Constructivism and psychotherapeutic method: Transitive diagnosis as humanistic assessment more

METHODS: A JOURNAL FOR HUMAN SCIENCE Annual Edition 1995 Articles Constructivism and Psychotherapeutic Method: Transitive Diagnosis as Humanistic Assessment by Jonathan D. Raskin and Franz R. Epting 3 Transcendental Interpretation: Approaching Ontological Questions in Psychological Research by Jeff Sugarman 28 Plausible Constructionism as the Rigor of Qualitative Research by David Rennie 42 Work i,w Progress Feminist Practice as Research by Lucia Albino Gilbert 59 Book Review Review of Jill G. Morawski Practicing Feminisms, Reconstructing Psychology: Notes on a Liminal Science by Kareen Ror Malone 69 Humanistic Assessment 3 CONSTRUCTIVISM AND PSYCHOTHERAPEUTIC METHOD: TRANSITIVE DIAGNOSIS AS HUMANISTIC ASSESSMENT JONATHAN D. RASKIN FRANZ R. EPTING Tennessee State University University of Florida Psychiatric diagnosis using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is a method of assessment that we believe is incompatible with a humanistic approach to George Kelly's Personal Construct Theory (PCT). Kelly's approach views mental illness as one among many possible subjective constructions by which deviant behaviors are understood. This counters the DSM-IV view, which sees mental illnesses as objectively observable entities that are usually biological. Kelly, himself, argued that personal construct psychology offers a way to understand deviant behavior that is preferable to a mental illness approach. Thomas Szasz also rejects mental illness. His critique focuses on the faulty use of metaphor; the mind, argues Szasz, cannot be physically sick. The critiques of DSM-IV methodology outlined by Kelly and Szasz are presented with a humanistic psychology framework methods in mind. Transitive Diagnosis, a constructivist approach to psychological assessment, is outlined and presented as a more humanistic methodology for generating clinical hypotheses in the effort to understand client problems. The need for the development of humanistic assessment methods as alternatives to the DSM is emphasized. Constructivism and Psychotherapy: Transitive Diagnosis as Humanistic Assessment The Humanistic Psychologist's Dilemma How does today's humanistic psychologist, uncomfortable using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), function as a psychotherapist in a field that currently endorses a categorical diagnostic methodology that seems theoretically incompatible with the most basic principles of humanistic psychology? As humanistic psychotherapists, we are faced with this question every day. Regardless of work setting (be it a hospital, university counseling center, mental health center, psychology department, or private practice) the categorical, DSM-IV diagnostic orientation surrounds psychotherapists and powerfully affects their professional lives. Humanistic therapists resistant to the limitations of DSM-style diagnosis are in an untenable position. Do we reject traditional diagnostic methods and risk professional isolation from our peers, or do we begrudgingly adopt whatever happens to be the current version of DSM despite its incompatibility with our theoretical approach to conceptualizing clients? In this paper, we apply a constructivist perspective to psy- chological diagnosis and expand upon the thesis of a previous paper, in which we argued that by combining the ideas of George Kelly and Thomas Szasz we can develop alternatives to the DSM (Raskin & Epting, 1993). Wc begin by summarizing the argu- ments of Kelly and of Szasz. We discuss similarities in their approaches to understanding psychological problems, and re- Humanistic Assessment 5 late this to the needs of humanistic psychologists dissatisfied with DSM-IV. We also outline an alternative diagnostic meth- odology called Transitive Diagnosis (Faidley & Leitner, 1993; Kelly, 1991b; Landfield & Epting, 1987), which we see as more consistent with the tenets of humanistic psychology. Brief Summary of a Humanistic Approach When people use the term "humanistic" to describe a theo- retical approach to psychology, many ideas are implied. How- ever, when we refer to humanistic psychology in this paper, we are talking about an approach to persons that emphasizes six points. First, we believe that humanistic psychology empha- sizes choice; from our humanistic perspective, people have choices and are capable of making life changes—even though doing so is often difficult. This contrasts with what we see as the medical model approach of DSM-IV—an approach which contends that "dysfunctional" behaviors are caused by mental disorders and that, in order to change "dysfunctional" behav- iors, the disorders must be eradicated through treatment. While conceptualizing interpersonal problems using the language of disorder and treatment need not always imply that people lack choices, it certainly encourages us to see clients as victims of disorders and therefore less capable of making choices. Second, we see the humanistic approach as emphasizing a collaborative form of psychotherapy. Clients are seen as the best experts on their feelings, thoughts, strengths, and weak- nesses. This conflicts with a DSM approach, which sees the diagnostician as the expert on such matters. After all, when us- ing DSM-IV it is the diagnostician who assesses and decides what the client's problem is and which disorders afflict the cli- ent. This relates to the third point that we feel is critical to hu- manistic psychology; humanistic psychotherapy tries to avoid making pejorative judgments about clients. This does not mean the humanistic psychologist lacks opinions about clients, but simply that he or she maintains awareness that such opinions 6 methods are based on a personal world view rather than objectively true notions of pathology. Forth, humanistic psychology sees people from a process point of view; people are always changing, evolving, and grow- ing—in this sense, a DSM-IV diagnosis is antithetical to a hu- manistic psychologist because it tries to capture the person within a static label. Fifth, humanistic psychology generally rejects mechanistic, reductionistic