Download gnosis: beyond disease and disorder to a diagnosis inclusive of gifts

GNOSIS: BEYOND DISEASE AND DISORDER
TO A DIAGNOSIS INCLUSIVE OF GIFTS AND CHALLENGES
Robert L. R. Hutchins, Ph.D.
Sonoma Developmental Center
Eldridge, California
ABSTRACT: A radical reorientation is needed for health to be the primary focus of diagnosis. Historically,
medical diagnosis has focused primarily on disease and that diagnostic perspective puts our clients at risk
of being reduced to clinical descriptions of pathology. This article introduces the Gnosis model, a concise
pragmatic extension of the diagnostic axes of the Diagnostic and Statistical Manual of Mental Disorders
(DSM), that includes the person’s goals, gifts, abilities, and supports.
Axis
Axis
Axis
Axis
Axis
I
II
III
IV
V
Gnosis
DSM Diagnosis
Calling and Goals
Core Gifts and Abilities
Physical Gifts
Psychosocial and Environmental Supports
System Gifts: Family/Community/Culture
Clinical Disorders
Personality Disorders/Mental Retardation
General Medical Conditions
Psychosocial and Environmental Stressors
Global Assessment of Functioning
Four examples of this Gnosis model are presented. The effect of using this more balanced diagnostic
practice is described and discussed.
Throughout millennia diagnosis has focused primarily on identifying diseases
(Crookshank, 1926). The basic premise is that we must first clearly name a problem
in order to treat or heal it. The process of diagnosing disease is an essential part of
the healing process, but it shows only a partial view of a person.
One can tell a story about a person in terms of what is strong and impressive or
a story that selects out for attention what is diseased or disordered (White & Epston,
1990). The selection process can be a powerful defining moment for the person’s
identity. Labeling someone as schizophrenic or borderline can be a virtual life
sentence. It can impose a reality on that person that can be difficult if not impossible
to escape. When we as clinicians focus solely on our clients’ problems, there is
a serious risk that they will be reduced to clinical descriptions of pathology.
Wouldn’t our clients be better served if we had a diagnostic tool that not only named
their illnesses, but their gifts and abilities as well? This paper presents the Gnosis
model as a way of meeting this need.
Both the words Diagnosis and Gnosis come from the same Greek root meaning ‘‘to
know.’’ Diagnosis initially meant to know clearly or directly, but through use has
come to mean to know and correctly classify a disease or disorder (Crookshank,
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Copyright Ó 2002 Transpersonal Institute
The Journal of Transpersonal Psychology, 2002, Vol. 34, No. 2
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1926). Gnosis carries a connotation of direct, true knowledge and has been
a synonym for direct knowledge of God, truth, or reality. Gnosis is used in this
article as a broader term for knowing that is not limited to a pathological orientation.
Instead, Gnosis is defined as a true, deep knowing of a person that includes both his
or her gifts and challenges.
THE CURRENT STATE OF DIAGNOSIS IN THE FIELD OF MENTAL HEALTH
Before we explore the Gnosis model, it is important that we understand the current
state of diagnosis within the field of mental health. Mental health diagnosis has
modeled itself after the field of medicine by concentrating on pathology. Thus,
diagnosis in psychiatry’s Diagnostic and Statistical Manual—DSM-IV (1994)
focuses on diseases and disorders and their classification. Specifically, the DSM-IV
assesses a person on five different axes in order to simultaneously present a person’s
primary psychiatric problem(s), long term cognitive or character issues, stressors,
and an overview of how well he or she is functioning in one brief summary. Clearly
the DSM’s pioneering use of a multilevel assessment, which began with the DSM-III
(1980), has provided a comprehensive and effective approach to planning treatment
and predicting outcome. Diagnosis, however, has continued to be limited to
categorizing and treating pathology.
Decades ago, before the first DSM, humanistic and transpersonal psychologists and
other healing arts professionals began to shift the overall context and frame of
treatment away from pathology and toward health. In the healing arts, there has been
a long-standing dialogue about the need to both know the individual and know and treat
his or her disease (Crookshank, 1926; McWhinney, 1989). In 1968, Maslow suggested
that we study the healthy aspects of human psychology instead of the sick aspects.
