For individuals that are taking the first step to seek help from mental health professionals, it is natural that they may be concerned with the possibility of a misdiagnosis, or perhaps an overdiagnosis. With the pre-existing stigmatisation of mental health disorders, clients would have needed to pluck up their courage to seek treatment in the first place. A misdiagnosis could not only hinder them from receiving the appropriate treatment for their affliction, but also allows for their distress to grow unchecked as their hope for recovery diminishes. In other words, accuracy in evidence-based mental health diagnosis is crucial, and this article aims to help you better understand how the diagnostic process works.
As the term “Evidence-Based Diagnosis” implies, psychiatrists or clinical psychologists take extra care to ensure that any diagnosis made is accurate, objective, and not subject to any form of personal bias. In some sense, this also means allowing for a safe, non-judgemental and compassionate environment. Primarily, clinicians would have to understand the client’s suffering and situation, before thinking about how that might relate to a possible mental disorder. Perhaps you may be unaware of this – clinicians do not simply jump straight into tying the client down with a specific diagnosis of a mental disorder. Before all else, clinicians have to consider if the client’s symptoms meet the definitions of a mental disorder in the first place. As per the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the definition of a mental disorder considers these five factors:
A behavioral or psychological syndrome or pattern that occurs in an individual
Reflects an underlying psychobiological dysfunction
The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
Must not be merely an expected response to common stressors and losses (i.e.. the loss of a loved one) or a culturally sanctioned response to a particular event (i.e. trance states in religious rituals)
Primarily a result of social deviance or conflicts with society
With reference to the definition of a mental disorder, it is particularly important to note that the consequences of a mental disorder is clinically significant, and causes a weighty amount of disruption to one’s lifestyle and day-to-day activities. For example, it is completely natural for one to feel upset over certain situations, and this does not necessarily mean that you have a case of depression. However, you might need to get it checked out if you find yourself unable to cope with prolonged feelings of sadness which start to interfere with your daily activities, or are causing you to have suicidal thoughts.
Of course, clinicians then assess the syndrome one displays. By “syndrome”, we mean a collection of signs or observable aspects of the client’s suffering (i.e outward expression or behaviour). The main point of this is to identify if the syndrome is clustered in an identifiable pattern that is noted to be severe or pervasive. During the assessment phase, clinicians also try to understand the internal experiences of the client. Besides their outward display of distress, their thoughts and feelings are also important information which counts towards the diagnosis of certain disorders. Upon identifying that the client is indeed suffering from a mental condition, clinicians then try “assigning” the client to a particular category. You can think of it as, “can the syndrome be broadly identified?” There are certain broad categories of disorders, such as anxiety disorders, or psychotic disorders. Needless to say, clinicians have to consider which category the client best fits in.
The last step of the diagnosis process concerns the further narrowing and identification of the specific disorder – branching out from the broader, generalised category and into the specific details. For example, a client could be diagnosed with Obsessive-Compulsive Disorder (OCD), a form of an anxiety disorder. Ideally, a specific disorder is identified during the diagnosis process for various reasons – for the sake of the clients themselves, but also for clearer communication with other mental health professionals (in the case of continuity of care), and even for legal or court matters. Under rare circumstances, some clinicians are able to identify the broad category of the mental disorder, yet are unable to specify the exact condition that the client is suffering from. In cases like these, their disorders will be labelled as “unspecified”, as per the 10th version of the International Classification of Diseases.
As mentioned, evidence-based mental disorder diagnosis is all about diagnosing clients accurately and objectively. To enhance objectivity, some clinicians go the extra mile, stopping to consider if the diagnosis given was biased, or influenced by his or her own culture and history. “Is the syndrome maladaptive?”, “Did I take cultural variables into account?” An objective diagnosis will certainly go a long way in ensuring that the client receives the most appropriate treatment, which will in turn enhance his or her recovery journey.
Overall, it is safe to say that it takes two hands to clap in every treatment process. Clients and clinicians should try as much as possible to work together, be it in the assessment or treatment phase. For an effective treatment, clinicians will do their best to assess the severity and pervasiveness of any syndrome using understandable language such that clients are well aware of their condition. However, clients also need to understand that transparency on their side is pivotal and that it will drastically impact the treatment process, for better or for worse, depending on their cooperativity and how much they choose to reveal.
Dr Robert Shwartz, Ph.D., PCC-S, Evidence-Based Mental Disorder Diagnosis: How to Increase Accountability, Efficiency and Objectivity, video recording, Mental Health Academy
With the introduction of the fast speed Internet, a new addiction was born – Internet porn addiction.