thinking about people. Reduction- ism can be useful in many scientific endeavors. However, from a humanistic viewpoint, understanding people's innermost thoughts, feelings, and meanings by invoking reductionistic ex- planations is most often counterproductive. In this sense, a hu- manistic perspective incorporates the Gestalt idea that the whole of human existence cannot be understood by breaking it into component parts. To break human existence into component parts is to treat people as passive, mechanical objects rather than as intelligent, active, and responsive beings. Much of humanistic psychology's emphasis on phenomenology grows out of the idea that reductionistic explanations of psychological phenomena are often unsatisfying. Finally, humanistic psychology has a positive view of people. Rogers (1959, 1961) maintains that people develop in positive, self-actualizing ways when provided with the core conditions necessary for growth and change. Humanistic psychology's emphasis on the positive, adjusted, self-actualizing aspects of human behavior is in stark contrast with DSM-IV's emphasis on illness and disorder (that is, DSM-IV's emphasis on what is "wrong" with people). As humanistic psychotherapists, we con- ceptualize client behaviors (even those that seem to hamper a client) as strategies devised to maximize personal growth within environmental confines that have, in the past or presently, in- hibited such growth. In comparison, DSM-IV conceptualizes client behaviors as symptoms of disorders afflicting clients and requiring treatment. In other words, DSM-IV terminology in- fers that clients are "broken" and need to be "fixed." While Humanistic Assessment both constructions (our"coping strategies" conceptualization and DSM-IV's disorder conceptualization) are viable alternative constructions of the same events, we do not construe a DSM-IV conceptualization as helpful to humanistic psychologists trying to understand the meaning behind a client's behavior. While concep- tualizing clients as disordered may be effective in some instances, it seems inconsistent with humanistic psychology's emphasis on the person's self-actualizing, meaning creating tendencies. Kelly and Szasz: Upholding the Humanistic Perspective Mental illness rejected. Both Kelly (1969a, 1969b, 1991b) and Szasz (1960, 1963, 1987, 1991) reject traditional conceptualizations of mental illness and, therefore, also reject traditional methods for diagnosing psychological problems. Szasz's objection to DSM-style diagnosis stems from its accep- tance of the very phrase "mental illness." Szasz (1974) argues that the term "mental illness" is a metaphor that has been taken literally. For Szasz, a mind—which has no organic correlate in the human body—cannot be sick in a physical sense; when we speak of "sick minds" we are speaking metaphorically. Be- cause Szasz (1974, 1987) believes that "mental illness" does not exist, all attempts to catalogue mental illnesses are mean- ingless. Diagnosing mental disorders becomes a futile exercise in which categories are added or discarded based on political maneuvers and social values rather than claims of scientific validity. While its authors (American Psychiatric Association [APA1, 1980, 1987, 1994) maintain that DSM diagnosis is "atheoreticaL" Szasz's criticism of mental illness convinces us that this is not so. The authors of the DSM-IV may not take specific theoretical positions regarding the etiology or best treat- ment for DSM-IV disorders. However, they do describe men- tal disorders as truly existing within the objective world. In our view, DSM-IV cannot be atheoretical when there are people who do not accept its most basic assumption that mental disor- ders exist and can be catalogued. methods The objective, atheorctical, cataloguing-of-reality stance espoused in DSM-IV (APA, 1994) appears inconsistent with our conceptualization of personal construct theory. Kelly (1969a, 1969b, 1991b) rejects the concept of mental illness because it does not fit with the tenets of personal construct psychology. From a constructivist point of view, DSM-style diagnosis is a construct system. Like any construct system, it is built upon underlying beliefs about human nature—specifically, in this in- stance, about what constitutes abnormality. Given that DSM- IV, like any system, springs from particular personal and social constructions, it cannot simply describe objectively true enti- ties that mental health professionals have '"discovered." Rather, it functions as does any construct system—as one among many ways to understand events and give thern meaning. In other words, DSM-IV is a complex construct system used by mental health professionals in order to make sense of deviant human behaviors. Acknowledging that DSM is a construct system does not mean that the DSM-IV serves no useful purposes. In fact, once its theoretical assumptions arc openly acknowledged DSM- IV can be used, just like any other construct system, to orga- nize, comprehend, and predict events. The problem for human- istic psychologists is that DSM-IV—with its static, reduction- istic, deterministic approach (deterministic in that DSM-IV en- courages seeing client behaviors as symptoms caused by their disorders rather than as strategies chosen to cope with difficult circumstances)—is a construct system in conflict with basic con- structions underlying humanistic psychology. Often these con- flicts are resolved in ways that result in humanistic psycholo- gists feeling pressured to compromise their theoretical beliefs. Biological model criticized. Both Kelly and Szasz firmly reject biological models for explaining psychological problems. Szasz argues that even though physiological bases for most mental disorders have not been identified, many people still insist that all or most abnormal behavior is primarily caused by biological malfunctions (Szasz, 1960, 1974). Szasz does not Humanistic Assessment 9 disavow the possibility that deviant behaviors can be caused by biological malfunctions. Rather, he objects to deviant behavior being labeled as illness when there is not clear evidence of bio- logical malfunction. Further, he