make your own conclusions and I encourage you to. In the spirit of SFBT I have a lot of knowledge in mental health, I don’t see myself as an expert. The client is the expert on their own life and without their input I would be lost.

In some sense I believe meaning is the essence of life. It defines how we see ourselves, how we make sense of our past, how we approach the future, how we view others and how we view the world. If humans are so highly subjective, meaning, in my opinion seems a great place to start when looking to bring about change. If you think about what touches us most deeply, whether it be music, art, poetry, the written word, or an experience with a close friend or loved one, you’ll likely find it’s the concept of meaning that binds all these things together.

Aren’t we all seeking a meaningful life? What would life be without meaning? Quite miserable I’d imagine, that’s why so many of us feel “lost” when our life becomes devoid of meaning or when the meaning, we thought it has changes, such as a significant other passing away, a break-up, job loss or as we enter into old age or retirement. The teenage years are a crisis of meaning, so is the midlife crisis in my opinion that I wrote about here: The Midlife Crisis and the Role of Responsibility

Steve deShazer and “Skeleton Keys”

“Any change stands a chance of starting a ripple effect which will lead to a more satisfactory future” – Steve deShazer

In his book Keys to Solution in Brief Therapy (deShazer, 1985) deShazer talks about the concept of “skeleton keys”, in essence a key that can open many locks. deShazer explains that certain “interventions” used by him and his team would be effective across many cases despite each individual case being idiosyncratically different (deShazer, 1985). These days in Solution Focused Brief Therapy we don’t suggest interventions or homework but I believe the broader concept still applies.

While problem-focused therapy seeks to find the exact key (an intervention) to unlock any number of specific locks (a diagnosis or a specific problem) SFBT takes a completely different approach. The framework of SFBT is exactly the same regardless of the presenting problem (which you might find surprising) and the broader focus of each session is exactly the same (the outcome the client hopes to achieve from coming to therapy). The “difference” between each session is created because every client is different and they come with unique perspectives, worldviews and the language they use when talking about “problems” or “solutions”.

With Every client the SFBT therapist is focused on the outcome the client wants to achieve, the difference achieving that outcome would make in their life, and the resources they already possess to achieve that outcome. This applies to each and every client despite the ideocratic nature of each individual’s complaint/problem/diagnosis. Every client has an outcome they want to achieve from therapy and it is this outcome that “anchors” the session. Contrast this with traditional “problem focused” therapy where the intervention is dictated by the problem the client brings. It’s a totally different way of working and a totally different way of progressing a session and achieving what the client wants to achieve.

Hence the name “skeleton keys” that can open many locks. The same “key” is applied regardless of the different shaped locks (the problem brought to therapy or the diagnosis). In problem focused therapy they spend much time trying to search for the “correct” key to fit a specific lock. The psychologist spends much time just trying to figure out what “lock” needs to be unlocked before they can proceed.

That means they have many “keys” (therapy modalities, “tools” and interventions) and any number of “locks” to unlock (because let’s face it human “problems” are constantly coming our way, solve one and along comes another!). However, what a client wants in my experience tends to be far more constant in my experience. For example, who doesn’t want more peace, more contentment, happier relations, more purpose and more meaning in their life? Broadly speaking that’s a constant among all participants regardless of their starting point. Problems however are vast and incredibly varied.

Contrast this with diagnosis and psychology as a discipline. Yes, there is the field of positive psychology but Clinical Psychologists overwhelmingly focus on psychopathology and “abnormal psychology”. In addition, most psychological research seems to focus on pathology when it comes to mental health. In my view diagnostic criteria keep increasing because there are any number of problems people have once you start looking, and despite our search we never find a “root cause”.

We are on a never-ending conveyor belt of problem solving. All that happens is we recategorizes and essentially reinvent new diagnoses to describe various clusters of symptoms and we go around in circles. Yet despite this reclassification, the symptoms themselves don’t change much, the categories just change and often symptoms overlap between disorders. How can we know which diagnosis is which with any level of accuracy? I feel at this point we are really just “rearranging the chairs on the Titanic”.

