Diagnosis and Case Formulation in Humanistic Psychotherapies

Introduction

The humanistic psychology movement emerged in the 1960s in the United States as a countercultural response to psychology’s limitations at the time (Moss, 2014). It offered a more holistic and less deterministic view than the predominant paradigms of that era, particularly psychoanalysis and behaviorism. In this pursuit, humanistic psychology advocated for the exploration of topics that had been largely neglected within traditional psychology from a systematic research standpoint, such as love, health, the human experience, creativity, and spirituality. While considered to be a pluralistic movement both theoretically and practically, it is united by core principles that emphasize studying the human being in a holistic manner, recognizing that all knowledge arises within a human context (Martínez, 1993). Humanistic psychology asserts that humans possess the capacity for decision-making, pursue goals, and assign equal value to both consciousness and the unconscious (Bugental, 1964). This perspective does not reject knowledge from other schools but rather seeks to broaden the understanding of the human experience, such as when Maslow suggested that a humanistic psychologist should also be well-versed in psychoanalysis and behaviorism (Villegas, 1986).

In addition to its diversity of ideas, some proponents of humanistic psychology were involved in both this movement and others; furthermore, within its ranks, psychologists and professionals from other sciences and arts were included. This inclusivity poses challenges when attempting to establish a clear theoretical delineation. In response to this diversity, Rowan (1989) identifies two major groups within humanistic psychologies. The first is based on the idea of an individual’s potential for health, whose main proponents are authors such as Carl Rogers and Abraham Maslow. On the other hand, the existentialist schools represented by John Mahrer and Rollo May, among others, reject the notion of a fixed human essence, instead emphasizing existential becoming, experienced moment by moment.

Over the past 60 years, the principles of humanistic psychotherapy and its proponents have gained global recognition, been translated into multiple languages, and led to the establishment of study centers across all five continents (Schneider et al., 2014). Furthermore, scientific evidence supports its effectiveness, placing it on par with other major schools of psychology (Angus et al., 2015; Elliott, 2002; Elliott et al., 2020; Lambert et al., 2016).

Despite its many contributions, humanistic psychology has at times been subject to lack of recognition, minimization, demonization, and caricature by other schools or influential groups (Elkins, 2009). Several historical developments help to contextualize this pattern. During the mid-20th century, psychodynamic and psychosocial models dominated mainstream psychology and psychiatry. In the decades that followed, the balance of influence gradually shifted. By the 1990s, the rise of the so-called “second biological psychiatry” (du Plock, 1997) signaled a renewed dominance of biomedical approaches to diagnosis and treatment, further sidelining alternative frameworks such as humanistic psychology.

One such example of minimization and misunderstanding concerns the persistent portrayal of humanistic psychology as rejecting diagnosis altogether, on the grounds that it is inherently detrimental to the client. This characterization has, at times, been extended to suggest that humanistic psychologists also reject psychotherapeutic approaches grounded in case formulation (Eells, 2009, 2022; Gonzalez, 2008; Greenberg et al., 2013; Johnstone & Dallos, 2006; Kramer, 2019; Pascual-Leone et al., 2016; Zubernis & Snyder, 2016). Such portrayals persist despite the sustained scholarly engagement with diagnosis and case formulation within humanistic psychology, including dedicated journal discussions, theoretical developments, and the articulation of diverse formulation models across its various traditions.

This article seeks to challenge the notion that humanistic psychologists do not engage in diagnosis or case formulation, arguing that the issue with this claim lies not in its inaccuracy but in its overgeneralization. While some humanistic therapists have indeed opposed diagnosis defined from a conventional or reductionistic perspective, this perspective cannot be taken as representative of the entire humanistic psychology community, particularly its contemporary stance.

Three areas of focus provide structure for the article, the first of which examines the internal discourse within humanistic psychology regarding the concept of diagnosis, addressing its theoretical and practical implications. The second section analyzes the discussion about the necessity and utility of case formulation within this framework. Finally, the third section presents a state-of-the-art review of case formulation models developed across various humanistic schools.

The significance of this work to the scientific community lies in its contribution to clarifying a widely misunderstood aspect of humanistic psychology—its approach to diagnosis and case formulation. Additionally, it serves as a valuable resource for educators and trainers by providing an updated state-of-the-art overview of this subject. Lastly, the article offers practical implications for professionals seeking to implement humanistic alternatives in case formulation within their clinical practice.