makes a distinction between "problems in living" (deviant behaviors resulting from difficul- ties adjusting to social, interpersonal, and political circum- stances) and brain diseases (which may indeed result in deviant behaviors). Szasz stresses that labeling someone experiencing "problems in living" as "mentally ill" allows us to dismiss that person's concerns, and even to treat that person against his or her will. We come to construe those experiencing "problems in living" as physically sick and in need of biological treatment rather than as individuals engaged in difficult, emotionally up- setting, personal struggles. Most psychologists who consider themselves humanistic do not conceptualize clients as sick in a literal, physical sense. Neither does Szasz. He encourages thera- pists to try to understand each client's unique concerns in order to conduct effective counseling. Kelly often attacks biological models of psychological ab- normality. For example, he criticizes the tenn "psychosomatic disorder," arguing that such a term is ... systematically meaningless. Psychosomatics' utilizes neither a consistently psychological system of explanation nor a consistently physiological system of explanation, but rather makes the gross philosophical error of presuming mat certain facts are themselves inherently 'psychological' or physiological', respectively. (Kelly, 1991b, p. 16) Kelly feels that both physiology and psychology arc con- structs which people use to classify events. The same events can be construed from a psychological or physiological per- spective, with different persons finding varying degrees of util- ity from each perspective. Kelly classifies his theory as a psy- chological one, and therefore believes that it need not account 10 methods for physiological variables. For humanistic psychologists, such a perspective can provide welcome relief. In today's medical model centered world, psychotherapists are increasingly being told that they are irresponsible if they do not approach their clients as complex collections of brain processes. Psychothera- pists who contend that medication is not necessarily the treat- ment of choice for those experiencing life difficulties are often dismissed by their more biologically oriented peers. To many in the psychological profession, psychology and biology increas- ingly appear to be one and the same. Even DSM-IV empha- sizes that "there is much 'physical' in 'mental' disorders and much 'mental' in 'physical'disorders" (APA, 1994, p. xxi). As alluded to above, from a constructivist perspective psy- chology and biology overlap in the sense that they are often different ways to construe the same information. However, even though Kelly sees the psychology-physiology distinction as a construction that people need not abide by, he personally chooses to maintain such a construction because he believes that it makes a necessary and important distinction. For us, as humanistic psychologists, this distinction involves attending to the idea that differences in biology do not necessarily imply disease. In a recent paper, Epting, Raskin, and Burke (1994) ask "if each person's biology varies to some extent, how do we determine which of these variations are normal" (p. 360). They discuss left-handedness, arguing that "while handedness does have some- thing to do with one's biology, rarely do we consider left handed people disordered, even though the biological factors that con- tribute to left handedness are statistically deviant" (p. 360). The point we are making is that one need not construe psy- chology and biology as identical and, even if one does, one need not assume that biological differences are necessarily medical problems requiring biological treatment. Taking our left-handedness example to its most absurd extreme, let us imag- ine a client whose presenting problem is dissatisfaction with her left-handedness. Does the fact that we construe left-hand- Humanistic Assessment 11 edness to have biological underpinnings necessitate that we treat this client's concern as a medical problem? Perhaps we can develop a drug that "cures" the "disease" of left-handedness. While treating the client's problem biologically is a viable pos- sibility, it seems obvious in this case that such an approach is not the only reasonable one. We could just as easily take a more psychological approach, helping this client explore her feelings about left-handedness while encouraging exploration of the con- struct system that leads her to experience such dissatisfaction. We might even help her learn to write with her right hand, and still not treat her left-handedness as a disease. This example generalizes to all interpersonal problems. While there may in- deed be biological factors at play in psychological processes, we need not abandon our humanistic counseling techniques in favor of biological treatments. Most importantly, our humanis- tic point of view encourages giving clients choice in how they address their problems. Sometimes they may choose medical treatments, and other times they may choose psychological ap- proaches. Because neither approach is "wrong" when freely chosen by a client, humanistic psychologists do not need to be ashamed or embarrassed by what they offer. Biological treat- ment of deviant behaviors may differ from humanistic psycho- therapy, but it is not necessarily better. Humanistic psychologists uncomfortable with pressure to unconditionally accept the medical model need only remember that psychological constructions of client behaviors may sim- ply be different from, not inferior to, physiological construc- tions of client behaviors. Our goal is not to eliminate a medical model approach to abnormality; while we personally may not endorse such an approach to interpersonal problems, we do not want to imply that our perspective is the one "true" perspective. Likewise, we do not want to be forced to abandon our humanis- tic orientation. We certainly are not arguing that biological ap- proaches are never preferable to psychological approaches. For example, psychotherapy alone will not repair a brain injury suf- 12 methods fered as the result of an