INTERNATIONAL JOURNAL OF PSYCHOTHERAPHY, VOL. 5, NO.

3, 2000

Diagnosis as care

241

diagnosis as politics

ANDREAS WEHOWSKY
Erdlicht Institut, Hakenweg 17, 26349 Jaderberg, Germany

Abstract This paper discusses the nature of diagnosis as a quest for truth and its application in
two different contexts, namely, psychotherapeutic relationships and non-psychotherapeutic interpersonal con icts. Using Ken Wilbers four quadrant approach to truth, the validity claims of four truth
dimensions subjective and objective as well as individual and collective dimensions are discussed
rst in regard to the psychotherapeutic relationship. Different modes of the therapeutic relationship are
described, based on the work of Martha Stark and Petruska Clarkson. The article shows how truth
is understood very differently in these various modes, thus con rming and elaborating on Wilbers
claims. While the overall purpose of diagnosis in a psychotherapeutic context is care, its painful
purpose within other relationships is usually to disqualify an opponent. In the second part of the
article, two fallacies of truth and some political functions of a publicly suggested diagnosis are
described. Diagnosis can even be used to disqualify an opponent for methods of con ict resolution such
as mediation, as will be discussed in reference to an example. Instead of compromising the various
dimensions of truth by a misplaced diagnosis within a political context, the article supports means of
con ict resolution as forms of social intelligence.

Part one: diagnosis as care

Diagnosis and the pluralistic approaches to truth
To ful l the etymological obligation rst: diagnosis means to know through distinctions.
Thus, diagnosis is the epistemological science of nding or constructing truth by
distinguishing phenomena according to various categories and dimensions.
Psychotherapeutic and psychiatric diagnosis has its own history. Today, major
classi cation systems like the `Diagnostic and Statistical Manual of Mental Disorders
(DSM) of the American Psychiatric Association (APA) and the `International Classi cation
of Diseases, Injuries and Cause of Death (ICD) which has been adopted by the World
Health Organization (WHO) intend to be internationally valid standards for diagnosis.
Therefore the ICD-10 has been developed in six different languages in parallel, rather than
merely being translated from English into other of the world s major languages.
Everybody knows that these standards are not only intensely discussed, but also revised
and modi ed by new research and paradigms and the development of different models for
diagnosis. One of the key interests of DSM and ICD is to provide an operational diagnosis
based on symptomatic criteria and the categorial description of processes of disease. A key
criticism of these attempts aims at their neopositivistic orientation in which the observable
data of behavior are overemphasised in relation to data of subjective experience, a tendency
to objectify the client. Another criticism discusses the de cits of etiological models which
have always been highlighted especially in psychoanalysis. On the other hand, purely
descriptive criteria of diagnosis help to give an empirical and operational orientation which
ISSN 1356 9082 (print) ISSN 1469-8498 (online)/00/030241 15
DOI: 10. 1080/13569080020012499

2000 European Association for Psychotherapy

242

ANDREAS WEHOWSKY

has been largely missing in psychoanalysis. Yet without balance they can lead to a reductionistic tendency to categorise behavior at its surface only. Kernberg (1998) advocates a
combination of surface and depth. He relates depth to structural criteria of personality
organisation. Observable behaviors at the surface can have completely different functions
according to the different frames of organisation their internal context so to speak. Phenomena at the surface could not determine diagnosis alone, yet they are meaningful if they are
related to structure. For the purpose of classifying not only symptoms but also personality,
scientists today do not only use categorial but also dimensional or axial approaches. Those
dimensions could include the subjective experience of the client s suffering, his relationships,
con icts, structure and developmental history.
The intention of this article is not to go more deeply into a discussion of diagnostic
classi cation systems. Instead, I would like to emphasise the complexity of the issue in
general terms and to support the efforts to integrate this complexity into a diagnostic
awareness which overcomes any forms of reductionism. As the discussion above already
shows, the categorisation of observable behavior and the linguistic construction of experience
and its underlying patterns need to be balanced rather than reduced to either side. One of the
clearest minds today in pointing out gross and subtle reductionisms in science and religion
is Ken Wilber. As diagnosis is related to a search for truth, I will summarize how Wilber
approaches the quest for truth.
Ken Wilbers approach
Ken Wilber distinguishes four faces of truth or validity claims, based on his four quadrants
approach to knowledge. These four validity claims are called objective or propositional truth,
interobjective functional t, subjective truthfulness and intersubjective justness.
Objective truth refers to empirical science in which propositional statements correspond
to observable facts, where `the map matches the territory .
Interobjective functional t refers to the intra-systemic meshings (which are adduced in
explanations) within empirical systemic science whose objects are observable behaviors
of systems or networks, like social systems, whose parts and processes intermesh in
functional t or dysfunction.
Subjective truthfulness refers to the sincerity and trustworthiness of subjective reports of
interior states and experiences. The question is not whether the map matches the
territory but whether the mapmaker can be trusted. The hermeneutic science of depth
psychology with its acts of interpretations is a good example, as in the distinctions
between authentic or defensive statements as an evaluation of trustworthiness.
Intersubjective justness refers to the rightness, goodness and fairness of mutual understanding and dialogue, the quality of the intersubjective space of our culturally evolving
beliefs, worldviews, paradigms and meanings.
Ken Wilber s approach is not only based on the four quadrants but also on nine major
levels or waves of development. The four validity claims of the four quadrants operate
through all these levels which are nested levels of reality between matter and spirit (their
ontology) as well as levels of knowing these levels (their epistomology). As the latter, they
represent waves of unfolding consciousness from the pre-conventional or pre-symbolic modes
of knowing, such as the sensorimotoric mode of the infant, up to post-post-conventional
modes of non-dual presence. Wilber also differentiates between three strands of knowledge
injunction, apprehension and con rmation which are essential to science itself and which
operate through all levels in each of the four quadrants. Yet for the purpose of my article, it
is not necessary to explain these complexities in more detail.

DIAGNOSIS AS CARE

243

In the psychotherapeutic discourse, similar distinctions to Wilber s are being made.

