Talking about diagnoses
• Potentially helpful ideas
• Can be offered as an option for understanding rather than fact or truth

Diagnostic labels have a special role in mental health services in that our funding to provide care can be dependent on identifying and applying a diagnostic label. A social constructionist epistemology opens up talk about diagnoses as ideas, which can be more or less helpful, rather than entities or truths. DSM IV and ICD 10 diagnoses have been carefully and explicitly constructed to facilitate communication among professionals and focusing of research enabling the development of collective wisdom.

Thus depression, for example, can be offered as an idea which has generated potentially helpful collective wisdom:

"Everyone feels sad and happy at different times, sometimes the sad, angry, negative feelings get a life of their own and they affect your body, your sleep, your thinking, etc. This can become a self-reinforcing cycle. That’s what we call a clinical depression. It’s a common experience which means there is quite a lot of collected knowledge about strategies people have found helpful. Would you like to hear about them?"

This contrasts from the quotation from the doctor patient in the beginning discussion of the fragility of holding of personal knowledge from a patient role:

"He told me I was depressed and that I needed antidepressants."

Offering people a choice as to whether they want to hear our thoughts, tentative telling or inquiry can be effective in making our views available but leaving the person room to take them up or not. Examples include:

“I’ve got a way of understanding about this which might be helpful, would you have any interest in hearing about it?”

In a clinical situation where a teenager presented with classic symptoms of a psychotic episode the clinician reported:

“I could see, that when I said that their son had a psychotic illness, I lost the family.”

The accuracy of the observation was borne out in that the family subsequently disengaged, moved, and their son lost the current possibility of psychiatric treatment. In similar situations presenting of diagnostic ideas in a more tentative way and noting and naming similar responses:

“I notice your expression changed [you looked away, etc] when I mentioned the idea of ‘psychotic illness’. Do you have some experience of this idea?”

This has enabled family members to speak of their experiences of relatives who had experienced disappointing outcomes following engagement with mental health services, or ideas about spirituality and other explanations. While this did not result in immediate taking up of psychiatric treatment on offer, it enabled connection to continue and the conversation to remain open.