One client who has fallen down the “Rabbit Hole” of porn addiction reports:
“I saw porn in Manga mags and comics when I was in my early teens and occasionally saw a porn mag.
It wasn’t until the fast speed Internet came in and I could stream videos on my mobile phone and iPad, that I started to watch it regularly. After a year or so, I started to watch it every day at home, when I was alone.
Later on, I started watching it in the bathroom of the office; then at my desk, and finally, in public places and on public transport – I am amazed I wasn’t caught by someone!”
Some clients come to therapy to kick the porn habit because they recognize that they have a problem. They have been “caught” multiple times by their partner – always promising to stop.
Or they may have inadvertently left sites open on the family computer. Some even get called in by HR at work and asked to explain the hundreds of times they have logged into porn sites, which the IT department has uncovered.
Others don’t see they have a problem – even when their experiencing porn-related erectile dysfunction, anejaculation, or loss of libido and intimacy with their partners and spouses.
They may simply consider this distressing, though natural, change in their relationship – a product of familiarity and boredom.
As it turns out – they may be quite wrong – because there is nothing “natural” about porn. It’s toxic and it can effectively hijack intimate relationships, which could otherwise have been healthy and fulfilling.
Clients with porn use compulsivity often say:
“I wouldn’t have come to therapy unless my partner had given me an ultimatum – “get help or we break up!”.
And it’s also common to hear:
“At first I thought I would just see a therapist once or twice to appease her, and let her know I want us to stay together”.
However, after discussing in therapy how long a client has been using porn, how frequently they were using it, where they were using it – and the type of porn they have digressed to watching – they often realize all the risks they are taking with their relationships, marriage, families, and their jobs or their studies.
One client reports: “the therapists gave me a detailed questionnaire. I was staggered by the report that came out. Seeing my behaviour over the last few years, what motivated me to do it, and how it changed me and my relationships, I became really worried.”
“I hadn’t realized that because of porn, I was losing interest in sex with her, I wasn’t present for my family, and I was getting irritated, restless and discontent at home and at work.
I thought that my problem with my sex drive and erections was our relationship – not the porn.”
These revelations, and many more, may be tough for a person with porn compulsion but at least they may be motived to take recovery actions.
But what about the partner or spouse? They may be feeling frustrated, angry, fearful and ashamed. They may be devastated.
They may be confused when friends, relatives and the community at large believe that porn is the “new norm” and that “boys will be boys”.
What can they do?
While relationships are all as different and unique as the people in them, there may be some common actions that spouses and partners may wish to consider.
Attend therapy with the person who has porn use compulsivity – and learn about Internet porn addiction. How it arises; what it looks like; is the behaviour compulsive – or is it a moral issue, a lack of discipline, selfishness – or have they just stopped loving or desiring me? In a couples’ session, you can also learn what the recovery actions are, what it takes to succeed in recovery, and how you will know that he is in recovery – and will he ever do it again?
Read about porn addiction and how porn changes the brain. There are many good websites with excellent information. Fight the “New Drug”, “NoFap”, and “Your Brain on Porn” are but a few sites with good articles and videos. Robert Weiss, Paula Hall and Stephanie Carnes also have helpful YouTube videos.
Insist that your partner initiates a regularly weekly couples’ check-in session; in which he shares: what actions he taken in his recovery that week and what he has learned; what actions he hasn’t done and why; what he will do next week; and what help he needs from you – and you always have the right to say “no”, or “yes, but…”.
Judge his recovery only by his actions – not by his promises, intentions, desires or apologies. What he says is important – but what he actually does, is definitive.
Create physical, emotional, spiritual and sexual boundarieswith him – and have consequences that you apply – without fail – whenever those boundaries are breached.
Stay connected with others about how you are doing and don’t isolate – but be cautious who you tell about his porn compulsion; only choose a few trustworthy friends or relations. Do not talk to everyone, including your children, when you are angry, in a rage, frustrated – or to retaliate – you are very likely to regret it later.
If you think an age-appropriate disclosure is beneficial for the children, work on a script together; and allow the person with the porn compulsion to deliver it. It is their responsibility to hold themselves accountable for their actions.
Take really good care of yourself. Treat yourself kindly and compassionately. Eat three healthy meals a day; sleep seven to eight hours; exercise regularly; take up yoga, Tai Chi and meditation. There are a wealth of Apps and YouTube videos out there – Calm, HeadSpace and Insight Timer are popular meditation Apps. Spend time with friends and family; take up new interests and hobbies – seek to relax and allow joy into your life.