Pieringer & Fazekas (1996) introduced four epistemological categories of self-experience
which they call phenomenological, dialectic, empirical-analytical and hermeneutic selfknowledge. Botella (1998) talks about two alternative discourses of objectivism and constructivism. Slunecko (1999) distinguishes between two logical types of reality which he calls
`nomothetic and `autopoietic . He asserts that truth cannot be reduced to an assumed correct
description of the world but is constituted by an `irreducable plurality of approaches.
Wilkinson (1999) forwards scienti c pluralism as `the only possible basis for a scienti c
psychotherapy . In a discussion of the diversity of science he differentiates between the
positivistic and hermeneutic conceptions of science and their different positions on the
question of causality which he discusses at length in his article on `phenomenological
causality . These are just a few examples from the eld of psychotherapy which show how
different epistemologies are re ected in the building of a meta-paradigmatic theory which
offers a necessarily pluralistic approach to truth. For the purposes of my paper, I choose to
build on Wilber s distinctions with which I am most familiar.
Diagnosis between observation and participation
In psychotherapeutic diagnosis, Wilber s four faces of truth and their related epistemologies
are interwoven. The observation of the client s visible behavior and his medical examinations
corresponds to the stance of objective truth. Attending to and interpreting the clients
subjective statements, as well as the introspective detection of the therapist s own states, is
guided by the principle of subjective truthfulness. Consideration of the client s past and
present embeddedness in social systems as well as the therapeutic relationship itself as a social
system explores issues of functional and dysfunctional processes and their effects, and hence,
interobjective functional t. The quality of dialogue, which involves on the side of the
therapist the overall interpretative and instructive reference to the theory and practice of his
psychotherapeutic training, and on both the therapist s and clients side the various belief
systems which are related to collective cultural norms and ethics, all relate to the principle of
intersubjective justness.
Thus, a therapist is in fact confronted with all these four faces of truth during the course
of a therapy. Here are some examples for the intermingling of objective, subjective, intersubjective and interobjective faces of truth.
As an observer, the therapist maps out a descriptive phenomenology of subjective internal
as well as objective external or behavioral events. He then tries to make sense of these data
in terms of hypotheses and interpretations. Although the phenomenological description of the
behavior might be fairly objective, perhaps even based on video documentation and research,
the acts of interpretation are hermeneutics, subjective and intersubjective constructions often
misunderstood as being objective or empirical-analytical. This misunderstanding shows itself
in the language of `discovering contents of the unconscious as if these were given things and
facts, treasures waiting to be brought to light. I would call this in a paradoxical way `objective
hermeneutics, a science of interpretive constructions of meaning pretending to be similar to
a natural science whose referents are sensory and measurable. The topographic issue of
rendering conscious what had once been unconscious, and the genetic issue of uncovering
and reconstructing the past, are examples which show that even the attempts of objectivity
can never be the same in this context as objective measurements in natural science. They can
only be hermeneutic approaches at plausibly discovering and constructing the formative
forces behind the visible behavior of the client. In short, the therapist as an observer utilises
both objective and hermeneutic knowledge.
As a participant in the relationship with the client the therapist is always co-creating a shared

244

ANDREAS WEHOWSKY

reality as a subjective agent at the same time that he tries to observe and assess that reality
as objectively as possible. How much a therapist consciously utilises his own subjective
experience depends not the least on her background in and use of the intersubjective
paradigms and discourse established within the psychotherapeutic eld of which the therapist
is a participant due to his training, ongoing education and possibly his own contributions. Yet
never can a therapist get around the fact that he is constantly both observer and participant
by de nition.
In many cases, the therapist himself, not only the client, is also a participant in social systems
relevant for the execution of the therapy. This is especially obvious in cases where the
therapist has to provide insurance companies with reports and diagnoses in order to receive
nancial support or complete payment for the therapy. In such a case, the therapist will have
to comply with the rules of the law which recognises particular therapies as scienti c and
therefore worthy of payment and the rules of the insurance companies to get the client being
recognised as entitled for payment. In Germany, insurance companies would not pay solely
for growth needs of clients. The humanistic stance of utilising therapy as a means to personal
growth and realisation is not supported. The client, who is called patient, has to be ill. This
may affect the therapist in several ways. First, he may be motivated to present the patient as
worse off in his report so that the insurance company will pay. Secondly, his perception of
the client may be affected by the insurance companys rules and required system of diagnosis.
He may shift his awareness more on the pathological and problematic side of the client, and
less on the clients resources and solutions. Thirdly, over time, the therapist s theoretical
matrix may get corroded by adjusting to standards which do not represent the full spectrum
of intersubjective discourse of psychotherapy but only the accepted methods of which
insurance companies think that they t their economic interests best.
In short, the therapist navigates and drifts constantly between participation and observation, in relation to subjective experiences of the client and his own, in relation to intersubjective
mutual in uence between the client and himself as well as their cultural embeddedness, in
relation to objective or factual events, medical data and behaviors and nally their interobjective
nesting within larger social systems.
Psychotherapeutic mainstreams focus differently on truth
Not only is each therapist involved in this complex net of diagnostic validities, but also the
main streams of psychotherapy themselves can partly be distinguished by their different focus
on the four faces of truth and their style of strategy. The following examples are presented
in a reductive fashion for the sake of clarity within the map, not as claims of fair representations of the territory.
Behavioral therapies focus mainly on behavior modi cation of the individual. For them,
internal con icts of intentionality and motivation as a possible unconscious structural
background of pathological behavior do not matter that much as interventions aim directly
at raising awareness of the behavior itself as the foundation of its modi cation. The truth
domain is the objective behavior of the client.
Systemic therapies focus on symptoms and behaviors in the context of social systems. The
individual is perceived mainly as part of a greater whole or web. Realigning communication
between the members of those systems according to their roles and overall ethical values is
a primary means of healing. The truth domain is interobjective functional t.
Psychoanalysis and depth psychology focus on internal structures, dynamics and relationships
in order to raise the consciousness of the individual to a higher degree of coherence. The
changes of behavior are more an indirect effect of this strategy than a directly approached
goal. The truth domains are the subjective and intersubjective insights and experiences. In