When you think about it there’s a limited number of ways, we can experience a particular phenomenon but an endless number of ways in which we can describe it, hence the increasing number of diagnoses in the Diagnostic Statistical Manuals. Then, with the increasing diagnoses we need to find a new “key”. That means we end up with even more types of therapy being created and in addition new types of medication to go with it. We keep finding more “problems” we need to address, well psychologists, psychiatrists and the psychological research community do anyway!

Lots of reinvention, very little new and innovative solutions. Very rarely any startling new outcomes for clients despite all the research and fanciful claims. I don’t think anything truly game-changing has come out of the psychology department when it comes to mental health since the 1990s. They seem to be out of ideas, it’s like we have stopped making progress. They’ve pigeon-holed themselves so much with their structuralist approach to problems that they’ve hit a wall. As I say most of what today’s psychologists, psychiatrists and researchers have to say is remarkably unremarkable. “Here’s another study that confirms what you already knew”.

The reason I think Solution Focused Brief Therapy works like a “skeleton key” is it encourages a client to do something different (an exception to their typical behaviour or approach towards solving a problem) which allows for a new perspective or approach and potentially a more innovative solution.

Psychology generally gives you an intervention that is very much the same as “conventional wisdom” and unless the “key” is right the lock won’t open. Meditation for example is a wonderful tool but it’s certainly not for everyone. Cognitive Behavioural Therapy performs well in research but some find it fairly useless. Performing well in the artificial environment of a University lab is certainly no guarantee of success.

I’m not saying SFBT will always work for everyone because there are other factors at play (a personality clash for example) but I think it has the best chance of working given its stance. It also doesn’t claim to be more than it is like psychology. There’s no expert stance; the client has the agency to choose and think for themselves which ultimately serves them well when therapy ends. It also stands out as innovative compared to 99% of therapy because it approaches problems in such a radically different way compared to traditional therapy.

In addition, it works with the client’s worldview, so rather than trying to “force” change it works within the client’s frame of reference and their repertoire of behaviours in the case of “exception finding. Lastly, I think there is more commonality between what clients want in their lives than what they don’t want. Problems are a dime a dozen and can take many forms but what clients want in my 8 years of experience using SFBT, is remarkably consistent across clients.

As I’ve mentioned, broadly speaking they want a life that has purpose and meaning, the freedom to be authentically themselves with confidence, to feel content with their life in general, feel calm and relaxed, have meaningful relationships with those important to them and to have hope for the future.

This is true regardless of why they have walked into my office. The details of their desired outcome, how they get to their desired outcome, with whom and what unique resources they possess can look different as you’d expect given they are unique individuals, but the overall themes are remarkably similar. I think because SFBT focuses on outcomes people want it taps into themes that are universal human desires. It is also possible that the fact SFBT focuses on language and meaning assists in this process. 

I don’t need to know your diagnosis to get you to where you want to go. The diagnosis is evidence of where you’ve been and no longer want to be. I only need to know where you want to go and then collaboratively support you to get there. It’s a vastly different way of thinking in the therapy space and it works.

So, if you’ve tried everything and want to give something different a go, I highly recommend Solution Focused Brief Therapy. It won’t work for everyone, but it might just hold the “key” for more innovative ways of working with mental health issues in the future. A “fresh take” is something I feel is desperately needed in a time when we are told we are in a “mental health crisis”.

Has anyone stopped to think that maybe trying to solve problems exactly the same way we have since Freud might not be working? That throwing money at psychologists to train even more of them to diagnose and pathologize may not be the answer? In my view, it’s time for a fresh approach and to be open minded to different ways of working. While it has been around since the 1970’s it may be that it is Solution Focused Brief Therapy’s time to shine. That’s my belief anyway. What you choose to do is of course up to you, but I wish you well and hope mental health services will improve in the future.

Conclusion

Hopefully, I’ve opened your eyes to some of the myths surrounding diagnosis and psychological research and some of the “pitfalls” of traditional therapy in my opinion. If you find a diagnosis useful, there’s nothing wrong with that. I think there is room for diagnosis particularly within the current system as it allows access to certain services and medication if that’s a route you choose to follow.

However, in my opinion, we need to reassess how we view “mental illness”, conduct psychological research (including how broadly we can realistically generalise the findings) and the types of therapies we use given despite the vast number we don’t seem to be very far ahead.

