In Protest of the Use of the Word “Hunch” in Psychological Diagnosis
In his textbook The Skilled Helper (9th ed. 2010) Gerald Egan develops a use of the word “hunch” as a way of formulating a core clinical hypothesis leading to a psychological or psychiatric diagnosis. Nowhere does Egan define what he means by hunch. A hunch is an impression something might be the case. It can range all the way from an expectation to a premonition or presentiment to a suspicion. Etymologically it is derived from the now-pejorative term “hunchback,” which refers to a person whose back and shoulders have been drawn forwards. A person who has a hunch has been pushed or bent into a similar shape, only conceptually instead of physically.
I would like to protest the use of the word hunch in clinical psychology as vague and imprecise. There are no clear standards or criteria for its application. It is a throwback to a kind of pre-scientific “folk psychology,” which has the potential to interfere with the process of identifying symptoms and reaching a diagnosis based on empirical data. Another way of expressing this is to consider a matrix of the diagnostic process. A clinical decision a disorder is present when in fact it is absent yields a false positive (a form of Type I error). A clinical decision a disorder is absent when in fact it is present yields a false negative (a form of Type II error). A diagnostic technique is “sensitive” if it correctly identifies the presence of a disorder and “specific” if it correctly identifies its absence. Serious consequences attend both false positives and false negatives. False positives result in therapeutic interventions that not only are inefficacious but also may have adverse side-effects. False negatives result in the underlying disorder not being identified or treated. Hunches create an environment of uncertainty and indeterminacy in the diagnostic process. Because of this ambiguity they are neither sensitive nor specific and potentially lead to the proliferation of false positives and false negatives.
Here are some of the things Egan has to say about hunches (p. 231 et seq.). A hunch is a way of helping a client to “see the bigger picture.” It enables the client to “see more clearly” what the client is “expressing indirectly or merely implying.” The client then can “draw logical conclusions” on the basis of what the client is saying. The client can “open up areas” that only are being hinted at. The client may “see things” that the client “may be overlooking.” In this way the hunch helps the client “take fuller ownership of partially owned experiences, behaviors, feelings, points of view and decisions.” A hunch is not a “license to draw inferences from clients’ history, experiences, or behavior at will” or to “load clients with interpretations that are more deeply rooted” in one’s “favorite psychological theories than in the realities of the client’s world.” Rather it is a “challenge” to the client that is “open to review and discussion.”
Nowhere does Egan state just how this process is supposed to work or what the hunch does to further or facilitate it. The hunch is not a statement of empathy. It does not “feed back” what the client says to the therapist, in a Rogerian sense. It is not a “probe” designed to elicit information about the client’s state of mind. Nor is it a tentative hypothesis, an interpretation or a provisional diagnosis. It is something emergent or in-between – neither bridging these concepts, defining one in terms of the other nor offering new information.
Since all of this is unclear let’s look at some examples based on Egan’s own case histories (Exercises in Helping Skills: A Manual to Accompany the Skilled Helper, 9th ed. 2010). In response to each vignette Egan instructs the therapist to develop a hunch and a reason for it, then to express it to the client. My objective is two-fold. First, to set forth a plausible clinical diagnosis and then restate it in the format of what I think Egan is looking for as a hunch. Second, to critique that possible formulation on the basis of what Egan actually says about hunches, what is implied by what he says, or what he should be saying in order remain consistent and for his concept to have any explanatory power.
Case #1 at p. 101
Clayton, a first-year graduate student in engineering, has been exploring his disappointment with himself and with his performance in school. His father is a successful engineer, but has not pressured his son to follow in his footsteps. Clayton has explored with his counselor such issues as his dislike for the school and for some of the teachers. He says: “I just don’t have much enthusiasm. My grades are just okay, maybe even a little below par. I know I could do better if I wanted to. I don’t know why my disappointment with the school and some of the faculty members can get to me so much. It’s not like me. Ever since I can remember – even in primary school, when I didn’t have any idea what an engineer was – I’ve wanted to be an engineer. Theoretically, I should be as happy as a lark because I’m in a graduate school with a good reputation, but I’m not.”
Provisional clinical diagnosis: “Client is experiencing internal conflict over career choice. Client lacks enthusiasm and motivation – client may be mildly depressed.” Hunch: “Is it possible you’re under a lot of pressure at school? You seem conflicted because you’re bored, but you also want to excel.” Critique: Even under the most optimistic view of their potential usefulness hunches are semantically pliable. Thus for Egan the phrases “Is it possible that …” or “maybe if …” or “have you ever considered that …” offer hunches whereas the phrases “I think you should try …”, “have you considered that …” or “have you considered trying …” are not hunches. They are prescriptive recommendations, which imply a course of action the therapist thinks the client ought to adopt. For Egan a hunch cannot be mandatory. It cannot be phrased in terms of what the client “needs” or the operational steps the client “must” take. Most of the time however these subtle nuances of interpretation simply are lost on the client. Egan is bogged down in “distinctions without a difference.” Although their semantics may be differ slightly this is superficial because each phrase expresses the same propositional content with the same emotional valency.