DIAGNOSIS AS CARE

245

the following, I will choose psychoanalysis for a closer look at further interesting differentiations.
Truth in the different modes of therapeutic relationships
The American psychiatrist and psychoanalyst Dr Martha Stark (1999) distinguishes three
modes of therapeutic action which correspond to three models of the therapist client
relationship. A closer look at these models will help us to deepen our understanding of the
different truth perspectives.
In model 1, which represents classical psychoanalysis, the therapist is the expert who de nes
the truth. He claims to be the objective observer who focuses on the internal dynamics and
structural con icts of the client and offers himself as a neutral object. The primary therapeutic agent and perspective is interpretation and insight. The understanding of the client is
based on the drive con ict model of early psychoanalysis, and the libido is seen as rst of all
pleasure seeking, not object seeking. Stark calls this a `one-person psychology that emphasizes enhancement of knowledge as the path towards resolution of structural con icts.
In model 2, which represents the corrective-provision perspective of self-psychology and
those object relations theories that emphasise the internal `absence of good, the client is the
authority of truth or truthfulness. The therapist offers himself as an empathic self-object for
the client. He focuses on the client s affective experience, supporting what is consciousnessnear rather than interpreting what is consciousness-distant or unconscious. The provision of
experience and its empathic validation is the primary therapeutic agent. Libido is seen as
object seeking, yet the focus is not on id needs but on ego needs. The therapist s understanding of the client is based on the de ciency compensation model, the conscious grieving of
losses is supposed to help building ego structures which have been insuf ciently present or
absent before. This is a `one-and-a-half-person psychology , as A. Morrison originally called
it, with the therapist s unidirectional in uence of providing a corrective experience for the
client. It can also be described as an I It relationship with a one-way giving for someone who
takes.
In model 3, which represents the relational perspective of contemporary psychoanalysis and
those object relations theories that emphasise the internal `presence of bad , truth and reality
are not merely discovered but co-created or intersubjectively constructed by two participants engaged in a relationship. Here the therapist offers herself as an authentic subject.
Whereas in model 2 the therapist decenters from her own experience in order to empathically
validate the clients experience, in model 3 the therapist stays very much centered in her own
experience for the purpose of an even deeper mutual in uence. The primary therapeutic
agent is the engagement in the relationship to develop the capacity for healthy, authentic
relatedness. The therapist s understanding of the client is not just based on the absence of the
good, but considers the presence of the bad in the form of the architecture of negative
introjects, lters through which the world of the client is perceived and shaped. The
therapeutic relationship is seen as a force eld through which the therapist is drawn and
induced into ways of participating that are speci cally determined by the client s early history.
Yet the therapist needs to be observer enough not to commit a failure of containment.
Between the twin dangers of getting lost in the old trauma relational con ict or getting
lost in the avoidance of authenticity relational de cit the therapist needs to clarify together
with the client the differences between subjective and objective transference and countertransference. Subjectivity here refers to in uences from the past, objectivity to the reality of
the present. This is a two-person psychology with bi-directional in uence and an I Thou
relationship.
This is how Stark (1999) summarizes the relation to truth in model 3:

246

ANDREAS WEHOWSKY

No longer is the therapist thought to have the inside track on the truth, as happens
in model 1. No longer is the patient thought to have the inside track on the truth,
as happens in model 2. Rather, the truth is thought to be something that is created
in the transitional space between patient and therapist. Like a transitional object, it
is part found and part created; it is part real and part imagined, as Winnicott
observed, reality is both objectivity perceived and subjectivity conceived. (p. 219)

This presentation of Stark s three models can easily be related to Wilber s perspectives on
truth.
Model 1 favors objectivity, although, as I have pointed out above, it is more precisely an
attempt at objective hermeneutics if it comes to topography. And yet, Freud s belief in the
catharsis of reliving the truth of past experiences, the genetic issue, highlights once more how
insight into some kind of objective reality and truth is related to healing within this model.
Pierre Janet, who preferred to rewrite truth and to change memory, appears to be much more
of a constructivist.
Model 2 shifts the healing paradigm away from objective truth to subjective truthfulness.
Close and empathic attention to the clients narrative is considered to release from the
bondage of old de cits and holes by establishing new structures from positive internalisations.
To meet subjective experience, not necessarily objective truth, is the key to evolution.
Model 3 once again shifts the healing paradigm into an even more complex territory of
intersubjective co-determination, hopefully heading in the direction of fairness, goodness and
justness. Beside the grounding of facing and affectively tolerating objective realities and
territories, the mutual construction of narratives and relationships which are coherent and
resilient enough to bridge the memories of past traumas into a more promising land of human
relationships comes to the fore.
If we put the three models into historical perspective, we see a general shift in the etiology
of psychopathology from nature to nurture, from the drive con ict model to experiences
within relationships, as Martha Stark points out. She quotes Jessica Benjamin, who put it all
in a nutshell by saying: `where objects were, subjects must be. It is a move away from a
mechanical worldview of observers looking at things to a worldview of participants. And if
these participants do not want to drown in their mutual enactments, they need to develop
their internal and external witness to an even higher degree of constancy and effective
exibility of perspectives.
As Stark is describing three different modes of therapeutic action enhancement of
knowledge, provision of experience, and engagement in relationship between which a
therapist should be able to shift, the psychotherapist Petruska Clarkson (1996) offers a
framework of ve relationship modalities for different traditions or approaches to psychotherapy. These modalities represent states in psychotherapy that often overlap so that in
principle all ve modes of relating might occur within one therapeutic relationship. The ve
relationships are:
the
the
the
the
the

working alliance;
transferential/countertransferential relationship;
reparative/developmentally needed relationship;
person-to-person relationship;
transpersonal relationship;

Even without going into deeper explanations of these ve modalities, their names alone are
suggestive of some correspondences to Stark s models. The transference/countertransference
relationship of unconscious wishes and fears can be related to Stark s mode of enhancement
of knowledge, since the experience distant unconsciousness is in principle accessible via