I believe all these areas need to be relooked at because of the very subjective way diagnosis is decided upon and the subjective way psychological phenomena is studied. I would like to see much more transparency for the public around how diagnosis criteria are decided upon and about the subjective nature of research in psychology, including reassessing what we can realistically conclude from the research. I’d like to see more transparency around how Clinical Psychologists arrive at their conclusions also especially considering the high prices consumers pay for their services. Can they really back up the claims from their research?

We need mental health services that are transparent to the public so they can make an informed decision on where to invest their money and I think governments need to be made aware of the many failings of psychology as a discipline so the solution to the current mental health crisis isn’t what we have always done which clearly isn’t working: Throw more money at Clinical Psychology departments and psychological research that seemingly gets us no further year upon year.

It’s a lazy solution that looks good on the surface (with the perception something is being done) but seems to fail to advance outcomes for the service user. Surely, it’s time to change tact, to reassess psychology as a discipline and certainly look more actively into the process of diagnosis and whether this is the right way forward.

I don’t have all the answers, I’m not even saying SFBT is the ultimate answer, I just like that it’s at least a fresh take on therapy (despite being around since the 70’s) and I believe it’s effective for the reasons I outlined. As a past consumer myself I know what I would want.

Transparency in the fields of psychology and psychiatry so I could make the most informed decision possible and research findings that are not based on what we “wish” they would be, but that are presented just as they are, honestly pointing out their limitations. I think for too long these fields have ridden on the credibility of the medical field without the data to back that up.

Lastly, I hope the brief introduction to Solution Focused Brief Therapy and how I think it works and why (based on reading deShazer, many others and continually practicing the approach) has provided you with an alternative way of thinking about mental illness, problem solving and opened your eyes to a vastly different way of working that you might find helpful. It is as evidenced based as any other approach (despite the misconceptions you might have heard) and you might just find it suits you better than other problem-focused traditional therapies. I encourage you to give it a try! All the best.

Here is some current research (a meta-analysis) of the effectiveness of SFBT: The current evidence of solution-focused brief therapy: A meta-analysis of psychosocial outcomes and moderating factors - ScienceDirect

Here is an earlier blog I wrote on Solution Focused Brief Therapy: What is Solution Focused Brief Therapy and How will it help me?

Tim Robinson - Counsellor

MCouns (Distinction). MSc Psych (Hons). PGDipHealSc  (Health Behaviour Change)

MNZAC - Full Member of NZAC

E-mail: timcounsellornz@gmail.com

Website: www.timrobinsoncounsellor.com

References

Davies, J. (2014). Cracked: Why Psychiatry is doing more harm than good. Icon Books

de Shazer, S. (1985). Keys to Solutions in Brief Therapy. W. W. Norton & Company.

de Shazer, S. (1988). Clues: Investigating Solutions in Brief Therapy. W. W. Norton & Company. 

de Shazer, S. (1991). Putting Difference to Work. W. W. Norton & Company. 

de Shazer, S. (1994). Words Were Originally Magic. W W Norton & Company.

de Shazer, S., Dolan, Y., Korman, H., McCollum, E., Trepper, T., & Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. Haworth Press.

Frances, A. (2016). Saving Normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life (First William Morrow paperback edition.). William Morrow, an imprint of HarperCollins Publishers.

Johnstone, L. (2022). A straight talking introduction to psychiatric diagnosis (2nd ed.). PCCS Books.

Maté, G. (2022). The myth of normal: Trauma, illness and healing in a toxic culture. Knopf Canada.

Szasz, T. S. (1974). The myth of mental illness: Foundations of a theory of personal conduct (Rev. ed.). Harper & Row. 

Websites:

The current evidence of solution-focused brief therapy: A meta-analysis of psychosocial outcomes and moderating factors - ScienceDirect

17. The Death Of Resistance: what is it and why it’s so important in Solution Focus

Analysis: Depression is probably not caused by a chemical imbalance in the brain – new study | UCL News - UCL – University College London

Replication Crisis | Psychology Today New Zealand

Youtube Video:

"Medicating Normal" | Docu | 76-min | EN (CC in: ES, DA, DE, FR, HE, IT, JA, NL, NO, PL, PT, SV, ZH)