Lukoff (1985) built on the work of Maslow by pioneering the diagnosis of mystical
experiences with psychotic features and by establishing a non-disorder category in
the DSM-IV for religious experiences. Before Lukoff, transpersonal experiences and
ways of being were often interpreted as pathological, and transpersonal experiences
that served a person’s growth and spiritual evolution rarely had a positive context
that was considered in diagnosis. Thus, Lukoff helped to de-pathologize religious
and mystical experiences for the broader community of mental health professionals.
Wilber (1984, 1986, 1987) and Washburn (1994, 1995), two important transpersonal
philosophers, expanded the framework for diagnosis when they described discrete
stages or levels of personal and spiritual growth. Although their systems differ in
significant ways, both Wilber and Washburn agree that ‘‘an individual must develop
a healthy and strong ego before he or she can successfully transcend that ego, and
that failure to do so results in a pathological state, often accompanied by great
subjective distress. Both also agree that a well-prepared individual can progress to
trans-egoic states that foreshadow ultimate reunion with the Absolute’’ (Lukoff,
2000).
The works of Wilber and Washburn provide a meta-diagnosis or a framing of the
range of states described in clinical diagnoses into a larger spectrum of
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consciousness. Although outside the scope of the present effort, one can imagine
a transpersonal DSM that names and classifies human potential in some standardized
way, perhaps using and expanding Wilber or Washburn’s system. However, we are
still a long way from such a transpersonal method of diagnosis.
Unfortunately there is still no universally accepted health-oriented clinical
diagnostic tool equivalent to the DSM. The Gnosis model serves as a step toward
filling that gap. The intent of this article is to make seeing the uniqueness and health
in a person central to diagnosis and treatment.
GNOSIS MODEL
The concept of Gnosis serves to complement and expand the DSM-IV axes. The
Gnosis/Diagnosis combination, referred to as the Gnosis Model, is intended to
provide a broader and more complete picture of an individual’s mental health. Just
as transpersonal psychology includes the psychologies that came before it in a larger
context, the addition of the Gnosis axes includes the DSM-IV axes while making the
DSM’s pathological focus only a subset of the overall understanding of the person.
Using the current DSM axes as a departure point for a more balanced approach
produces the following levels of analysis.
Table 1
Gnosis Model
Axis
Axis
Axis
Axis
Axis
I
II
III
IV
V
Gnosis
DSM Diagnosis
Calling and Goals
Core Gifts and Abilities
Physical Gifts
Psychosocial and Environmental Supports
System Gifts: Family/Community/Culture
Clinical Disorders
Personality Disorders/Mental Retardation
General Medical Conditions
Psychosocial and Environmental Stressors
Global Assessment of Functioning
Origin and Development of Gnosis
As a young clinician, I fell in love with the concept of diagnosis. Knowing and
naming a problem seemed marvelous, like a hunter catching its prey or a detective
successfully solving a mystery. As a result, I spent years enthusiastically diagnosing.
I wrote a dissertation that was a kind of mythic diagnosis of the core or archetypal
patterning of a person’s life (Hutchins, 1984).
When I started working with people with developmental disabilities in 1987, the field
was about to undergo a revolution. The passage of the Americans with Disabilities Act
in 1990 and its enactment into law in 1992 marked a turning point in developmental
services. A human rights movement emerged in the ‘‘disabilities’’ field insisting that
people’s gifts and abilities be the focus of attention, not their deficits (Snow, 1994).
This new paradigm focused on what a person could do rather than what a person could
not do. Similarly, support became seen as the key ingredient in success rather than
overcoming problems or appropriate adjustment. Thus, the philosophy of de-
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velopmental services had suddenly leapt from an expert-driven, interdisciplinary team
model to a person-centered, humanistic model of treatment.
With this person-centered humanistic model of treatment as a guide, the idea for
a gifts and abilities diagnosis came to me in 1994 during a spiritual retreat. At first,
the simple shift from pathology to gifts and abilities seemed like a minor revelation.