accident, while biological treatment might. In Szasz's view, this is because a brain injury truly is a biological problem. Kelly would concur, arguing that a brain injury falls outside of psychology's range of convenience. How- ever, in the realm of human relations and emotions psychologi- cal approaches should not be discarded, or even ranked second behind biological methods. We encourage humanistic psycho- therapists to stand up for themselves and hold true to Kelly's constructivism—which emphasizes the utility of psychological counseling when working in the arena of interpersonal relations. Kelly's Personal Construct Theory and Humanistic Principles Kelly (1991a, 1991b) sees the person as an active agent con- tinually trying to make sense of events in a personally mean- ingful fashion. While Kelly does not deny that biological and environmental influences impact on persons, he emphasizes that how people construe and make sense of such influences is criti- cal to understanding them. For example, two people may be diagnosed with prostate cancer. They did not choose to develop cancer; it was beyond their control and, in this sense, deter- mined. However, each of the two persons may construe the implications of a cancer diagnosis differently and exhibit dif- ferent responses. In this sense, Kelly sees both persons as ac- tive agents whose behaviors are not fully determined by their environments or biology. Of course, the idea that persons are capable of actively con- struing events despite the presence of biological and environ- mental factors is a philosophical assumption. We do not deny that we assume a degree of agency; however, we want to make equally clear that assuming a lack of agency is also an assump- tion. Most research paradigms in abnormal psychology simply assume entirely deterministic positions to be correct. Radical behaviorism assumes all deviant behavior is shaped by envi- ronmental circumstances. Psychoanalysis assumes all neurotic Humanistic Assessment 13 behavior is caused by internal drives and the distribution of psy- chic energy throughout one's system. Cognitive approaches as- sume that all dysfunctional behavior is the result of illogical thinking. If the specific deterministic assumptions of these theo- retical approaches are accepted, then each of these approaches yields worthy information. Personal construct psychology makes assumptions as well. From our point of view, construct theory assumes that people are active agents who construe events within the environmental and biological constraints imposed on them. While people are influenced by environmental and biological factors, their behaviors, feelings, and attitudes are not entirely the products of these factors. Personal construct theory (Kelly, 1991a) assumes that people actively create internal representa- tions of the world. It is not biology or the environment that directly causes behavior, but rather the way in which one ac- tively imbues meaning in environmental and biological occur- rences that influences behavior. Because Kelly sees persons as active agents capable of con- struing, we see his approach to client assessment as more con- sistent with humanistic psychology than is a DSM-IV approach. The active construing process that people engage in is not taken into consideration in DSM-style diagnosis. DSM-style diagno- sis, it seems to us, encourages seeing client problems as en- tirely determined and client responses as symptoms of the dis- orders with which they are diagnosed. This makes little sense to us. Could not two people who receive the same DSM-1V diagnosis be entering therapy for entirely different reasons and with utterly different constructions of events? While a DSM perspective docs not rule out viewing clients as complex, active agents struggling to find meaning in diffi- cult events, it also does not encourage it. This is why we feel that attempts at integrating a humanistic, person centered as- sessment with a DSM-IV diagnosis ultimately fail. As previ- ously mentioned, we acknowledge that DSM-IV and humanis- tic conceptualizations constitute different constructions of the 14 methods same events. Further, Kelly was the first to admit that we need not be slaves to our construct systems; that is, we should feel free to vacillate between apparently contradictory constructions of the same events if we feel that doing so helps us to better cope with our surroundings. While we respect humanistic psy- chologists who choose to integrate DSM and humanistic as- sessments, we believe the drawbacks of using DSM-IV that we have outlined above outweigh the advantages. An additional and quite practical drawback involves health insurance reimbursements. Many of the arguments in favor of encouraging humanistic psychologists to accept DSM diagno- sis seem to be motivated less by a theoretical appreciation of DSM-IV than by a desire to collect health insurance reimburse- ments. Collecting health insurance reimbursements is a politi- cal issue that requires the attention of all mental health profes- sionals. However, it is a poor theoretical rationale for humanis- tic psychologists to adopt DSM diagnostic methodology. Out- side of insurance reimbursements, DSM-IV seems to offer little that enhances the humanistic psychologist's efforts to under- stand the individual client at hand. In our view, it actually of- fers much to harm the humanistic psychologist, especially as insurance companies and health management organizations increasingly use a client's DSM diagnosis to determine how many sessions will be covered and what modes of treatment are acceptable. In a professional climate that we feel already is not highly responsive to humanistic psychology, the use of DSM- IV diagnosis as a way to dictate type and length of treatment does not bode especially well for humanistic psychotherapies. Qualities Important for Understanding Client Meaning Both Szasz and Kelly reject the underlying constructions which the DSM uses to understand deviant behavior. Kelly (1969a) contends that a categorical approach to psychological difficulties—wherein persons are assigned a disorder which then dictates treatment—discourages