DIAGNOSIS AS CARE

247

insight. The developmentally needed or reparative relationship very obviously relates to the
mode of provision of experience. And the person-to-person relationship corresponds to the
mode of engagement in relationship.
Beyond these, Clarkson (1996) introduces two more modalities. The working alliance
considers the contracts, agreements, goals and general bond between therapist and client
which create the containment for situations in which processes get rough and might otherwise
threaten the existence of the relationship. The transpersonal relationship introduces a
transcendent dimension of a presence and encounter beyond words, problems and roles, a
place of timeless stillness, openness and the emergence of profound qualities.
The following quotation from Clarkson (1996) shows the closeness of her concepts to
Stark s, although strangely enough according to the bibliographies of both books, they do
not acknowledge each other at the time of their writing:
The ve relationships are differently emphasised in different approaches, but they
appear to form a potentially coherent whole. The working alliance seems to have
more to do with the scienti c and academic tradition, the transference/countertransference relationship with the Freudian and Kleinian psychoanalytic orientation; the
developmentally needed or reparative relationship with the innate evolutionary and
healing forces of life itself or Physis, ; the person-to-person relationship with the
existential/humanistic tradition; and the transpersonal comes from religious, oriental
and occidental spiritual traditions. (pp. xiii, xiv)

Diagnosis between symmetry and asymmetry

Looking at the therapeutic relationship between therapist and client in terms of roles de nes
this relationship as an asymmetric one. The function of diagnosis in this context is based on
care of the therapist for the client, as psychotherapy itself can be de ned as care of the soul.
Diagnosis is an ongoing reference to truth in the service of the client s healing and/or better
coping. Professionally, diagnosis is considered as an activity of the therapist, not of the client.
The purpose of care is the foundation of an ethics of diagnosis which, for example, should
protect the therapist from the danger of a counter-transferential diagnosis which would let the
client down and derange care into blinded admiration or attack. Counter-transferential
diagnosis takes place when counter-transferential participation draws the therapist so strongly
into either an idealising or a devaluing position that the observer function of the therapist
collapses. When counter-transferential participation becomes the basis for a diagnosis, we see
the paradox that a therapist who is actually in the state of having lost his asymmetric role
responsibilities nevertheless uses his asymmetric role as a seemingly objective therapist to
misuse diagnosis itself, independently of the question of whether this maneuver is consciously
intended or not.
Diagnosis is supposed to be as objective as possible, based on the role responsibilities of the
therapist within an asymmetric relationship. Diagnosis is supposed to derive from a professional observer with expert knowledge. However, the perspective of different modalities of
relating within the therapeutic relationship has shown that the role asymmetry nevertheless
contains human symmetries based on mutual participation. To the degree of participation,
the therapist is an involved subject. The seemingly clear-cut asymmetric role relationship is
actually generating continual tension between observation and participation, asymmetry and
symmetry, objectivity and subjectivity, and interobjectivity and intersubjectivity. All this
within a relationship of subjects who treat each other as objects and self-objects at times. And
yet, diagnosis is monological, not part of the therapeutic dialogue. It is subject to intersubjective dialogues of intervision and supervision, embedded within the professional discourses of

248

ANDREAS WEHOWSKY

psychotherapy. These dialogues are intended to support and check the therapist who is
unavoidably in a dual relation to the client as professional expert and human being.
If diagnosis is understood in the context of care, these considerations support a heightened
sense of ethical responsibility. The principle of participation suggests that diagnosis emerges
from an interactive and thereby formative process. The therapist becomes part of what she
diagnoses by way of interacting. As an emergent, the diagnosis itself is recursively feeding
back into the process as a hidden agent. Diagnosis is a basis for interventions and prognosis,
a guideline for treatment and the anticipatory knowledge of what might emerge in the future.
Psychotherapeutic research has clearly shown that expectations are one of the factors of
ef cacy. Probably this is not only true for the expectations of clients, but also the anticipations of therapists. Thus diagnosis itself has formative in uences.
Another aspect of ethical consideration is the that diagnosis often focuses mainly on
pathology and less on resources, at least if a decent structural perspective is missing a
perspective that considers levels of functioning and integration, not only symptoms, problems
and suffering. Without structural analysis, the danger is more eminent to over- or underpathologise. To underpathologise means to underestimate a persons handicaps and to miss
a grounded understanding of the persons suffering. Therapy might become illusory sur ng.
Yet to overpathologise may be the more prominent trap. A pathology oriented diagnosis in
itself tends to narrow down awareness and perception. The caricature examples are medical
diagnoses which reduce persons to their diseased organ: `the stomach in room 5 , the
depersonalisation turn. Humanistic psychology has traditionally taken great care to differentiate between pathologies and the person. Never was a person to be reduced and identi ed
with her pathology. The pathology is seen as something we have, not what we are. Yet a
diagnosis of who we are is usually underrepresented in our manuals. This is the disease of our
profession. It may not re ect a lack of compassion, but a lack of consciousness and love.
Goldberg (1998) is commenting on this issue in many of his articles:
In short, current analytic theories emphasize loss and psychopathology in how
people live their lives. They pay relatively little attention to the admirable and
constructive mainstreams of human development the capacity for empathy,
identi cation with others, affection, caring, compassion and altruism that foster
moral responsibility. (p. 224)
Part two: diagnosis as politics
Two fallacies of truth
Parallel to the depersonalised `stomach in room 5 , in psychotherapy too the distinction
between person and pathology gets sometimes blurred. This occurs in language as soon as
pathological tendencies are spoken of as persons. If, for example, narcissistic tendencies are
represented in the personalised form of talking about `the narcissist. Talking this way creates
an ideal type which is supposed to be known as ctitious, as has been the mythological gure
of archetypal Narcissus. It is a construct of map, not of territory or a real person. It is talk
which personalises a pathology and depersonalises the person, even without probably intending to depersonalise a real human being. But language is suggestive and formative. The
construct of `the narcissist is what I would call a person/pathology fallacy in which pathology
gets personalised and the person reduced to her pathology. In territory, this would only be
possible if there were a narcissistic structure so severe that it could dominate a person 100 per
cent. It would actually collapse and dissolve the person into mere pathology. There is no
territory which would t this map. But establishing such an ideal map, even if for convenient
language reasons, rst collapses the distinction between person and pathology, usually upheld