It was like shifting from a photographic negative to its printed picture, with the dark
places being replaced by the light. It seemed obvious and simple: if we can diagnose
for what is diseased or disordered, then we can diagnose for what is healthy. The
levels of interpretation used by the DSM-IV (1994) were clearly useful. Instead of
focusing on a person’s problems, however, the focus became a person’s gifts and
abilities. The first versions of Gnosis involved simply replacing the pathology focus
with a focus on gifts and abilities. Core Gifts and Abilities replaced the DSM-IV’s
Axis I, Gifts of Character replaced Axis II, Physical Gifts replaced Axis III, etc.;
Supports replaced Stressors etc., etc.
Thus, initially I only focused on the positive aspects of certain clients who otherwise
had long and illustrious negative histories. My colleagues reported that they could
understand what I was attempting to do, but they felt it was either unrealistic or
unbalanced. It was then that I began combining the positive diagnosis with a more
traditional DSM diagnosis, which seemed more acceptable to both the staff and the
clients. I recognized that seeing only the positive was as limiting to a person’s reality
(in a similar although inverse way) as seeing only a person’s pathology. A real
Gnosis, a true and deep knowing of a person, must include both a person’s gifts and
his or her challenges.
Over the past 8 years, the Gnosis model has evolved through several different
versions with axes shifting, being added, or being dropped. This process of refining
was fed by my own extensive clinical experience in person-centered settings and
feedback from colleagues and students. Specifically, simple versions were circulated
to colleagues and taken to conferences for feedback. In addition, the Gnosis model
was introduced to undergraduate and graduate students in psychology during their
clinical practica on diagnosis. At present, it is being taught to psychology interns and
new psychologists as the format for case presentations during group supervision at
my developmental center. I also recently gave a medical education lecture on the
Gnosis model to physicians. As a result, some clinicians, students, and interns have
taken this tool into their clinical practices. I welcome your comments, and I am
intensely interested in the effects of using this model with people and systems.
Gnosis Axes
The Gnosis model on one hand utilizes the current DSM-IV’s axes to describe diseases
and disorders and on the other hand introduces a parallel set of axes to outline a person’s
gifts and abilities. These new Gnosis axes are a simple distillation of a person-centered,
wellness paradigm that orients itself around a person’s calling, goals, and core gifts,
and the support systems necessary to realize them. The Gnosis axes, themselves, are
fairly self-evident in meaning and level of interpretation. A Gnosis for gifts and
abilities, like a traditional diagnosis, uses all available sources of information about
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a person. A Gnosis is most successful when it is a co-created. Thus, a Gnosis is best
done in direct collaboration with the client and his or her circle of support.
Axis I (Goals or Calling). This axis refers to a person’s calling or life goals, his or
her sense of mission, vision, or destiny. Hillman’s book entitled Soul Code (1996)
provides a description of this kind of teleological knowledge. Hillman theorizes that,
‘‘each person bears a uniqueness that asks to be lived and that is already present
before it can be lived’’ (p.6). It is this knowledge of destiny, the innate knowing in
a tiny acorn that it has the potential to be a great oak tree, which is captured in Axis I.
This axis can easily be used to differentiate short term, long term, and life goals.
Thus under this axis one might note a person’s calling as a writer and then note such
specific goals as writing a novel or theoretical treatise.
Axis II (Core Gifts and Abilities). This axis refers to those gifts and abilities that
are essential to a person. Gifts in music, mathematics, or art are some obvious gifts
that might be included. This axis is also used for gifts of character, such as
perseverance, honesty, and trustworthiness. This axis excludes physical gifts and
abilities as these are covered in Axis III. One accessing question for this axis is
‘‘What is the unique contribution that this person makes through her or his life?’’
A female artist friend provides a clear example of such core gifts. She is both deeply
creative and open-handedly generous to the extent that she gives away much of her
art. The centrality of her gifts of creativity and generosity come through in the
blissful, childlike pleasure she takes in creating and sharing her work with others.
Axis III (Physical Gifts and Abilities). This axis refers to a person’s physical gifts
and abilities. These gifts include athletic prowess, gross and fine motor skills, and
physical appearance. A female colleague provides a good example of someone with
physical gifts and abilities. She transformed herself through martial arts training into
a woman of great physical grace and presence. Her physical skills are now a source
of inspiration as she teaches others.