psychotherapists from fully Humanistic Assessment 15 understanding the idiographic constructions which clients use to understand their worlds. Faidley and Leitner (1993) argue that DSM's theoretical assumption that disorders arc best un- derstood using clusters of symptoms results in clinicians being expected to ... be less concerned with the meanings of the symptoms for the person than with the existence of the symptoms for an external checklist. If the therapist is more concerned with inner meanings than symptoms, the therapist will likely find the DSM to be at best annoying and at worst damaging, (p. 45) Meanings are quite personal, and often quite idiosyncratic. No diagnostic category can adequately convey the individual- ized meanings derived from a client's experience. Again, Faidley and Leitner (1993) address this issue, contending that "Kelly is advocating a total rethinking of traditional nosological catego- ries as well as the process of psychological testing" (p. 49). They pointedly ask whether . . . traditional approaches open treatment options for therapist and client, options that put personal meaning at the center of our approach to the other? If these categories are not useful from the viewpoint of a psychology of personal experience, Kelly is advo- cating their total abandonment. (Faidley & Leitner, 1993, p. 50) In addition to encouraging the abandonment of categorical diagnosis, Kelly (1991b) proposes an alternative approach to assessment called Transitive Diagnosis. Several construct theo- rists have elaborated the process of Transitive Diagnosis (Faidley & Leitner, 1993; Landfield & Epting, 1987) Below, a brief over- view of how Transitive Diagnosis might be used to generate clinical hypotheses in a counseling setting is presented. Before proceeding it seems necessary to consider what information is conceptually useful in construing clients and their problems. Faidley and Leitner (1993) describe qualities of information that 16 methods might be helpful in assessing a client's meaning system. These qualities are summarized below. Useful and rich. A constructivist approach to counseling encourages psychotherapists to think about the ways they conceptualize client problems, and to evaluate how useful these conceptualizations are. Does one's conceptualization allow for a richer understanding of a client's "hopes, struggles, fears?" (Faidley & Leitner, 1993, p. 50). Further, are conceptualizations tied not only to empirical data, but to theoretical underpinnings? A humanistically inclined constructivist approach emphasizes that both theory and data are critical factors in the process of constructing systems for understanding behavior. Finally, does one's conceptualization allow for multiple understandings of a client's concerns? Getting locked into one way of thinking about a client can limit creativity brought into counseling sessions, and can lead to all client behaviors being construed using a re- stricted number of constructs. A current example of this in- volves conceptualizing clients as "borderlines." It seems that many therapists, once they have construed a client to be "bor- derline," see all client behaviors as a function of the "border- line" diagnosis. This circular and one dimensional kind of think- ing can be quite dangerous, especially if no alternative conceptualizations are entertained, and is precisely the reason why a constructivist approach encourages multiple conceptualizations of client issues that do not rely on assigning clients to broad categories. Adequately permeable. A permeable system is one that can be generalized to new people and events. Of course, an overly permeable system doesn't allow for much discrimina- tion between different kinds of client problems. Likewise, an impermeable system allows for no generalization whatsoever. In thinking about clients, it is important to be capable of making hypotheses based on generalizing from past client experiences, but without necessarily assuming that these hypotheses will be entirely (or, sometimes, even partially) correct in the current situation. Humanistic Assessment 17 Process-oriented. Kelly feels that persons arc always en- countering new experiences and revising their expectations and outlooks accordingly. In other words, people are constantly changing. Faidley and Leitner (1993) argue that "our ways of understanding our client should allow us to understand and an- ticipate the client's continual creation and re-creation of her world" (p. 51). Transitive Diagnosis occurs throughout the coun- seling process, as a client's constructs arc continuously reevalu- ated. People are seen as forever in a stale of process. This contrasts with assigning people to categories because catego- ries are all or none propositions; you either belong to the cat- egory or not. Therefore, the subtleties of process are lost in a categorical approach. Experimentally valid and creative. Kelly (1991b) pro- posed taking a "credulous approach" in trying to understand clients, wherein the counselor accepts what the client says at face value and assumes that it is true. In so doing, the counselor and client can begin collaborating in understanding the client's way of construing circumstances. Hopefully, this will result in both client and counselor coming to "see how the client's mean- ings, while possibly getting him into serious trouble, are under- standable creations given the context of his life" (Faidley & Leitner, 1993, p. 52). Once client and counselor share an un- derstanding of the client's meaning system, they can work to- gether in helping the client creatively experiment with alterna- tive constructions of events, and the subsequent behavior changes these alternative constructions might lead to. Sociality. Faidley and Leitner (1993) emphasize the im- portance of interpersonal relationships in optimal psychologi- cal functioning. The process of Transitive Diagnosis allows for the development of an important interpersonal relationship be- tween client and counselor. This relationship is based on the shared understanding that the client and counselor come to have of the client's construct system. 