A Humanistic Approach to Diagnosis

Within humanistic psychology, some influential authors have expressed reservations about the biomedical diagnostic model. For example, Rogers (1951) indicated that diagnosis “is unnecessary for psychotherapy and may actually be a detriment to the therapeutic process” (p. 220). More recently, as noted by Rowan (2015) in the latest Handbook of Humanistic Psychology, “the existential-humanistic view is that you cannot diagnose human beings, and using the word assessment does not improve matters” (p. 557). While this assertion reflects a strong stance within certain strands of humanistic thought, it resonates with broader clinical efforts—such as person-first language—to prioritize individual over the label. Consistent with this perspective, psychiatric diagnosis fails to accurately capture the client’s experience, may not facilitate psychotherapeutic change, and is even regarded by some as a potentially harmful practice.

Humanistic psychologists have also offered responses to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), beginning with an open letter from the Society for Humanistic Psychology in 2011. The letter was signed by over 15,000 mental health professionals and more than 50 international organizations (Kamens et al., 2017b). The Journal of Humanistic Psychology dedicated five issues to discussing DSM-5 and exploring alternatives (Kamens et al., 2017a, 2018, 2019a, 2019b, 2019c). Other notable efforts include the establishment of an APA Division 32 task force, the Global Summit on Diagnostic Alternatives, and panel discussions at APA annual conferences (Robbins et al., 2017). The critique of DSM-5 centers on four key issues: (a) the lowering of diagnostic thresholds; (b) the introduction of new disorders that risk inadequate treatment for vulnerable populations; (c) insufficient empirical support for certain proposals; and (e) the biologically focused definition of mental disorder, which neglects socio-cultural dimensions.

It is possible that the critique of psychiatric diagnosis from the hegemonic biomedical model may have contributed to the myth that humanistic psychology does not engage with diagnoses, as suggested by various authors both within and outside the field (i.e., Eells, 2009, 2022; Gonzalez, 2008; Greenberg et al., 2013; Johnstone & Dallos, 2006; Kramer, 2019; Pascual-Leone et al., 2016; Zubernis & Snyder, 2016). However, as previously noted, humanistic psychology is a pluralistic movement where diverse perspectives on a given topic coexist—and diagnosis is no exception. While some authors express strong criticism of conventional diagnostic practices, other propose rethinking the concept of diagnosis altogether, exploring its historical, etymological, clinical, and philosophical dimensions in ways that are more congruent with the humanistic values.

It can be argued that humanistic psychology, as a whole, has made significant contributions toward new forms of diagnosis by classifying and understanding human experience and suffering. Evidence of this affirmation can be found in concepts such as the Real Self, Ideal Self, and incongruence in person-centered approaches; boundary disturbances, contact cycle, and stages of neurosis in gestalt therapy; sense of life, creative, experiential, and attitudinal values, as well as noogenic neurosis in logotherapy; experiential level, frozen wholes, in addition to ways of disconnecting from direct reference to experience such as circumstantial orbit, explanatory orbit, clear emotions, and reengineering in experiential therapy.

Other authors within this framework have suggested new diagnostic categories aimed at overcoming depersonalized or reductionist psychopathological notions. For example, the proposal of a fragile process as a replacement for the traditional personality disorder diagnosis (Warner, 1998), Longden (2017) advocated for the Hearing Voices Movement’s non-pathologizing, culturally sensitive approach to understanding the voice-hearing experience; likewise Schulz (2018) presented the Informed Consent Model as an alternative to the diagnosis of gender dysphoria, offering a pathway to affirmative interventions, such as hormone treatment, for transgender individuals.

Furthermore, changes have been proposed in the diagnostic process itself. For instance, some authors have advocated for expanding the areas considered within a diagnosis to include an examination of both the individual and the context in which they live. From this perspective, mental pathology is seen not solely as an intrapsychic or structural issue, but as a complex phenomenon that arises from the interaction of various systems in which the person is involved (Criswell & Serlin, 2014; Fischer, 2014; Mann, 2010). In these views, the client is not passive in their diagnosis; rather, they actively collaborate in its development and discussion (Ladd & Churchill, 2012), even acknowledging and valuing the possibility that the client may disagree with their diagnosis (Forgione, 2019). In this context, alternatives to the dominant biomedical diagnosis emerge, such as case formulation (Cooke & Kinderman, 2018; Johnstone, 2018)—discussed in detail in the following section of this article—or Rubin’s (2018) theoretical proposal, The Classification and Statistical Manual of Mental Health Concerns, which emphasizes the aspects that concern the person rather than categorizing the presumed pathology.