Axis IV (Psychosocial and Environmental Supports). Psychosocial supports are the
people, ideas, and relationships that assist a person (i.e., the software of support).
Psychosocial supports are classified as either current or needed. Current
psychosocial supports are those that a person already has in his or her life. This
is usually the immediate support system surrounding a person, such as family,
friends or caregivers. Needed psychosocial supports are the additional peoples,
ideas, and relationships considered necessary for a person to actively move toward
his or her life dreams and/or to express his or her gifts and abilities. A good example
of needed supports comes from a support group I led several years ago in which
a bright and capable 40-year-old woman admitted that she had always wanted to be
a doctor. With support from the group and some providential serendipity, she took
the steps to apply and enter medical school. She is now a physician.
Environmental supports are the environments and physical tools that assist a person
(i.e., the hardware of support). Like psychosocial supports, environmental supports
are classified as either current or needed. Current environmental supports are those
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already functioning in a person’s life, such as an electric wheelchair. Other examples
of current environmental supports might include certain forms of technology, such
as computers, email, and the internet, or the physical aspects of a social support
system, such as a co-housing development. Needed environmental supports are the
additional environments and physical tools considered necessary for a person to
actively move toward his or her life dreams and/or to express his or her gifts and
abilities.
Axis V (Systems Gifts and Problems). This axis refers to the social systems that
assist or hinder a person: system gifts or system problems. It can be used for social
systems that bestow gifts and abilities on a person and those that support the
unfoldment of a person’s gifts and abilities. It can also be used for social systems
that remove gifts and abilities from a person and those that obstruct the unfoldment
of a person’s gifts and abilities.
Axis V is divided into three sub-axes: family, community, and cultural. Each subaxis is classified as either current or needed. Examples of family gifts that have been
bestowed might include exquisite pastry-baking skills passed down through
generations of women in a French family or debating skills promoted in a lawyer’s
family. Community gifts might include such life-changing, active support as that
received from participation in Alcoholics Anonymous or from living in a community
of ethnically diverse yet like-minded individuals. Gifts of culture might include
a person’s folklore, such as cultural hero stories (e.g., Horatio Alger) or cultural
routines (e.g., the American work ethic of being on time and working hard).
As for social systems that hinder a person, the social system axis provides a way to
address systems’ issues that are clearly missing from the current DSM-IV’s levels of
analysis. In order to make an accurate diagnosis, one must know the systemic level
at which a problem occurs and at which it can best be treated. A person’s problems
may be a function of individual biology, psychology, social/environmental setting,
or social systems within which the person lives and functions. Thus, a person’s
problem might not be a function of his or her own pathology, but rather a function of
the social or cultural systems surrounding him or her. For example, attempting to
cope with racism as an individual’s problem may assist that person in day-to-day
living, but do little to actually treat or solve the problem. Conversely, changing an
entire social system of treatment, as has occurred with the development of the
Supported Living model for people with developmental disabilities, can solve many
problems without requiring any change on the part of the individual.
As a result, Axis V is often used to summarize the positive and/or negative effects of
the social systems surrounding a person. It is my position that the DSM-IV should be
expanded to include an axis for social systems analysis, and that the DSM’s current
Biopsychosocial model (Engel, 1980) needs to be expanded to a Biopsychosociocultural model. If and when the DSM-IV has an axis that addresses issues such as
poverty, racism, and rigid top-down hierarchical organizational structures, then the
Gnosis axes can simply reflect positive gifts.
Finally, system gifts that are needed (as opposed to current) provide an opportunity
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to visualize the system level of supports needed for a person’s life to come to full
expression.
Please note that there is no attempt here to provide specific criteria for health or for
a person’s gifts and abilities. Such criteria would be useful and would perhaps make
this tool more effective. However, the DSM-IV (1994) is literally the product of
hundreds of people and many contributing organizations, and classifying and
codifying health would likely take a similar number of people and organizations, if
not more.