18 methods Transitive Diagnosis and Hypothesis Formation: A Methodological Framework Kelly (1991b) identified several stages in the process of Transitive Diagnosis: formulating the problem, understanding the client's construction of the problem, evaluating the client's construct system, management and treatment. More detailed overviews of these steps are available elsewhere (Kelly, 1991b; Raskin & Epting, 1993). Herein, we wish to focus briefly on methods used to evaluate constructs in Transitive Diagnosis. Construct dimensions defined. Essentially, Transitive Di- agnosis involves assessing clients solely according to their con- structions of events. Kelly (1991a) felt that people organize their experience by creating constructs, which are bipolar di- mensions describing events and their perceived opposites. Ac- cording to Kelly, in order to have a conceptualization of what something is, one must also have a conceptualization of what something is not. Hence, constructs are bipolar dimensions (a representation and its perceived opposite) invented by people to imbue events and relationships with meaning. People invent constructs to account for and comprehend their experiences in the world. When functioning optimally, people continue to em- ploy those constructs which have been predictive in the past, allowing for the anticipation, prediction, and comprehension of experiences; likewise, they discard or revise constructs that do not allow for anticipation, prediction, and comprehension of events. Many methods for eliciting personal constructs have been developed, with Kelly's (1991a, 1991b) Repertory Grid perhaps the most well known. While a discussion of construct eiicita- tion techniques is beyond the scope of this paper, a recent re- view by Leitner (1995) outlines a wide array of construct elici- tation methodologies. One of the most humanistic aspects of personal construct psychology is that it readily acknowledges that there are many effective ways to construe the same events. Understanding the idiographic constructions of each person is important in under- Humanistic Assessment 19 standing that person psychologically. For example, one person's experiences might lead him to hold the construct "happy/sad." However, another person's experiences might lead her to hold the construct "happy/ugly." Yet another person's experiences might lead to construing die opposite of "happy" as "respon- sible." The meaning of "happy" for each of these persons is somewhat different; constructs are idiographic inventions. Tran- sitive Diagnosis involves using various personal construct meth- odologies to elicit personal constructs from clients. These con- structs are then evaluated in an effort to understand the ways in which they both assist and detract from client efforts to func- tion effectively in the world. Faidley and Leitner (1993) and Landfield and Epting (1987) outline guidelines used in evaluating construct systems. Sev- eral of these guidelines are presented below in order to provide a flavor for the kinds of inquiries a humanistically oriented per- sonal construct psychotherapist might make during the process of Transitive Diagnosis. 1. Assume for the moment that the poles of a construct represent, to some extent, contrasting aspects of a person's dimensions of meaning. Kelly (1991a, 1991b)cmphasizes that client meanings are idiosyncratic and personal. What seems like the logical and meaningful opposite pole of a construct dimen- sion for one person might seem quite foreign to another. How- ever, in taking a credulous approach to client meaning and ac- cepting the client's construct dimensions as representing some- thing meaningful (however incomprehensible these dimensions initially seem), psychotherapists can allow themselves room to creatively generate potential hypotheses about client meanings. Faidley and Leitner (1993) provide an excellent example. They discuss a client for whom the dimension "depressed/irrespon- sible" is salient, observing that a therapist might . ,. dismiss this strange duality, assuming the person had tempo- rarily lost himself in some inner confusion. Alternately, we could 20 methods treat the construct as if these poles are in contrasting relation to each other. One might imagine that, for this person, depression implies being responsible for life while happiness implies irre- sponsibility. (Faidley & Leitner, 1993, p.61) 2. Certain parameters of a person's behavior can be en- compassed by his or her constructions. In hypothesizing about how clients might behave, we can look at their elicited con- struct dimensions. The dimensions of meaning which one uses to comprehend events and relationships provide ample material which a therapist can use in trying to anticipate client actions. Again, Faidley and Leitner (1993) provide an excellent example, citing the construct dimension of "passive/murderous." A per- son utilizing this construct may indeed behave passively. How- ever, the therapist working with this client might wish to con- sider the possibility of violent, and perhaps murderous, behav- ior from this client should he or she be encouraged to become less passive (Faidley & Leitner, 1993). 3. Observe the simplicity and abstractness of the person's interpersonal construing. Does the client interpret the behav- ior of others in simple, concrete ways or in complex, abstract ways? Often more abstract construing is viewed as implying a more sophisticated capacity to comprehend and appreciate another's interpersonal behavior. Of course, it is important to keep in mind "that certain persons actually may use more com- plex social understandings but be unable to express them ad- equately in words" (Landfield & Epting, 1987, p. 120). 4. How often does the person describe social interactions? To what extent does a client describe others in terms of social interactions as opposed to in terms of physical attributes, tal- ents, tasks, or formal roles (Landfield & Epting. 