The diagnostic function

Definition: Delivering information about the presenting issue particularly with regard to factors implicated in the cause or maintenance of the problem.

The diagnostic function refers to the way that clients’ mental imagery can operate as a means of generating insights into the condition or issue that is brought to therapy. All therapeutic approaches that accept the client’s imagery as meaning laden would acknowledge this function, either implicitly or explicitly as Leuner does in the following statement:

We have referred to this freely developed imaginal landscape as the ‘catathymic panorama,’ which can be roamed in all directions. As I will show you in the following, this panorama is of great diagnostic value and within a short time gives the therapist a relatively broad view of the patient’s predominant conflictual constellation.

(1984: 17)

This diagnostic function does not depend on how the image is produced. The image might have arisen spontaneously for the client in the course of the session (or the image might have been brought to the session by the client as something meaningful). Or it could have been deliberately elicited either through helping clients translate their presenting issue into a representative image or through using a guided imagery script pertinent to their presenting issue. An example of the latter would be the purposively diagnostic procedures developed by Shorr, (mentioned in Chapter 3) - he instructs his client to imagine two different animals (people, things, etc.) compare them and have them interact. He believes that this process reveals the client’s internal conflict. It is clear how much importance that Shorr attributes to this function when he asserts that, ‘A person’s imagery, more than any other mental function, indicates how he organises the world’ (1983: 463).

No matter how the image arises, it is deemed to carry information that, on further exploration and unpacking, will shed light on the presenting issue or themes the client is bringing. It is important to note that by using the medical model term ‘diagnostic’ this is not meant to imply that particular images have a fixed and universal meaning. Counselling and psychotherapy recognise to a greater or lesser extent that meaning and experience is symbolised or encoded in images in different ways. For instance, images can condense a range of aspects and meanings into one symbol. Or another example would be symbolic transposition, i.e. the process by which an important figure or event is represented in another symbolic form. Furthermore, people’s imagery is shaped by individual, social and cultural conditions and contexts (matters of interpretation are discussed at length in the second part of this book).

This function does not determine how meaning is extracted from the mental image. Depending on the therapeutic approach espoused by the therapist the image may be approached in different ways. In classic psychoanalysis, the analyst would approach the client’s mental image or fantasy with a particular view. Here the surface image is generally viewed with suspicion as it may be defending against the exposure of repressed material. The analyst will view the image through a particular interpretative framework seeking its latent meaning. Humanistic therapies, on the other hand, view the process of making sense of the image as led by the client. However, Hall et al. issue the following caution, ‘Even some of the systems that suggest the counsellor should allow the client to interpret their own imagery have implicit forms of interpretation contained within the model’ (2006: 54).

More recently, some contemporary CBT approaches have become interested in this diagnostic potential; clients’ mental imagery is starting to be viewed as an emotional bridge that offers a means of tracing back to the source of current difficulties. A simple example of this would be the therapist asking questions to determine the historical cause of distressing intrusive imagery. And, as discussed in a previous chapter, there is more openness to the imaginal perspective as a source of valid knowledge in its own right. Butler and Holmes (2009) in their discussion of the use of drawings in working with childhood trauma comment on the way that clients make meaning from their images. This leads them to identify one of the functions of imagery is linking things up or making connections between thoughts and feelings.

The following example illustrates the diagnostic function in action. This illustration is taken from Silverman’s (1987) innovative clinical work with mental imagery. Although he worked from a psychoanalytical perspective, he argued that it was important for psychoanalysis to develop a wider understanding of the therapeutic operation of imagery and to not limit itself to its narrow focus on latent meaning.

In his report of clinical work with a ‘neurotic’ client he describes one session when she complained that she felt emotionally ‘dead’. After spending the first half of the session unproductively analysing her defences and transference, he asked her to allow an image to come to mind. She reported visualising an image of an electric chair; and as she did so, she made an immediate connection with an abortion she had had five years previously. In addition, she was also aware that this was linked with a recent miscarriage that she had been discussing in her therapy. The mental image allowed her to understand that this miscarriage was unconsciously associated in her mind with murder and this association led her to cut off her feelings. Silverman reported that this understanding allowed his client to move beyond the impasse created by the emotional block.

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