Using the Gnosis Model
Using the Gnosis model and axes is more than merely enhancing the DSM-IV
(1994). It involves shifting one’s central focus and clinical concerns to a view that
incorporates a person’s problems as well as his or her goals, gifts, and abilities. The
effect of this shift can be profound. The shift has to be more than a change in talk or
the dominant theory; it must also be a change in walk or the actual practices that
implement it. Thus, it must be a change in the treatment system. Such a change in
view can mean the difference between being treated as a diseased or disabled person
for whom experts make decisions and being treated as a person who can make
decisions for him or herself. The system using the Gnosis model can take any form
so long as it helps the person be seen as a whole and focuses on realizing the
person’s goals and gifts and overcoming his/her challenges.
Four examples are presented below. Two are actual clients whose identities have
been disguised; two are composites. I have tried to present a broad range of possible
conditions. The Gnosis model can be applied to anyone regardless of challenges or
gifts. Take these examples as merely suggestive, not as prescriptive or limiting. I am
interested in others exploring and using the Gnosis model and carrying on a dialogue
about our discoveries. In each story there are two sections: Pre-Gnosis and PostGnosis. As you read these stories please consider what view you would have of
these people and their lives if you only had access to their DSM-IV diagnoses. What
is added by having a Gnosis as well as a diagnosis?
Claire’s Story
Pre-Gnosis. Claire (Table 2) is a talented visual artist in her early 30s. She has
three children, ages 4, 8, and 11. Claire’s husband, Tom, abandoned her and quit his
well-paid computer-programming job. This left Claire, who had been a homemaker,
without income and support. Claire and her children moved in with another single
parent family. She went through her family savings in the first 4 months and began
to pay her bills with credit cards. She was traveling on a bus looking for jobs when
she suddenly felt she could not breathe, her heart started pounding, and she felt she
was going to die. She got off the bus at the next stop, and the feeling of dread and
doom receded as she walked. At first she thought it was just a bad day, but a week
later, on her way to another job interview, the same thing happened again. After the
fourth time, Claire talked with a friend who was a therapist. This friend recognized
her problem as panic attacks. Claire went to see a psychiatrist who prescribed an
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107
Table 2
Claire
Gnosis
Diagnosis
Axis I
Calling: Artist, mother.
Goals: High paying job to support her
family and return to more joyous and
less strained parenting.
Clinical Disorders: 300.01 Panic
Disorder without Agoraphobia.
Axis II
Core Gifts and Abilities: Caring,
generous, and empathetic. Clear
communicator and social organizer.
Clear voice, gift for singing harmony
and playing by ear.
Personality Disorders/Mental Retardation:
Some compulsive traits, but no
diagnosis.
Axis III
Physical Gifts: Physically strong. Good
with her hands.
General Medical Conditions:
Gastroesophageal reflux, insomnia.
Axis IV
Psychosocial Supports Current: Strong
godparents for children, and good
women friends.
Environmental Supports: Shared house with
other single parent.
Psychosocial/Environmental Problems:
Problems with primary support group:
Severe parenting and financial
stresses after divorce.
Axis V
System Gifts, Family: Family of strong faith
who provides emotional and financial
support when needed.
System Gifts, Community: University
re-entry program provides counseling,
childcare and parenting support.
System Gifts, Culture: Women’s movement
has helped build support structures for
women like Claire.
Global Assessment of Functioning Scale:
50 serious symptoms interfering
with life during acute period.
antidepressant. Subsequently she stopped having panic attacks, but she still felt
anxious and overwhelmed.
Post-Gnosis. Claire’s parents and her children’s godparents helped her through
this difficult period. Her parents provided interim financial support and took the
children over most holidays. The godparents provided respite by taking the children
on alternate weekends. The godfather also connected Claire to a Women’s Return to
Work program at the nearby state university. This program assessed her gifts and
abilities and assisted her in setting goals and building a support system. She took
advantage of the university counseling center for herself and for family therapy. Her
social support system and finances became more stable. Concurrently she was able
to learn cognitive behavioral techniques to handle her anxiety.
John’s Story
Pre-Gnosis. John (Table 3) is a handsome young man who is good with his hands.