DIAGNOSIS AS CARE

249

by structural analysis, into the person/pathology fallacy. Secondly, it may also lead to a
map/territory fallacy in which the projected map gets confused with the reality of the territory.
A language which exchanges the name for a pathology, as in our case `narcissism , with a
personalised form like `the narcissist , is well on the way to commit the map/territory fallacy.
At this stage, the care for the person, the core of the territory, gets linguistically abandoned.
The real person falls prey of the linguistic turn next. The ctitious construct of the map now
reappears as a real player with references to a real territory. The territory is made to t the
map instead of keeping in mind that the map, as a relative construction of truth, is not the
territory. If the map of personality structure is taken as a personalised absolute (as in `the
narcissist ) and has no relative meaning anymore (as in `narcissism ), hope for the person
dissolves. The therapeutic prognosis dies.
Of course, a pathological structure can dominate a person to such a degree that psychotherapeutic attempts do not seem to be bene cial anymore. Kernberg talks about the
syndrome of maling narcissism in which the pathological grandiose self is in ltrated by severe
aggressions and antisocial behavior. If nally the stage of an antisocial personality is reached,
there is no prognosis for psychotherapeutic treatment. Yet in less severe cases, the diagnosis
of a narcissistic personality might well dissolve during treatment, according to Kernberg. This
shows that structural analysis is important, in order to avoid the confusion of identifying a
person with a pathology. To my knowledge, the distinction between person and personality
is well maintained by Kernberg.

Diagnosis as legitimisation and attack

In the context of the asymmetrical psychotherapeutic role relationship, diagnosis performs a
necessary function, the purpose of which is care. Outside this role relationship, a psychotherapeutic diagnosis is usually misplaced and ful lls a political function. A misplaced diagnosis
may occur within symmetric or asymmetric hierarchical relationships of participants when
there is no role of a professional observer who is supposed to be objective and impartial
enough and suf ciently distant from the system. When this condition is absent, diagnosis
might become an instrument of power to disqualify an opponent. Gottman (1995) (professor
of psychology, director of the Seattle Marital and Family Institute as well as author of several
books on families and marriages) talks about `character attacks to characterise criticisms
which do not address behavior but someones personality. Goleman (1996), well known
author of books on emotional intelligence, calls this a `character assassination. To commit
such acts is not a treatment for healing but a treatment of wounding. Care within symmetric
relationships of mutual participation requires to avoid character attacks, which Gottman calls
the rst horsemen of apocalypse within relationships, in favor of complaints on behaviors.
Within asymmetric hierarchical relationships and contexts in which some persons and
groups have more power than others, the misuse of psychotherapeutic diagnosis may be part
of exerting political in uence, usually against others in the service of repression, exclusion
and even extinction. As diagnosis is a legitimising basis for actions or omissions, it is usually
at the root of mobbing up to the extreme form of political pogroms. Wilhelm Reich called this
emotional plague. Unfortunately, the misuse of diagnosis outside the protecting frame of the
psychotherapeutic relationship has been a well-known maneuver within the history of
psychotherapy itself. The doctor and psychotherapist. Inge Rieber-Hunscha (1998) found
clear words in a presentation about Otto Rank:
The misuse of professional competence for one s own bene t by pathologizing a
person with the goal of her elimination to put through ones own interests is
comparable to a `character murder (P. Gay) which has been applied by analysts not

250

ANDREAS WEHOWSKY

only with Rank, but also with other troublesome analysts (especially with Sandor
Ferenczi, CarlGustav Jung, Wilhelm Reich).1
In direct contrast to a diagnosis made in a psychotherapeutic context, which is anything but
for the public, the politically motivated diagnosis needs to be spread into public to become
effective. Its function is to legitimise political action, it needs to be known.
A key, and sad, component of diagnoses as character assassinations within the history of
psychotherapy is the fact that they are usually committed by people who were in multiple role
relationships with the ones they turn now against. They were therapists and clients, teachers
and students, founders and followers, friends and colleagues in short, not just observers but
participants in the development of manifold social relationships, with a mixture of symmetries
and asymmetries. The con icts that often arise in such relationships did not nd proper
con ict management or resolution, they escalated into emotional blackmail and open warfare. The intergenerational transmission broke down into intergenerational destruction.
Constructive `aggressive playback , as Samuels (1993) called it, escalated beyond control and
broke any containment. Battegay (1996) talks about `reciprocal narcissistic involvement
between leaders and disciples which, if it breaks up negatively, usually leads to mutual
accusatory projections of the bad other vs. the good self.
Under such circumstances, therapeutic knowledge often ceases to be a vehicle for solutions
and becomes twisted into weapons. Diagnosis nally comes along in the coat of objective
monological observation no self-critical words about ones own intersubjectively engaged
participation and contributions to escalating con icts, no interobjective systemic understanding, no sociological re ection of power issues, interests and economies, no subjective
re ection of countertransference, and nally, no dialogue. Diagnosis of the other suggests the
objective correctness of one s own engagement and legitimizes the breakup, the forced
exclusion, the nal ban, the disquali cation of the other by virtue of one s own superior
perspective which reduces truth to one face alone, the seemingly objective judgement of the
other as perverse.
Above all, the possibility to build a triangle with a third party to help modulate the con icts
and to build a wider container in the rst place is literally avoided at all costs. This issue
touches on one of the key problems of psychotherapeutic schools which Heward Wilkinson
(1999), senior editor of the International Journal of Psychotherapy, psychotherapist and trainer,
has thoroughly discussed as the tension between centralism or central leadership and
constitutionality.
The lack of constitutional ground on which to face our radical power issues and
differences, in psychotherapy, leaves a vacuum for power-mongering, and marginalization, paralleling the wider vacuum of our political world as a whole. (p. 117)
One difference between central leadership and constitutionality concerns their relationship to
memory both as personal narrative and collective consciousness of history. On a political
level, the extreme `upsurge of primal power (Wilkinson, 1999, p. 122) 6 might be based on
an induced loss of memory, as for example for previous forms of constitution. On the other
side, it is exactly a function of constitutionality to maintain memory as a basis for continuity
and history. Why is memory so important? Because psychotherapeutic healing itself includes
the healing of memory. Trauma leads to splitting of personality and dissociation, the splitting
of memory structures. Memory is closely related to the coherence of identity.
Without coherence of identity as the basis of memory there can be neither personal
narrative and history, nor any scienti c de nition of knowledge and reality. (p. 122,
emphasis in original)

