The Great Dilemma

Updated: Mar 23, 2020

Symbolic Interactionism & Case Conceptualization It was the third year of my undergraduate degree in social work when I heard my professor say, "not everyone suffers from the same depression." I was perplexed. At the time, I was taking an elective course called Mental Health and Social Work, where we were learning how to conduct a biopsychosocial assessment, which means a comprehensive evaluation of one's well-being, as well as learning how to arrive at a differential diagnosis. I was also frustrated that I was developing a skill that I would never be able to use because, in Ontario, social workers do not have access to the Protected Act of Communicating a Diagnosis

Nevertheless, one brave student raised their hand, which was not me, to ask: "I do not understand what you mean as everyone has to satisfy the same criteria for diagnosis." She responded by saying that whilst everyone must meet the diagnostic criteria for depression. It's etiology, onset, and prognosis varies depending on the patient. The particular mechanisms upon which depression thrives is unique to each patient.  My professor was a proponent of Symbolic Interactionism, which asserts that each of us generates the meaning of our experiences based on how we symbolically interact with the world, and/or, the symbols available to us. She, therefore, argued that we must work with patients to develop a shared understanding of the genesis of their depression and how it lives out day today. 

She did not use the term 'case' conceptualization to describe this iterative process of developing a narrative understanding of one's struggle with psychological 'disorders.' Case conceptualization describes the process where a healthcare practitioner engages with a patient to draw a comprehensive picture of what is happening for them rather than merely attending to an inventory of symptoms. For example, in depression, some of the symptoms include hopelessness, feelings of failure, suicidal ideation, persistent sadness, fatigue, etc. However, the conditions under which one feels hopeless rests on how they define hope and so on. 

Those with lived experience who currently see a social worker or psychotherapist, ask them: what is your conceptualization of my emotional or psychosocial distress? Similarly, a patient with a broken leg does not always share the same pattern of fractures of another patient. Thus treatment must be adjusted to each person. The same rule applies to psychological treatment. Telling a patient, they are depressed with a severity specifier does little to illustrate what treatment ought to look like or what the patient ought to do to improve their mental health. 

Whilst there remains incredible debate about the validity and reliability of the Diagnostic Statistical Manual of Mental Disorders; it remains a cornerstone in mental health care. I argue that the centrality of differential diagnosis over case conceptualization is a matter of philosophy of science and political imperatives.  From Empiricism to Hermeneutics Empiricism is what drives differential diagnosis, which is a philosophical position that privileges objectivity over interpretive methods of critical thinking. Differential diagnosis in the DSM allows clinicians to identify the 'presence' of specific symptoms whilst using psychometric measures to establish a baseline; notwithstanding that the precepts upon which these measures are based are the domain of subjective experience.  Hermeneutics, on the other hand, prizes interpretative methods of analysis wherein we construct a rubric of one's functioning that is grounded in their lived experience and the contexts in which these experiences unfold. From a hermeneutic standpoint, symptoms offer a vehicle to enter lived experience to develop a fuller picture of what is happening on a case by case basis.  I have seen myriad cases of misdiagnosis because clinicians miss the nuance of context. For example, whilst working in an outpatient clinic in Nova Scotia, I was working with a patient who was referred to me by their family doctor for Intermittent Explosive Disorder (IED)which stated is someone who experiences extreme rage that occurs suddenly wherein they feel they have little to no control. 

Upon listening to their story, the patient seemed to be riddled with anxiety about intrusive thoughts that they were liable to kill someone, so they refused to leave their home. As I probed more, they became increasingly agitated in our appointment. They displayed their anxiety in frustration and defensiveness. Thus it took on the quality of an explosive disorder.  As we continued to build a picture of their distress, it was clear they were very much aware of their mounting agitation which stemmed from fear they were going to hurt someone. In joining with them to unfold their story to map out their distress, it was evident they were struggling with Obsessive-Compulsive Disorder (OCD) not IED. A misdiagnosis that would not have been identified without a hermeneutic orientation to assessment. We must not forget that context MATTERS!

The tension between hermeneutics and empiricism rests on the dichotomy between positivism and constructivism. The enlightenment era ushered in an era of scientific advancement that centred objective study of social and natural phenomena that denounced esoteric, existential, or spiritual epistemologies. Claims to valid knowledge rested with those with the ‘capacity’ to ‘do’ science with the requisite tools.

Enlightenment-era thinkers heralded positivism as a vanguard of truth. However, when science sees itself as distal from the world it seeks to understand - it is vulnerable to becoming an ideological tool to advance political agendas. We see this when groups, often those in positions of power, take parts of a study's findings or represents a study's findings as absolute truth. My sense is that we forget knowledge is always partial, and any good scientist remembers that scientific findings are hypotheses subject to revision as we get better data.   

Conversely, hermeneutics comes from classics and the humanities as interpretative approaches to knowledge production. In healthcare, the political push for evidence-based practice to streamline services for cost-effectiveness and to reduce variability in-clinic care sees hermeneutic approaches as not only costly, but too subjective or difficult to 'police'. In the UK, social work is experiencing an epistemological shift where practice-based evidence is seen as just as important as evidence-based practice, which means experiential knowledge counts because the ‘real’ world is messy and nonlinear. Practice-based evidence acknowledges that as clinicians we are generating new data each day because as we apply the accepted wisdom of the day we are refining it based on immediate real-world feedback. 

Therefore, I urge clinicians, or those with lived experience, reading this not to reduce assessment and treatment to differential diagnosis based on symptoms, or empirical facts. Further, I call on clinicians to contextualize their clinical practice within philosophical frameworks that inform it as to be a reflexive and critical healthcare provider, which goes a long way to ensure the best possible outcomes for those with whom we consult. 

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