John was physically and sexually abused as a child. He grew up in a large, singleparent, minority family. He got into drugs and sex in his early teens. In his early 20s,
while drunk, he molested a cousin. Consequently he was arrested, convicted of
molestation, and imprisoned for 18 months. During probation he was cooperative,
and he looked forward to making a new life for himself. He was helpful and well
liked. Unfortunately no employer was willing to hire a convicted sex offender. After
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Table 3
John
Gnosis
Diagnosis
Axis I
Calling and Goals: Marry girlfriend,
get a good job as a mechanic.
Clinical Disorders: 296.0 Bipolar Mood
Disorder, Manic with mood congruent
psychotic features. Rule out Pedophilia
315.00 Reading Disorder/Dyslexia. History
of alcohol/drug abuse.
Axis II
Core Gifts and Abilities: Personable,
genuinely likable, well-spoken, polite,
helpful, humorous (can laugh at
himself), and creative storyteller.
He has gifts in understanding engines
and things mechanical.
Personality Disorders/Mental Retardation:
Rule out Antisocial Personality
Disorder, history suggests possible
personality disorder not apparent in
current setting.
Axis III
Physical Gifts: Good gross and fine motor General Medical Conditions: None.
skills, handsome, attractive smile. He is
good with his hands and likes to build
things and take them apart.
Axis IV
Psychosocial and Environmental Supports:
Current: Committed girl friend. Job
Coach in autobody work. Junior
college course in auto mechanics.
Needed: Job as mechanic.
Psychosocial/Environmental Problems:
Stigma of being sex offender. Multiple job
rejections, inappropriate job
placement.
Axis V
System Gifts, Family: Large caring family
nearby.
System Gifts, Community: Gnosis oriented
group home.
System Gifts, Culture: Minority culture
supportive of those discriminated
against like John.
System Problems: Social stigmas of sexual
offense, mental illness, and racist
stereotypes against minority males
prevent meaningful opportunities to work
in the community.
Global Assessment of Functioning Scale: 35
severely impaired during acute
episode.
a long job search, he was placed in a sheltered workshop with disabled people. The
paid work ran out, and he was expected to sit and watch TV with his disabled coworkers. At that point he appeared depressed. He stopped getting out of bed and
refused to go to work, saying there was no point. Soon thereafter he began to talk
rapidly about being a rock promoter, and he claimed that people had stolen his
fortune. His sleep was disturbed, and he sought to make phone calls all over the
country to supposed music contacts. He was started on neuroleptic medication. His
anger and irritation increased, he started threatening staff, and he was eventually sent
back to jail. Six months later he returned to the group home, and the Gnosis process
began.
Post-Gnosis. John was well liked at his group home. When John returned to the
group home, the stigmatization process that had led to his decompensation was
reversed. Staff pointedly treated him as a respected equal. He focused on his
mechanical gifts and was able to seek meaningful work. Then a staff friend was
enlisted to be his job coach in an auto body shop. A year later, he started an auto
mechanics training course at the local junior college. Probably most important,
a former girl friend reconnected with him, and they became a committed couple. Their
relationship grew to be solid and satisfying. At present, they are planning to marry.
Concurrent with the social support, he was placed on a mood stabilizing anticonvulsant.
The helpful factors in his treatment seemed to be returning him to full membership
Gnosis: Beyond Disease and Disorder
109
in society and connecting him with goals and a feeling of having a meaningful
future. The medication was eventually discontinued, and John continues to do well
without it. He finished probation and now is seeking employment as a mechanic in
a large auto shop chain.
Charlie’s Story
Pre-Gnosis. Charlie (Table 4) is a man in his 40s with a ready smile and
a persistent attitude. Charlie was living with 40 other people in a large group setting.
He was well liked but not well understood. His receptive language was very good
and his comprehension excellent, but his expressive language was unclear. The staff
did not have time to adequately listen to him and learn who he was. His own goals
were not articulated or understood. He used a hand-propelled wheelchair to move
about. His seizures were not well controlled and were very debilitating for him. He
occasionally got angry, threw things, and hit people.
Post-Gnosis. His life has transformed through shifting to a wellness-oriented
system of care. Six years ago, Charlie moved from his large, institutional, problemdominated home to a Gnosis-oriented home that focused on his goals and gifts and
Table 4
Charlie
Gnosis
110
Diagnosis
Axis I
Calling: Write his stories.