DIAGNOSIS AS CARE

251

Thus, the healing of memory involves an integration of split-off parts of memory as a

precondition for the construction of a coherent narrative. On a political level, it is the
function of constitutionality to offer a wider and more balanced narrative than centralism
would like to have it. Wilkinson says:
The equivalent of memory in the political domain is constitutionality, mediation,
the basis of continuity, and the possibility of history. (p. 122)
History is constantly being re-written under changing perspectives. Narratives uctuate in the
service of various social and cultural interests. A pathologising narrative, based on centralism
instead of constitution, might legitimise political action not only by a loss of memory but also
by reframing. The reframing into diagnosis by a central force and in a political context is not
to recover memory, but to legitimise a split.
Wilkinson relates mediation with a personal level and constitutionality with the political
level. Yet there could be a combination of both. Constitutionality in principle can include
guidelines for the use of mediation, rules requiring it, and even structures to regulate it in case
of personal and contractual con icts which do not only involve the direct participants who
enact the con ict but which affect a wider community of colleagues and trainees. The
psychotherapeutic schools and professional organisations usually have ethic committees but
none that I am aware of have guidelines or structures for mediation. I think it would be
worthwhile to consider the question if mediation could become part of a psychotherapeutic constitution
in its own right.
Diagnosis and the exclusion of con ict resolution
In a recent article on `Transference, politics, and narcissism , Boadella (1999b) touches
lightly on the issue of mediation. He discusses a scenario where a protagonist is `in an
encounter with narcissistic perversion which necessitates the development of `forms of
resistance to the boundary invasions . He comments:
The narcissist will seek to soften this resistance, by brute force, or when that fails by
manipulative appeals for mediation, to weaken the boundaries that stand against him.
(p. 305, my emphasis)
But who is to say whether an appeal for mediation is `manipulative ? Could this be the
protagonist, especially if he is the same who puts out the diagnosis on his opponent,
interpreting his intentions through the map of pathology, and who declares himself as
healthy, legitimising his actions? Wouldnt the protagonist himself be exhibiting behavior
that, far from ruling out mediation, actually requires mediation here? And wouldnt it be the
task of the mediators to decide about a potential misuse of mediation? What if the appeal for
mediation is coming independently of `the narcissist from third parties, including key
institutional organs of the constitution of a psychotherapeutic school itself?
These questions have implications. Not only is somebody being put down as a narcissist,
but the potential of mediation itself is being put down, and, if the last question is valid, the
constitution gets depotentialised. Furthermore, the appeal for mediation itself is made an
object of suspicion instead of being supported it can be shamed. If the negative reading of
the intention behind an appeal becomes the standard, it might have a future intimidating
effect for anybody. This example of self-righteousness is actually contraproductive to any
attempt at con ict resolution. In a culture in which there is a growing consciousness of the
need for con ict resolution and dialogue, and the promise of these modalities, it is discouraging in its backward direction. But it might forward superior interests of centrality, an
agenda of other priorities.

252

ANDREAS WEHOWSKY

Postmodern philosophy teaches us an important tenet that meaning is contextual. On one

side, the reasons for Boadella s remark and article and the reasons why I choose to write a
critique may be understood as purely within an academic context. Yet there has also been a
trans-academic context which I think has been important for his writing of the article in the
rst place. Do examples of Boadella s article refer to such a context? Yes, some connections
are suggestive. Has such a context been made public? Yes, it was. Has there any linkage been
made between Boadella s description of a pathological disorder and a real person? Yes, in
another publication, in parallel to his article s rst publication, tendencies were suggested.
Would people who know that context possibly make a connection between Boadella s article
and this context, including people involved? Very likely.
What this context was is not the concern of my article. Neither a discussion of Boadella s
presentation of narcissism, nor the validity of his diagnostic hint to a real person in a parallel
publication. Enough to say that there was a context, that I have been a part of it and that I
am responding to Boadella s article with a certain sensitivity and involvement. I dont want
to hide what the reader might guess anyway, sooner or later.
What I am concerned with is the politics inherent in Boadellas article. I regard these as:
(1) The person/pathology fallacy. The extensive use of the noun `the narcissist melts down the
distinction between a pathology and a person. If language doesnt maintain this distinction the ground is laid for the second fallacy.
(2) The map/territory fallacy. Not only merges pathology and person into an ideal construct
of map as in the rst fallacy, but now map and territory start to merge. There is nothing
in the territory which doesnt t the map and theres nothing in the map which allows us
to see more than pathology. Except, except if the narcissists `house of cards, built on
`unreal foundations, has nally collapsed! Then, and only then can a revival of distinctions be hoped for again.
(3) The reduction of truth. This is taking place in two moves:
(a) Of the four validity claims, only two seem to survive: subjective hermeneutics
wearing the coat of objective analysis of behavior and events. This reduction serves
to avoid any participatory, intersubjective and dialogical epistemology as a basis for
con ict resolution in favor of a monological objectifying epistemology as the basis
for character disquali cation.
(b) If a quest for truth is to enter social and political territory beyond the therapeutic
relationship, the instruments for diagnostic truth must likewise expand. A discussion
of interobjective issues role relationships within evolving systems, power issues
concerning decisions on how resources such as training territory, trademarks, and
money will be allocated, rights, the shaping of contracts and so forth would require
a systemic and socio-political viewpoint. If such an interobjective diagnosis is
abandoned in favor of a purely personalising diagnosis, we have reductionism pure
which is neglecting the peculiarities and intricacies of the territory it is referring to.
Ironically, Boadella s view on narcissism beyond the therapeutic relationship itself is
in fact as deeply apolitical in its neglect of any social analysis as the image of St
George vanquishing the dragon.2
(4) The displacement of diagnosis. Boadella s article is only partly based on clinical vignettes.
Its aiming at politics, as its title already declares. Of course, psychotherapeutic diagnosis
has many times throughout history been transferred to socio-psychological discourses,
and rightly so. Organisations and societies have their own psychodynamics, just like
individuals. But nobody can ever step outside of it all, thus, we have four approaches to
truth, not just one of pure objectivity. And then, there is a hot zone of participation which
should disqualify the participants from engaging in diagnosis, and leave it to others

