Psychiatry usually depends on a cross-section diagnosis to make an equation between a set of symptoms and an illness. We much prefer process diagnosis because it allows us to develop a much richer picture of complaints and behaviours related to the context of life-history. It allows us to analyse the interaction between symptoms.
The first thing we do is to establish which complaint came first. This makes it possible to find out whether or not all subsequent complaints were an understandable reaction to the first one. If hearing voices were the first symptom and the person then becomes very isolated, the isolation can be explained in a number of ways. It could be a result of direct orders from the voice (“Don’t answer the phone”, “Don’t go out”) or from feelings of shame or the voices make it difficult to carry on normal conversation and it is easier to avoid people, or when the voices are provoking the hearer to laugh at the wrong moment, this could be interpreted as inadequate affect.
This is how the whole complex of symptoms – delusions, confusion, poor concentration, inadequate effect ,isolation, is unpacked. We discuss them with the patient in relation to the situation or emotion in everyday life that triggers them. The idea is to make the symptoms comprehensible.
When hearing voices was not the first symptom the whole complex may have started as a result of the person becoming isolated after some traumatic event, with the voices following from this later. This is why the systematic nature of process diagnosis is so important. Establishing the existence of symptoms is not the main issue; it is their functional relationship to the person which is most telling.
The functional relationship with life-history
When hearing voices is connected to a traumatic experience and or to problems coping with certain emotions or situations, the person concerned becomes sensitized to the same or similar situations or emotions. A certain vulnerability develops that is a specific ‘sensitivity. Process diagnosis tries to identify the primary stress factor in order to work out how the patient’s sensitivity developed.
A conventional life history proceeds in chronological order, but leaves out a great deal of information about the relationship of individual symptoms to life-history. In a process interview we focus on the time when the voices were first heard, or when the first symptom appeared, and ask the voice hearer about their personal situation and what was going on in their lives then. ( see further Making Sense of Voices chapter three about the importance of warning signs).