Goals: Walk; reduce seizures; have
a meaningful, intimate relationship;
get paid well; and be respected
for his work.
Clinical Disorders: No diagnosis.
Occasionally explosive, not
diagnosable.
Axis II
Core Gifts and Abilities: Good friend;
persistent, clear decision-maker;
creative and original story ideas.
Personality Disorders/Mental Retardation:
Mild to moderate mental retardation
and cognitive challenges.
Axis III
Physical Gifts: Physically strong with
stupendous, infectious smile.
General Medical Conditions: Expressive
Aphasia, Seizure Disorder, and
problems of balance.
Axis IV
Psychosocial Supports: Current is
one-to-three staffing, awake overnight
staff, movement trainer, and co-writer
with computer skills. Needed are
friend and girlfriend.
Environmental Supports: Current is Rifton
walker, plus bed with padded rails.
Needed is none.
Psychosocial/Environmental Problems:
Mild: due to living with those not of
his choosing.
Axis V
System Gifts, Family: Foster family
reconnected.
System Gifts, Community: Small
customized home with staff team that
supports his full participation in
decision-making.
System Gifts, Culture: California after
revised Lantermann Act, 1993, can be
supportive of people with disabilities
in person-centered systems.
Global Assessment of Functioning Scale:
45—Pervasive physical problems
require consistent staff support
and supervision.
The Journal of Transpersonal Psychology, 2002, Vol. 34, No. 2
provided the supports he needed to realize them. Staff members at his new home had
the time to fully listen to him. As a result, he became a published author through cowriting with staff members. He started walking again with a Rifton walker. He
significantly reduced the frequency of his seizures through volunteering to be the
first person in his institution to have a Vagal Nerve Stimulator implanted. He
reconnected with his foster family, and he began dating a new girlfriend.
Anne’s Story
Pre-Gnosis. Anne’s (Table 5) father died when she was 10, and her mother began
to drink heavily. Her mother moved them away from her friends in the city to a small
town in the country. During this period, Anne’s mother was verbally abusive, and
Anne became depressed and suicidal. At one point, she was rejected by her best
friend and felt powerless and hopeless. She became unable to speak voluntarily for 2
weeks. At that point, a therapist suggested medication. She then pulled herself
together enough to avoid hospitalization and medication.
One day, while walking on the beach, Anne felt crushed by her mother’s rejection.
She then realized that she was not perfect in the way her mother wished, but she was
perfect in the way nature wished. She understood that she was like all of the rough
waves in the ocean: she was part of the whole, and the whole was beautiful. She
heard an unseen, benevolent male voice say, ‘‘Love your brother; the Majesty is to
share.’’
Table 5
Anne
Gnosis
Diagnosis
Axis I
Calling: Be a writer, creative artist, and
teacher to ‘‘Love and share the
Majesty.’’
Goals: Find teachers and community to
support her vision.
Clinical Disorders: 296.2 Major Depressive
Disorder, Single Episode.
Axis II
Core Gifts and Abilities: Intellectually
brilliant, creative, artistic, intense, and
passionate about life.
Personality Disorders/Mental Retardation:
No diagnosis.
Axis III
Physical Gifts: Generally healthy and well
coordinated. Penetrating deep blue eyes.
Sexually open.
General Medical Conditions: Terminated
pregnancy at 17. Mononucleosis and
pneumonia in past year.
Axis IV
Psychosocial Supports: Current is
empowering second mother figure and
strong girlfriend. Needed is none.
Environmental Supports: Current is
physically residing in second mother
figure’s home. Needed is none.
Psychosocial Problems: Alcoholic, verbally
abusive mother.
Environmental Problems: Several moves
during adolescence resulting in loss of
community/friendships.
Axis V
System Gifts, Family: As noted above.
System Gifts, Community: Supportive
college psychology department.
System Gifts, Culture: Humanistic
transpersonal world community provides
context and direction.
Global Assessment of Functioning Scale:
50 (current)–serious symptoms
during acute 2-week period.
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Post-Gnosis. A motherly psychology professor met and took a liking to Anne.