Porn blocking software administration. If you are open to it, you may be asked to be the security administrator for the porn blocking software that will prevent porn from being seen on his devices and the family computer. Consider carefully whether this would cause you more distress – or whether you wish to support him by ensuring that the security blocking software is in place.
Consider seeing your own therapist – sometimes porn and deceit can be felt as profoundly as a relationship betrayal. It takes time and help to get through the trauma.
Some partners feel shame, and some question whether they are the cause of the porn compulsion. Some partners are confused and devastated by all the lies and deceit. They don’t know what is real anymore. Talking to a supportive therapist can help you through this.
For many individuals, therapy is a rather intense and personal topic, and it could have taken them a lot of courage to finally seek the help that they need. Keeping this in mind, it is exceptionally crucial that one finds the right therapist, for there’s a pre-existing implicit clinical belief that the level of treatment effectiveness is greatly dependent on the therapist-client fit. Of course, every client would love to be able to – ideally – find that one therapist whom they can fully open up to from the very beginning, but in reality, that may not be the case. At times, it is necessary to assess your relationship with your therapist and evaluate if there’s the good rapport you need for your sessions to be a success. Ultimately, it boils down to whether you feel a steady, reliable and safe connection with the therapist, and whether you are making the progress you hope for.
To give you some background, studies over the years have shown that the more similar the therapist and the client, the higher the rate of recovery. As an example, an assessment instrument entitled the “Structural Profile Inventory(SPI)”, which measures seven “independent yet interactive” variables (behaviours, affects, sensory imagery, cognition, interpersonal, drugs/biological factors or BASIC-ID), showed that client-therapist similarity on the SPI predicted a better psychotherapy outcome for the client as measured by differences pre- and post-treatment on the Brief Symptom Inventory. Moreover, the demographic similarity between therapist and client facilitates positive perceptions of the relationship in the beginning stages of treatment, enhances commitment to remaining in treatment, and at times can accelerate the amount of improvement experienced by clients. More precisely, it can be said that age, ethnicity, and gender similarity have been associated with positive client perceptions of the treatment relationship. With gender and cultural similarities appearing the most strongly preferred among clients, these domains generally enhance clients’ perceptions of their therapists’ level of understanding and empathy, and as a result, sessions are judged to be more advantageous and worthwhile. However, besides these, there are also other means to assess your “fit” with your therapist, and we’re here to discuss just that.
First and foremost, consider if you are seeking help in the right place. Does the therapist you are looking at specialise in the area you are seeking help for? Before we can even touch on the topic of interpersonal therapist-client fit, it is important for you to take the time to do some research on various therapists’ profiles – in other words, to sift through and read up on their respective areas of expertise. Typically, therapists would have their area(s) of specialisation up on their online profile directories. It would be clearly indicated if they specialise in areas such as substance abuse, family therapy, or even anger management. It goes without saying that, for example, it would be inappropriate to consult a psychologist who specialises in child psychology when you’re clearly looking for someone who can help you with your substance-use addiction. With that said, it is to no one’s benefit for you to rush into therapy blindly.
Once you have chosen the potential therapist that you are most likely to want to have see you through your road to recovery, another essential question you should ask yourself is whether you are comfortable with their suggested mode of therapy. During consultations, you will have the opportunity to enquire about their recommended techniques or treatment methods that will be explored during your subsequent sessions. If you are uncomfortable with any particular process, giving honest feedback and exploring other methods is always an option. However, at any point, you also have the right to seek other therapists who may be able to help you in other ways that don’t put you in a tight spot. After all, therapy is all about having a safe and comfortable space for you to sort out your difficulties.
When assessing your interpersonal connection with your therapist, make sure to trust your gut. This way, you’ll also be able to track your progress better and to seek alternative help if required. Some questions you can ask yourself are:
Am I satisfied with the current balance of talking and listening with my therapist?
Is my overall therapy experience safe, warm, and validating?
Am I fully assured that I’m in a non-judgemental space where I can be fully honest?
How much has the therapist helped me to gain greater insight into my own behaviour and thoughts so far?
Am I becoming more capable of coping (independently) with stressful or triggering situations over time?
Am I noticing more positive changes in myself, as compared to when I first started therapy?
As mentioned, a major deciding factor should also be on whether you find yourself noticing positive changes in your thought cycles and behaviour after a couple of sessions. At the end of the day, therapy should be about working towards achieving your desired outcome, and should definitely not be limited to weekly venting sessions. Although venting and letting out hard feelings can provide temporary relief, it fosters a client’s dependence on the therapist over time and further reinforces the client’s problems. Therapy should instead help you to feel more confident that you’ve developed the relevant skill sets in order to cope with whatever emotional challenges that brought you to seek therapy in the first place.