DIAGNOSIS AS CARE

(5)

(6)

(7)

(8)

(9)

253

instead. An individualised diagnosis within a political context that is not a genuine

socio-psychological diagnosis of the whole system, is in its legitimising function more
part of a diseased system rather than it is vehicle for truth. As such, it is part of the
problem, not of the solution. Even if it s offered as care, it still tastes like weapon.
The denial of participatory enactment. It follows Stark s model 1 of classical psychoanalysis
and establishes a dualism of health the protagonist vs. pathology the narcissist. It
simply has no credibility when it involves the history of multiple role relationships, as well
as contracts and issues of a whole psychotherapeutic school.
The denial of subjective truthfulness to the person who is identi ed as narcissist. The denial of
subjective truthfulness functions as the self-legitimising method of disqualifying the
opponent for mediation. `Language is more important than truth: this is the kernel of all
narcissistic propaganda (Boadella, 1999, p. 303). If this is so, and again, if the map gets
completely projected onto territory, there is no partner for dialogue indeed. A dehumanising move. And the listeners are prepared: watch out, the more you feel convinced by
the narcissist, the more you are trapped by propaganda. Sounding convincing becomes
a measure of how poisonous the pathology is.
The refusal of con ict resolution. This is based on a structural analysis that denies
somebody else the competence to participate truthfully in con ict resolution procedures,
led by third parties. Instead, it hands someones fate over to life itself, in which the
protagonist is, needless to say, a key actor. It is a tenet of con ict resolution that the
parties subjective ways of experiencing the situation, which are the basis for their
behavior, need to be made transparent to themselves and to each other. This is more
important than the search for objective truth. The intersubjective struggle to negotiate
subjective constructions of truth, in order to somehow nd a mutual understanding and
solution, is essential in con ict resolution.
The abandonment of structural distinctions. The construct of a personalised pathology
creates an either-or situation. You are a narcissist or you are not. The person who has a
pathology instead of being it has instantaneously evaporated. Accordingly, the structural
diagnosis plays out the extremes. There is no place of health. And this is the very
foundation of all the other political moves described above.
Put it all to sleep by scapegoating. Once the evil is identi ed, everybody can feel relieved.
`Now we know what the problem was, nobody saw it before. But now the evil is excluded
and its voice obscured, sigh once again, and forget the wider face of truth, too dif cult,
too threatening, be silent about it and stay away from it. Stay neutral, dont raise your
voice, by any price, dont get political. I thank the people who have not been like that.

Integral diagnosis as social intelligence

Without diagnosis, without a quest for truth, any intervention or action would be disoriented
and blind. Diagnosis is an ongoing basis for treatment in its attempt to make valid distinctions. The reference to four major truth perspectives has shown that diagnosis has individual
and collective as well as subjective and objective dimensions. These are needed to know
reality in all its complexity. The other concern of my article has been the distinction between
the intention and use of diagnosis as either care or politics. This should not be misunderstood
as a qualitative distinction between therapy and politics. The realm of politics needs a caring
diagnosis of political consciousness as much as people coming for psychotherapeutic treatment. Rather, the distinction is between a caring or damaging use of diagnosis. A key
criterion for distinguishing between care and damage that has emerged in the psychotherapeutic discourse of the last century, is that one must re ect not only on the degree of empathy
and insight that exists, but also on the degree of participatory and mutual involvement that

254

ANDREAS WEHOWSKY

exists, be it in symmetric or asymmetric relationships. This understanding is articulated

differently from psychodynamic, behavioral or systemic perspectives, but the overall consequence is that con icts have a chance to be solved if impartial third parties are engaged to
offer a wider container and fresh perspectives to restore broken dialogs and to transform
blame into curiosity. The experience of learning from past failures encourages me to support
wholeheartedly the new consciousness to install such forms of con ict resolutions as a
possible part of any truly responsible constitutionality. I hope that psychotherapeutic schools
can assimilate and develop leading edge forms of social intelligence and political care within
their communities, to prevent the old regressions of taking refuge in the misuse of diagnosis.

Notes
1.

2.

Translated by the author, A.W. Der Mi brauch beru icher Kompetenz zum eigenen Vorteil mit Hilfe der
Pathologisierung einer Person mit dem Ziel, diese auszuschalten, um eigene Interessen durchzusetzen, ist
vergleichbar einem `Charaktermord (P. Gay) den Analytiker nicht nur bei Rank, sondern auch bei
anderen unbequemen Analytikern angewandt haben (insbesondere bei Sandor Ferenczi, C.G. Jung,
Wilhelm Reich).
Which, again ironically, had a deeply political meaning, as he came to symbolize the ght of the Roman
Church against dissenters, the Celtic Church and the Messianic Bloodline. See Gardner (2000, p. 2).