1987)? Faidley and Leitner (1993) argue that by "studying the content of the social descriptors, the clinician may be able to generate hypoth- eses about tlie characteristic ways the client approaches the re- lationships she does have" (p. 63). Humanistic Assessment 21 5. Observe the overuse of a construct dimension. Over- use is defined by Landfield and Epting (1987) as the appear- ance of a construct dimension as often as twenty percent of the time. Faidley and Leitner (1993) give the example of someone for whom the dimension "attractive/unattractive" was central, and how reliance on this construct impacted her own self-per- ceptions and her perceptions of relationships. Often when a con- struct dimension is identified as one that a client uses often, client and counselor can discuss the potential advantages and disadvantages of relying so heavily on such a dimension. This is often followed by the client and counselor formulating alter- native construct dimensions that the client might employ, and encouragement that the client test these constructs out in real world situations in order to decide whether the client finds them useful and helpful in reaching his or her therapeutic goals. 6. Does the person show a tendency toward self-refer- ential description? Does the client see others as self-centered and self-absorbed? Further, does the client repeatedly make references to him or herself? If so, how does this impact the client's relationships with other people? Again, discussing the advantages and disadvantages of self-referential construing with a client can often be helpful. The client gains understanding into his or her way of viewing relationships, and then becomes better able to decide whether to continue construing relation- ships in such a manner or whether to experiment with new con- structions of interpersonal relationships. 7. Does the person tend to employ language and con- structs that seem strange, peculiar, and obscure? Faidley and Leitner (1993) emphasize the importance of common mean- ings for successful interpersonal relationships. After all, if each of us had construct systems so utterly different from everyone else's, successful and rewarding interpersonal relationships would be difficult, if not impossible. The argument that even incomprehensible behavior has underlying meaning behind it is a powerful one from a humanistically constructivist view- 22 methods point, and is very consistent with the ideas of Szasz (1974). The question that psychotherapists must ask themselves is what is the best way to work with persons whose interpersonal construc- tions are so "eccentric" that they seem incomprehensible? 8. Has the person used at least one construct dimension that implies openness to experience at one pole and closedness to experience at the other? Put simply, a person who is able to construe the possibility of change is likely to more effectively and more quickly make changes in his or her life than someone lacking a construct involving change. Of course, an important goal of counseling might actually be to help a client experiment with and elaborate a construct dimension involving change. Perhaps helping a client elaborate a construct dimension involving change is precisely what occurs when a client (in his or her initial counseling sessions) is educated about the process of psychotherapy and, therefore, becomes more "psychologically minded." 9. Do several poles suggest death, destruction, depres- sion, confusion, and withdrawal? Clients whose constructs involve death, depression, and withdrawal may indeed be strug- gling with these concerns. Of course, many themes may be seen running throughout a client's constructs. Special awareness and attention to themes involving death, destruction, confusion, de- pression, and withdrawal is important simply because clients experiencing such concerns may be experiencing their circum- stances as more desperate than those whose constructs suggest patience, forgiveness, independence, empathy, an ability to tol- erate stress, and hopefulness (Landfield & Epting, 1993). 10. Note descriptive modifiers that are either extreme or moderating. Constructs employing modifiers like "always," "never," "very," "absolutely," or "perfectly" may "represent more significant and core understandings" (Faidley & Leitner, 1993, p, 66). A client who uses these modifiers a great deal may expe- rience most of their construct dimensions as highly significant and central to self. This may make flexibility and compromise difficult for such a client (Faidley & Leitner, 1993). On the other Humanistic Assessment 23 hand, modifiers like "sometimes," "a bit," "somewhat," and "pos- sibly" may indicate a tentative approach that allows flexibility (Faidley & Leitner, 1993). Use of such modifiers also may point towards "difficulty making decisions or to readily acquiescing to others as a way of keeping central values from being on the line" (Faidley & Leitner, 1993, p. 66). 11. Does the person give only one pole of his construct in response to the construct-elicitation question? Perhaps the contrast pole of a construct is being avoided. This may indicate that the client feels threatened by the contrast pole. Of course, the client simply may not be able to effectively elaborate the contrasting construct verbally. Finding ways to help clients better elaborate and understand their own constructed assumptions and meanings is a critical element in successful counseling. 