Naturally, there’s no guarantee that we will find chemistry with the first therapist we meet. The chemistry between people varies, and sometimes it’s just not possible for us to force it. Thus, it is important to remember that a lack of fit between therapist and client is no one’s fault. However, remember that the ball is in our court, and it is within our control to start looking in the right place for the sake of our own well-being.
1 Herman, S.M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. Journal of Psychotherapy Practice and Research, 1998 Winter; 7(1): 56-64.
2 Luborksky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two Helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480-491.
3 Jones, E. E., (1978). Effects of race on psychotherapy process and outcome: An exploratory investigation. Psychotherapy: Theory, Research and Practice, 15, 226-236.
4 Blase, J. J. (1979). A study of the effects of sec of the client and sex of the therapist on clients’ satisfaction with psychotherapy. Dissertation Abstracts International, 39, 6107B-6108B.
Beutler, L.E., Clarkin, J., Crago, M. and Bergan, J., 1991. Client-therapist matching. Pergamon general psychology series, 162, pp.699-716. (Accessed 30/08/2020)
Ever since people first crushed and fermented grapes, the dark hand of alcoholism has been present. When the first games of chance and competition were born – so too was the addiction to gambling.
We can well imagine that abusing cannabis came, even as it was used for medicinal and religious purposes in the 3rd millennium BC.
And breathing in the toxic smoke from burning tobacco was a daily human habit, well before Christopher Columbus landed in the Americas in 1492 and brought it back to Europe.
But now, in our digital age, technology has accelerated our addictions.
And the stress and isolation brought to us by COVID-19 have pushed many to addictions they never thought they had.
Alcohol and cigarettes can be delivered to our doors from digital orders placed on mobile phones. The Dark Web and chemistry have conspired to create hazardous new psychoactive substances that pose as cannabis, available with a few keystrokes on a laptop. An Internet poker or roulette game can be found 24 hours a day, every day of the year. The Internet has sped us down the path of over-shopping, over-eating, and over-playing competitive games.
Ever adaptable and flexible, the Internet has even created new addictions – such as Internet pornography and anonymous sex “dating”.
If we are unlucky enough to fall down these digital “rabbit holes”, what are the results? Alice’s Wonderland? Or: failing health and finances; anxiety; depression; isolation, fractious and failing relationships, lost schooling and jobs; self-harm; and suicidal thoughts. “Jails, institutions and death” – as Alcoholics Anonymous warn us. A life without meaning, purpose or dignity.
But just as addictions have been accelerated by technology and new ones invented, technology has also enabled us to make recovery more convenient, available, cheaper, effective, and timely.
The longest journey for people suffering from addictions has been from the “bottle” to the therapy room. Any number of “barriers” stood in the way. Not enough time, not enough money, not enough knowledge of which therapist to see or what recovery involves.
But the biggest barrier of all to entering recovery was shame.
Now, therapy can be done on the Internet: information about therapists can be Googled; prices compared; social service agencies offering low-cost therapy or even free therapy can be found, and rich information and video testimonies on the recovery journey can be reviewed.
Best of all, Zoom therapy can be conducted with a therapist “once removed” from the personal space of the client by computer screens – and in the comfort of the client’s own living room or bedroom. Clients could even maintain much of their anonymity. In this safe space, shame may deign to take a back seat.
With digital recovery free from barriers, even if the sufferer is still reluctant to seek help, they may be more inclined to reflect on why they remain reluctant to get and receive help. If they do start to reflect honestly – they have started their first step on their recovery journey.
But more can be done with digital recovery.
I would submit that the next significant step in using the Internet to accelerate recovery is to bring the therapist to the clients where they are – on the sites that feed their addictions and perpetuate their suffering.
A therapist could join as a “player” in Animal Crossing, Fornite, a poker or roulette game. They can then engage suffering players in unthreatening and therapeutic conversations. Perhaps PornHub will produce an avatar “ambassador” – a therapist who guides users through a porn compulsiveness assessment? Perhaps the GrabEats avatar therapist will help customers with alcohol and calorie counts, consumption and portion control, alcohol use and dietary information – and motivational conversations to help customers build their resolve.
Engaging suffering people in their digital space opens a whole new avenue for the helping professional to guide someone towards a path of meaning and purpose.
Therapists may wish to think “Digital” – and harness the power of technology to enrich people’s lives – even if technology can also impoverish them.