References
ARBEITSKREIS , O.P.D. (Ed.) (1996). Operationalisierte Psychodynamische Diagnostik. Bern: Hans Huber.
BATTEGAY, R. (1996). Group leaders: charisma and possible changes in religious congregations, political
movements, and psychotherapy schools, International Journal of Psychotherapy, 1, pp. 35 43.
BOADELLA, D. (1998). Welt der Sinne und Sinn der Welt, Energie & Charakter, No. 18, pp. 10 31.
BOADELLA, D. (1999a). Aspects of relationships between colleagues, in: Newsletter 2. Internationales Institut
fur Biosynthese IIBS: Heiden.
BOADELLA, D. (1999b). Transference, politics, and narcissism, International Journal of Psychotherapy, 4, pp.
283 311.
BOTELLA, L. (1998). Clinical psychology, psychotherapy and mental health: contemporary issues and future
dilemmas, International Journal of Psychotherapy, 3, pp. 255 266.
CLARKSON, P. (1996). The therapeutic relationship. Whurr Publishers: London.
GARDNER, L. (2000). Genesis of the grail kings. Element: Shaftesbury.
GOLDBERG, C. (1996). Critical Issues confronting the profession of psychotherapy: now and into the new
millennium, International Journal of Psychotherapy, 1, pp. 23 33.
GOLDBERG, C. (1997). Chautauqua Institution Lecture: the responsibilities of virtue, International Journal of
Psychotherapy, 2, pp. 179 191.
GOLDBERG, C. (1998). The indifference of psychoanalytic practice social and moral responsibility,
International Journal of Psychotherapy, 3, pp. 221 230.
GOLEMAN, D. (1996). Emotional intelligence, Bloomsbury: London.
GOTTMAN, J. (1995). Why marriages succeed or fail. Fireside: New York.
KERNBERG, G.O. (1984). Severe personality disorders. Yale University: London.
KERNBERG, G.O. (1998). Die Bedeutung neuerer psychoanalytischer (und psychodynamischer) Konzepte fur die
(Befunderhebung und) Klassi kation von Personlichkeitssto rungen, in: H. SCH AUENBURG, H.J. FREYBERGER,
M. CIERPKA & P. BUCHHEIM (Eds) OPD in der Praxis. Hans Huber: Gottingen.
PIERINGER, W. & FAZEKAS, C. (1996). Die vier prima ren Erkenntnismethoden als wissenschaftliche Leitlinien
fur die Selbsterfahrung in der Psychotherapieausbildung, Psychotherapie Forum, 4, pp. 229 238.
RIEBER-HUNSCHA, I. (1998). Fruher vernichtet heute vergessen? psychosozial, No. 73, pp. 95 113.
SAMUELS, A. (1993). The political psyche, Routledge: New York & London
SCHAUENBURG, H., FREYBERGER, H.J., CIERPKA, M. & BUCHHEIM, P. (Eds) (1998). OPD in der Praxis, Hans
Huber: Gottingen.
SLUNECKO, J.T. (1999). On harvesting diversities into a dynamic directedness, International Journal of
Psychotherapy, 4, pp. 127 144.
STARK, M. (1999). Modes of therapeutic action, Jason Aronson: Northvale, NJ.
THOMANN, C. (1998). Klarungshilfe: Kon ikte im Beruf. Reinbek: Rowohlt.

DIAGNOSIS AS CARE

255

W ILBER, K. (1995). Sex, ecology, spirituality. Shambhala: Boston & London.

W ILBER, K. (1997). The eye of spirit. Shambhala, Boston.
W ILBER, K. (1998). The marriage of sense and soul. Newleaf: Dublin.
W ILBER, K. (1999). Integral psychology, in: The collected works of Ken Wilber, Vol. Four. Shambhala: Boston.
W ILKINSON, H. (1998). Phenomenological causality: and why we avoid examining the nature of causality in
psychotherapy: a dialogue, International Journal of Psychotherapy, 3, pp. 147 164.
W ILKINSON, H. (1998). Identity and diversity and psychotherapy will too many shes break the net?
International Journal of Psychotherapy, 3, pp. 5 12.
W ILKINSON, H. (1999). Psychotherapy, fascism and constitutional history, International Journal of Psychotherapy, 4, pp. 117 126.
W ILKINSON, H. (1999). Pluralism as scienti c method in psychotherapy, International Journal of Psychotherapy,
4, pp. 313 328.

Resume Cet article discute le diagnostic comme quete de verite, et son application dans deux
contextes diffe rents: dans la relation psychotherapeutique et dans des con its interpersonnels non-psycho-therapeutiques. Lapproche de la v6rite fondee sur quatre quadrants de savoir, developpee par
Ken Wilber, de crit les revendications de validite de quatre dimensions de veridite: subjective,
objective, individuelle et collective. Cettes dimensions sont d abord discutees dans le cadre de la
relation psychotherapeutique. Des modeles differentes de la relation therapeutique sont decrits, basees
sur les travaux de Martha Stark et Petruska Clarkson. L article d6mon1re comment dans cettes
modeles differentes la verit6 est concues d un facon tres different. Tandis que, dans le contexte
psychotherapeutique, lintention d un diagnostic est le soin du client, dans des autres relations
lintention douloureuse est souvent la disquali cation des opposants. Dans la deuxieme partie de cet
article sont decrits deux faux raisonnements et quelques fonctions politiques des diagnostics publics. Ce
genre de diagnostic public peut meme servir a disquali er un opposant aux methodes de resolution des
con its, comme la mediation. Au lieu de compromettre, par une diagnostic mal plac6 dans un
contexte politique, les dimensions diffe rentes de la verite, cet aride veut soutenir des modeles de
resolution des con its comme formes d intelligence sociale.
Zusammenfassung Dieser Artikel diskutiert Diagnose als Suche nach Wahrheit und ihre
Anwendung in zwei verschiedenen Kontexten, der psychotherapeutischen Beziehung und in nichtpsychotherapeutischen, interpersonellen Kon ikten. Ken Wilbers Annaherung an Wahrheit, die auf
vier Quadranten des Wissens basiert, beschreibt die Gultigkeitsanspru
che von vier Wahrheitsdimensionen, subjektive, objektive, individuelle und kollektive Dimensionen. Sie werden zuerst im Hinblick
auf die psychotherapeutische Beziehung diskutiert. Verschiedene Modelle der therapeutischen
Beziehung werden beschrieben, auf der Grundlage der Arbeiten von Martha Stark und Petruska
Clarkson. Der Artikel zeigt, wie Wahrheit in diesen Modellen sehr unterschiedlich verstanden wird.
Wahrend die allgemeine Absicht von Diagnose im psychotherapeutischen Kontext in der Sorge (care)
um die Klienten besteht, ist die schmerzhafte Absicht in anderen Beziehungen gewohnlich die
Disquali zierung von Gegnern. Im zweiten Teil des Artikels werden zwei Trugschlusse der Wahrheit
und einige politische Funktionen offentlich suggerierter Diagnosen beschrieben. Diagnose kann sogar
benutzt werden, um einen Gegner fur Methoden von Kon iktlosungen wie z.B. Mediation zu
disquali zieren, wie an einem Beispiel gezeigt wird. Anstatt die verschiedenen Dimensionen von
Wahrheit innerhalb eines politischen Kontextes durch eine falsch platzierte Diagnose aufs Spiel zu
setzen, unterstutzt der Artikel Modelle der Kon iktlosung als Formen sozialer Intelligenz.