Case #2 at p. 102
A man, who is now 64-years-old, retired early from work – when he was 60 years old. He and his wife wanted to take full advantage of the “golden” years. But, his wife died a year after he retired. At the urging of friends, he has finally come to a counselor. He has been exploring some of the problems is retirement has created for him. His two married sons live with their families in other cities. In the counseling sessions he has been alternately dealing with the theme of loss and the theme of redefining his golden years. He says: “I seldom see the kids. I enjoy them and their families a lot when they do come. I get along real well with their wives. But, since my wife has been gone, I don’t make the effort I should to make it happen. I have a standing invitation from the boys and just recently I’ve decided I’m going to get off my sofa and start living again. I won’t kid you; it will be bittersweet. I dread those times when I’ll want to turn to her and enjoy the moment and she won’t be there. I don’t want my boys to see their father shattered an I sure as hell don’t want to see pity in their eyes.”
Provisional clinical diagnosis: “Client is depressed because of wife’s premature demise. Client is in process of coping with loss, developing new interests, discerning meaning in life. Client is afraid of appearing to be weak.” Hunch: “Have you ever considered developing new interests, getting out and socializing more with other people? I wonder if a fear of appearing weak or incapable in front of your sons has led you to distance yourself from them.” Critique: For Egan a hunch must avoid implying an unequal power relationship between the therapist and the client. Phrases such as “I have an idea that …” or “I’m wondering if …” do not express hunches because they disrupt an atmosphere of equality and collaboration between the client and the therapist. If this is true, though, then hunches are useless. The client wants the therapist’s interpretation of the situation and the therapist’s advice. The client wants to know what’s wrong and what can be done about it. The client is not looking for abstract suggestions or a watered-down version of an operationalized action plan.
Case #3 at p. 102
A 33-year-old single woman is talking to a psychiatrist about the quality of her social life. She has a very close friend, Ruth, on whom she has become somewhat dependent. She is exploring the ups and downs of this relationship. This is the third session. During the sessions, she comes on a bit loud and somewhat aggressive. She says: “Ruth and I are on again off again with each other lately. When we’re on, it’s great. We have lunch together, go shopping, all that kind of stuff. But sometimes she seems to click off. You know, she tries to avoid me. But that’s not easy to do (she laughs.) I keep after her. She’s been pretty elusive for about two weeks now. I don’t know why she runs away like this. Something must be bothering her. I know we have our differences. But we always get over them.”
Provisional clinical diagnosis: “Client is overly dominating and controlling in the relationship. Client has unrealistic expectations for the relationship.” Hunch: “I have the idea you may need to restructure your relationship with Ruth and consider finding some new friends at the same time. Is it possible that Ruth may be feeling overwhelmed by the relationship and her elusiveness is her way of dealing with it?” Critique: Egan is committed to the concept a hunch must express uncertainty. Even as it communicates an insight the therapist has about the client it necessarily involves a risk of possible misinterpretation. From an ethical standpoint however this is a slippery slope. The therapist should not say something to the client if the therapist knows it potentially is misleading. The therapist should strive to eliminate ambiguity, not create it.
Case #4 at p. 103
A 35-year-old divorced woman, who has a 16-year-old daughter, is talking to a counselor about her current relationship with men. She mentions that she has lied to her daughter about her sex life. She told her that she doesn’t have sexual relations with men, but she does. In general she seems quite protective of her daughter. She does not know for sure if her daughter is sexually active but she has the feeling the day is not far off when she will start having sex. She says, “I guess I’ve been afraid that if I told her I was sexually involved that I would lose my authority. How can I tell her to wait until she’s married when I’m having sex outside of marriage? And, if I were honest, how much would I have to tell her? Wait. Maybe I can be more honest with her about what I believe without needing to detail my own life. Really this is about how much I love her, not a tell-all TV show. I’ve wanted to connect with her on this and I think this might be the way. Sometimes, though, it feels like such a risk. What if it goes wrong?
Provisional clinical diagnosis: “Client is conflicted over new roles occasioned by the divorce. Client is concerned about the structure and nature of her relationship with her daughter and issues such as sexual identity, disclosure, honesty and their consequences.” Hunch: “I have the idea you and your daughter might want to sit down and talk this through. She may be less naïve than you think and perhaps by airing your different perspectives you can achieve a workable compromise. I wonder if you are feeling especially protective of your daughter because she is nearing the age that you were when you had her.” Critique: For Egan a hunch must provoke the client’s thought process and offer a new perspective for the client to consider. It must help the client get in touch with the client’s feelings. This however is more like an empathetic response. At this stage of the therapeutic process the client already is supposed to have the idea the therapist empathizes. The therapist would not be in a position to offer even a dilute interpretation unless the therapist already had gathered sufficient data to make a provisional clinical diagnosis. All the hunch does is present a watered-down version of an operationalized action plan.
In conclusion, for Egan, having a hunch and expressing it to a client is a little bit like talking to a bright eight-year old. It is a guru-like pronouncement presented in an informal, folksy way. But it is a superfluous and potentially misleading step in the process of psychological diagnosis, which readily can and should be eliminated.