It is also important to note the way in which some humanistic authors have employed psychiatric diagnoses and disease classifications without expressing significant reservations or distinctions compared to other perspectives. A notable example is Frankl’s (2014) Logotherapy in Clinical Practice, where he examines classical psychiatric entities such as perversions, various types of neuroses, and even hysteria.

Regardless of a humanistic practitioner’s stance on diagnosis, the ability to assess clients, formulate diagnoses, and develop comprehensive hypotheses has become a standard for all psychotherapists. For instance, Farber (2010) identifies three functional competencies every humanistic psychologist should possess as “evaluation, diagnosis, and conceptualization of problems and concerns” (p. 31), while Roth et al. (2009) emphasize diagnostic skills as a critical element in their report, The Competences Required to Deliver Effective Humanistic Psychological Therapies, developed under the framework of the Centre for Outcomes, Research, and Effectiveness at University College London. From a contemporary perspective within the person-centered approach, it is also acknowledged that, although diagnosis formulation presents certain challenges, it is a reality that therapists across all modalities must learn to navigate effectively (Wilkins, 2005), particularly when working with individuals facing severe mental health issues, such as suicidal behavior.

Finally, it is important to acknowledge that, although some humanists raise concerns about diagnostic practices, many therapists operate within healthcare systems where biomedical diagnosis is often required for administrative, legal, or institutional purposes. Moreover, in countries such as Chile—home to one of the authors of this article—patients have the right to receive a diagnosis upon request (Ley N° 20.584, 2012) and formal diagnosis are often required to access state-funded mental health services, fulfill private insurance requirements, or respond to judicial inquires. While this situation varies internationally, it highlights the institutional frameworks within which humanistic therapists, like all practitioners, must operate. Importantly, many humanistic psychologists also recognize the potential benefits of diagnosis, such as validating a person’s suffering, providing a shared explanatory framework, and facilitating access to services and communities of support.

Case Formulation from a Humanistic Approach

As previously indicated, questions have been raised in the literature regarding whether humanistic psychology has given sufficient visibility to case formulation (Eells, 2009, 2022; Gonzalez, 2008; Greenberg et al., 2013; Johnstone & Dallos, 2006; Kramer, 2019; Pascual-Leone et al., 2016; Zubernis & Snyder, 2016). However, humanistic approaches have long engaged in case formulation practices by addressing the client’s unique characteristics. This section will highlight these contributions and illustrate how humanistic psychology has articulated rigorous and coherent frameworks for the practice of case formulation. To situate the discussion, it is first necessary to define case formulation as understood in the current literature.

Case formulation is “a process of developing hypotheses about the causes, precipitants, and maintaining factors of psychological, interpersonal, and behavioral problems, as well as a plan to address such problems” (Eells, 2022, p. 2). Johnstone (2018) indicates the importance of distinguishing between case formulation as an event and as a process. The former corresponds to formulating a client case, which can be developed in an academic article, during supervision, or even in a psychotherapy class. The latter involves making sense of the client’s distress, with their involvement and participation. Johnstone (2018) refers to this process as psychological formulation, distinguishing it from psychiatric formulation—often rooted in a nomothetic approach, aiming for standardized diagnoses and interventions guided by universal psychological laws. This perspective frequently relies on tools such as the DSM or International Classification of Diseases (ICD) and manual-based treatments. In contrast, psychological formulation underlines the importance of an idiographic approach, prioritizing individualized understanding and interventions tailored to the unique context and experiences of each client.

Psychological formulation has been proposed as an alternative to psychiatric diagnosis (Johnstone, 2018), based on its potential to act as a bridge and establish negotiation between a therapist’s knowledge and their client. Moreover, case formulation has an ideographic focus and serves as the link between general principles of psychology and the particular characteristics of each client (Kramer, 2020). While research on its therapeutic effects is in an early stage, evidence suggests that psychological formulation could contribute positively to therapeutic change by adapting therapy and the use of language to the client’s needs (Johnstone, 2018).