This woman accepted and cared for Anne. She saw Anne not only as gifted but also
as a gift in and of herself. Anne moved in with the professor and lived with her the
last year before college. She then entered a humanistic psychology program that
continued and deepened her sense of health and well-being. Since then, her mood
has fluctuated, but she has never returned to being at risk for suicide. Beyond simple
health, she has also become a teacher and exemplar of her vision.
DISCUSSION
The Gnosis model intentionally highlights what most clinicians already do in their
practices. Any competent clinician, regardless of orientation, seeks to foster and
support a person’s gifts and abilities as well as aid him or her in overcoming
personal challenges. In addition, clinicians in supported-living, person-centered
planning and futures-planning formats have been using person-centered methods,
which the Gnosis model summarizes, for decades (O’Brien, 1992, 1998; Smull,
1992). Finally, clinicians with a humanistic or transpersonal orientation have
focused on health for 40 years or more. What has been missing across the board has
been a practical way to marry the traditional medical approach with the approaches
developed in humanistic, transpersonal, and person-centered work. The Gnosis
model provides such a synthesis.
Gnosis Limitations
The problem with any brief summary of conclusions about a person, regardless of its
ability to filter out bias, is that it produces a limited and diminished version of that
person. It is similar to only getting the headlines about a person and not the real
substance. With this in mind, the Gnosis model should merely serve as headlines
that lead us to the fuller, richer story. Headlines, after all, are meant to summarize
and draw us into the story, not to stand alone. Thus, when using the Gnosis model,
we should seek to tell a client’s story more in the manner of a literary biography or
a novel. We must continue to remember that our clients are people with problems
and abilities, not merely problems and abilities by themselves.
Final Thoughts on Gnosis
Most clinicians have participated in numerous clinical case reviews in which
extensive descriptions of a person’s problems dominated the consciousness of the
group to the exclusion of all else. This pathological focus has tended to create
a negative, trance-like state within the group and poison the view of the client and
his or her potential for healing.
The Gnosis model, with its more inclusive process that insists on seeing other, more
positive aspects of a person, can help the group break out of this trance. The
response of clinicians to using the Gnosis model has been uplifting and life
affirming. In my work with many clients who are non-verbal or limited in their
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ability to express themselves, staff members are often relied upon to describe their
clients. The effect of talking about a client’s gifts and abilities has been to help staff
members access those gifts, create a more positive reality, and tell a story of
strength. Instead of hiding the diagnosis in the clinical record and avoiding talking
directly with the client about it, as one might do with a psychiatric diagnosis and
a volatile client, staff members have actively displayed Gnosis evaluations as a wall
poster in clients’ rooms. It became clear the Gnosis process was on the right track
when the mother of one of the clients asked to use his Gnosis as half of his memorial
service program after he tragically died.
CONCLUSION
The intent of a conceptual process, such as diagnosis, is to select what we choose to
value as worthy of attention and discard what we choose to value as unworthy of
attention. Thus, it functions like the zoom lens on a camera to either narrow or widen
the view of the world that we see. When we use a problem-focused diagnostic
process, we can easily lose sight of the whole individual. The disease becomes the
primary focus, often to the exclusion of the person. The Gnosis model brings the
person and his or her concerns back to the forefront, while still honoring the need to
provide treatment for his or her problems.
This article is a call to re-see our clients and each other in terms of each person’s
goals, gifts, abilities, and the supports needed to fully realize them. The effect of
such a process on people whose lives have been dominated by problems can be
profound. The effect of implementing systems of care based on these premises can
be liberating.
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The Author
Robert Hutchins currently serves as a psychologist to the State of California’s,
Sonoma Developmental Center and to community group homes. He has been
a mental health clinician since 1977 and a psychologist since 1987. His clinical work
includes six years as founding consultant/team member of a self-directed-work-team
charged with the responsibility to create a new system of care for those with
developmental challenges. His written work includes workbooks to assist in goal
setting and support building and articles on seeing beyond disabilities to our shared
basic humanness. Robert has been married for 28 years and has two young children.
Please contact Robert if you are interested in applying the Gnosis Model in your
practice. He is particularly interested in systems that might want to further field test
the model.
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