What are diagnostic concepts?
The term diagnosis refers to a concept derived from Greek and can be understood as a thorough (slide) knowledge (gnosis) of one’s (in this case) psyche. Thus, the word diagnosis refers to a precise conception of a psychological problem on an ideographic level. If we stick to the original meaning of the word diagnosis, we immediately see a confusion because the Diagnostic and Statistical Manual (DSM) is a taxonomy, and taxonomies, by definition, are groupings based on agreed-upon characteristics. Taxonomies are very useful for research and administrative purposes, but one might question whether we should use them for our clinical care. The word “descriptive diagnosis” seems created to close this confusion in language and understanding. It often encompasses more nuance and complexity and includes, for example, development and attachment, personality, somatics, context and system, substance (drug) use and finally a person’s symptoms. However, it is not the descriptive diagnosis but the DSM that determines a patient’s treatment choice in current standards of care. As a healthcare professional, you are expected to act according to these standards or deviate from them in a very reasoned way. Thus, our diagnostic concepts are very decisive for the design of mental health care.
Why do we need to dissect and review them?
Even though the DSM is currently still the most dominant way to understand psychological suffering, there is currently a countermovement going on. Our understanding of mental suffering is shifting due to increasing criticism from academics, thinkers and those with experiential knowledge that is getting louder with each new edition of the DSM. Kueger, Hopwood, Wright and Markon (2014) conclude that the DSM is “fundamentally broken” after reviewing more than 30 years of critical literature (p. 246). Just before that, the director (Thomas Insel) of the National Institute of Mental Health declared in 2013 that the institute was no longer funding research based on DSM categories. Many authors noted problems related to the limited validity, reliability, loss of information and diagnostic instability of the DSM. Criticism of the categorical system of mental disorders consists of many different arguments, but the most fundamental criticism is the fact that the DSM system is based on a priori categories and lacks a solid empirical basis(Kapur, Phillips & Insel, 2012; Skodol, 2012). In summary, great practical and fundamental things go hand in hand with the DSM.
Why a qualitative approach?
The question of alternatives to the DSM can be approached in several ways. For example, you can think about literature reviews, conducting questionnaires among experts, or you can think about qualitative research. Qualitative research can challenge conventional ideas, inspire new theorizing and also stimulate change(Gergen, Josselson, Freeman, 2015). If you are asking a relatively new question, you need an approach that allows for open, in-depth and broad research. When asking a relatively complex question, it can help to capture the complexity of the issue better than other research methods, such as questionnaires where both the question and the answer options are already defined. In other words; a qualitative method allows for a bottom-up research approach from which new meanings and concepts can emerge. Especially when we want to understand a phenomenon in depth, or try to record a new concept, qualitative research lends itself extremely well. So when we think about alternatives to the DSM, qualitative research can come in very handy!
How does dissecting and revising diagnostic concepts through qualitative research work?
When you want to uncover meanings of diagnostic concepts, you can do interviews. Based on your question/topic, create sub-questions/sub-topics and based on that you will create your interview. You can be guided by theory in doing this, although too much theory can actually take away originality and cloud the unbiased view you need. So this is balancing. Once you finish your interview, it may make sense to conduct a few interviews to see if you want to make any adjustments to your interview. You want your interview to find out something about how the person you are interviewing sees, understands, experiences or feels something. In doing so, you need an open, curious mind and the other person needs an open space to put their experiences into words and language. This is a precarious process with many similarities to the psychotherapeutic process. When you have conducted enough interviews to satisfactorily answer your question, stop the data collection phase. You start delving into the data and trying to become familiar with it. You can do this by writing vignettes or drawing up mind maps of each interview. The first patterns then usually begin to emerge in your mind. Next, you start coding. For this, you can use programs that can support you in this, such as Atlas-ti and Maxqda. This is a process of identification of themes, revision of themes, refinement of themes and finally a definition of themes where you also start giving names to themes and thus are also creating. Have your research team read and check into this. You ultimately want as “representative a representation” of the data as possible even in qualitative research. You can present the results in language, tables or figures. It is advisable to explain your main findings well and to preserve and accommodate the richness of your research in the presentation of your results.
Points of interest
- Be aware that much current research is constructed and formulated from the DSM; 90% of RCTs use a DSM definition of mental suffering. Keep this in mind when coming up with your question and research design.
- Realize that as an interviewer you also bring baggage and make interpretations. You have to think not only about your educational baggage, but also your social and emotional baggage. Your gender, social class, age, status, ethnicity, values, beliefs and personal history play a role in how you listen and what you value and make important. Elicit your key values or views in light of your research.
- Make sure you have a clear roadmap when doing qualitative research (see, for example, Braun & Clarke, 2006; 2020) and a good program that can support you in coding.
- Delve into proper attitudes & techniques to interview well; being able to interview well is akin to good psychotherapy