12. Imagine that the subject's personal construct dimen- sions are your own. Were you to adopt the client's construct system, how might you perceive the world? From our perspec- tive effective assessment, as well as effective counseling, is in- timately related to how well the counselor is able to cmpathically understand the client's constructions. Trying to place oneself, as the therapist, in the shoes of the client in order to view the world as the client does, is perhaps the most important aspect of the therapeutic process. Transitive Understanding Transitive Diagnosis does not end with the initial elicita- tion of constructs; because constructs arc always evolving as people encounternew experiences, Transitive Diagnosis involves continually attempting to monitor and understand client con- structions as they change during the course of therapy. When one uses personal constructs to understand clients, one can both come to understand the client and also begin helping the client to experiment with alternative constructions of events that may prove more useful than current constructions. Further, Transi- tive Diagnosis is not separate from the psychotherapy process; 24 methods the two are intimately related and overlap in most respects. The point being made is that we feel Transitive Diagnosis is a begin- ning for humanistic psychologists because it posits a thoroughly new and innovative way to approach client assessment and therapy than that found in DSM-IV. Hopefully, Transitive Di- agnosis encourages therapists to explore alternatives to the DSM that are more theoretically consistent with a humanistic stance. We have employed the phrase "Transitive Diagnosis" thus far, partly in order to maintain consistency with the terminol- ogy George Kelly used, and partly in order to present Transitive Diagnosis as an alternative assessment method to DSM-IV. However, because Transitive Diagnosis is so different from DSM-IV diagnosis, we actually prefer the term "Transitive Un- derstanding" to "Transitive Diagnosis." Our reasons for this preference rest on our belief that the former term is more in keeping with the spirit of personal construct psychology, and better describes what therapists employing this approach are actually doing. Therapists are trying to understand the client's constructions of the world, realizing that this is an ever-con- tinuing process. Diagnosis, as a term, has become reified in many ways. For us, it implies coming to a preemptive conclusion about a client, and then relying on that conclusion throughout the course of therapy. While the term "diagnosis" need not nec- essarily have this preemptive connotation, in today's diagnostic climate it usually does. Therefore, we believe that the using the term "Transitive Understanding" allows us to move away from the unequal power relationship that is inferred whenever an ex- pert professional is asked to diagnose a patient's problem, and to move towards a more equal power relationship in which both client and therapist attempt to understand each other and work towards mutual therapeutic goals. Humanistic Assessment Methodology and the Future The writings of George Kelly and Thomas Szasz relate to the dilemmas that today's humanistic psychotherapists face. Humanistic Assessment 25 Those who share our discomfort with a DSM-IV approach to client assessment may wish to explore alternative assessment modalities, including Transitive Understanding. Humanistic psychotherapists need not merely accept DSM-IV diagnosis as a necessary evil in the practical world of health insurance and reimbursement. Instead, humanistic psychotherapists should develop alternative diagnostic schemes that better suit their theo- retical and applied philosophies. Wc offerTransitive Understand- ing as one such scheme. It is our reading of both Kelly and Szasz that developing constructive alternatives to traditional nosologies is both encouraged and desperately needed. In order to insure a future for humanistic approaches to psychotherapy, the future must include the development and dissemination of theory and research in the area of humanistic assessment methodologies. References American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washing- ton, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of menial disorders (4th ed.). Washington, DC: Author. Epting, F. R., Raskin, J. D., & Burke, T. B. (1994). Who is a homosexual? A critique of the heterosexual-homosexual di- mension. The Humanistic Psychologist. 22x 353-370. Faidley, A. F., & Lcitncr, L. M. (1993). Assessing experi- ence in personal construct psychotherapy: Personal construct alternatives. Westport, CT: Praeger Publishers. Kelly, G. A. (1969a). Ontologieal acceleration. In B. Ma- he r (Ed.), Clinical psychology and personality: The selected papers of George Kelly (pp. 7-45). New York: John Wiley. 26 methods Kelly, G. A. (1969b). Man's construction of his alterna- tives. In B. Maher (Ed.), Clinical psychology and personality: The selected papers of George Kelly (pp. 66-93). New York: John Wiley. Kelly, G. A. (1991a). The psychology of personal con- structs: Vol. 1. A theory of personality. London: Routledge. (Original work published 1955). Kelly, G. A. (1991b). The psychology of personal con- structs: Vol. 2 . Clinical diagnosis and psychotherapy. London: Routledge. (Original work published 1955). Landfield, A. W., & Epting, F. R. (1987). Personal con- struct psychology: Clinical and personality assessment. New York: Human Sciences. Leitner, L. M. (1995). Dispositional assessment techniques in experiential personal construct psychotherapy. Journal of Constructivist Psychology, 8, 53-74. Raskin, J. D., & Epting, F. R. (1993). Personal construct theory and the argument against mental illness. International Journal of Personal Construct Psychology, 6, 351-369. Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of science: Vol. 3. Formulations of the person and the social contact (pp. 184-256). New York: McGraw Hill. Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin. Szasz, T. (1960). The myth of mental illness. American Psychologist, 15,113-118. Szasz. T. (1963). Law, liberty, and psychiatry: An inquiry into the social uses of mental health practices. New York: Macmillan. Szasz, T. (1974). The myth of mental illness: Foundations of a theory of personal conduct (rev. ed.). New York: Harper and Row. Humanistic Assessment 21 NeCStV"DiagnoseS are no, disease, Ue Lane, 338, 1574-1576. ______ Author Note This is a substantially expanded and revised version of a presentation entitled "Humanistic Psychotherapy in a Mecha- nistic World: George Kelly, Thomas Szasz, and the Struggle to Reconstrue Mental Illness," which was given in August, 1994 at the 102nd Annual Convention of the American Psychological Association, Los Angeles. The presentation was part of a sym- posium entitled "Phenomenology, Constructivism, and Psycho- pathology—Alternatives to the DSM." Address correspondence to: Jonathan D. Raskin, Depart- ment of Psychology, Tennessee State University, 3500 John A. Mcrritt Blvd., Nashville, TN 37209-1561.