Based on such assertions, humanistic psychologies work more closely with case formulation than standardized therapies, operating primarily within the framework of psychological, rather than psychiatric, formulation. Numerous humanistic proponents have expressed ideas supporting this conclusion. For example, Perls (1972) criticized standardized techniques in psychotherapy, considering them superficial tricks that divert focus from authentically engaging with the patient’s experience. Similarly, Rogers (1951) emphasized understanding the unique and unrepeatable experiences of individuals. While Rogers’ therapy is sometimes mistakenly reduced to reformulation and clarification, research indicates that he employed a wide range of interventions tailored to each patient’s needs (Brink & Farber, 2001). This commitment to individuality is also central to the existential school. Although it acknowledges universal human structures, such as the inevitability of mortality, its focus lies in exploring how each person uniquely encounters and interprets these shared existential elements (Iacoveu & Weixel-Dixon, 2015). This approach underscores the humanistic emphasis on personalized, context-sensitive therapeutic practices, setting it apart from more rigid, standardized methodologies.

Based on the exposition thus far, humanistic psychology emerges as a school of thought equipped with a diverse array of theories and empirical evidence. These resources facilitate a comprehensive understanding of the client, enable diagnosis in its broadest sense, and support the development of tailored intervention plans. Moreover, consistent with its core values, this approach prioritizes adapting its theoretical principles to align with the client’s unique lived experience. In essence, case formulation embodies a working method that most closely reflects the values of humanistic psychology. To reinforce this perspective, the following section will present examples from the literature that illustrate this alignment.

Conclusion

In conclusion, it can be affirmed that the field of humanistic psychology, as a whole, actively engages in diagnosis and case formulation, in contrast to existing misunderstanding and prejudice. While some authors have critiqued reductionistic diagnostic practices rooted in the standard medical model, others have emphasized the importance of expanding diagnostic practices to incorporate lived, subjective experience and personal meaning, rather than advocating for their eradication. This perspective illustrates the diversity of views within the humanistic movement, where critique is often accompanied by constructive proposals for more integrative and ethical forms of diagnosis.

It has been demonstrated that the wide ranging humanistic approaches, such as person-centered therapy, gestalt psychotherapy, existential psychotherapy, and emotion-focused therapy, employ structured methods to understand and address clients’ individual needs. Case formulation in humanistic psychology involves a careful appreciation of the uniqueness of each individual, thereby distancing itself from reductionistic approaches. Authors like Carl Rogers and Fritz Perls have advocated for adaptability and creativity in therapeutic intervention, emphasizing the importance of understanding each person’s unique experience.

The theoretical depth of humanistic psychology has been underscored, challenging simplistic misconceptions about this movement. Humanistic psychologists have robust theoretical foundations, supported by empirical research and a diverse array of theories that inform their practices. Through the presentation of emblematic case studies and case formulation methods, it has been demonstrated that humanistic practitioners engage in a reflective and rigorous process to understand and address individuals’ psychological challenges. In this vein, methodologies such as HSCED and MDCR demonstrate that humanistic psychology has not only developed approaches to guide clinical practice but has also provided research tools for the analysis of clinical cases.

While it has been argued that humanistic psychology does engage in diagnosis and case formulation, important questions remain. These include whether current efforts are sufficient, whether they provide a viable alternative to the dominant biomedical diagnostic model, and how they address internal critiques—that is, such as those articulated by Hoffman et al. (2020) about diversity and multiculturalism. Further considerations include exploring the differences between humanistic case formulation models and those of other approaches, identifying the distinctions between expert and novice humanistic practitioners in formulating cases, and investigating the most effective training methods for developing this competence.

Ultimately, the ongoing commitment of humanistic psychotherapies to research and ethical standards must be emphasized. These principles encourage practitioners to continually strive to provide the best possible service, grounded in the current state-of-the-art. As such, the importance of assessing clients, developing diagnoses, and conceptualizing cases cannot be dismissed or omitted. Rather, it presents an opportunity to develop expertise in these areas, while remaining critically aware of the potential dangers of diagnosis, and at the same time being respectful and empathetic in communicating our professional opinions to those who seek our help.