Why Diagnose?
Why Diagnose?
or many people, including some therapists, "diagnosis" is a dirty word. We have all seen the misuse of psychodiagnostic formulations: The complex person gets flippantly oversimplified by the interviewer who is anxious about uncertainty; the anguished person gets linguistically distanced by the clinician who cannot bear to feel the pain; the troublesome person gets punished with a pathologizing label. Racism, sexism, heterosexism, classism, and numerous other prejudices can be (and have often been) handily fortified by nosology. Currently in the United States, where insurance companies allot specific numbers of sessions for specific diagnostic categories, often in defiance of a therapist's judgment, the assessment process is especially subject to corruption.
One objection to diagnosing is the view that diagnostic terms are inevitably pejorative. Paul Wachtel recently referred to diagnoses, for example, as "insults with a fancy pedigree." Jane Hall writes that "labels are for clothes, not people." Seasoned therapists often make such comments, but I suspect that in their own training it was helpful for them to have language that generalized about individual differences and their implications for treatment. Once one has learned to see clinical patterns that have been observed for decades, one can throw away the book and savor individual uniqueness. Diagnostic terms can be used objectifyingly and insultingly, but if I succeed in conveying individual differences respectfully, readers will not recruit diagnostic terms in the service of feeling superior to others. Instead, they will have a rudimentary language for mentalizing different subjective possibilities, a critical aspect of both personal and professional growth.
The abuse of diagnostic language is easily demonstrated. That something can be abused, however, is not a legitimate argument for discarding it. All kinds of evil can be wreaked in the name of worthy ideals-love, patriotism, Christianity, whatever-through no fault of the original vision but because of its perversion. The important question is, Does the careful, nonabusive application of psychodiagnostic concepts increase a client's chances of being helped?
There are at least five interrelated advantages of the diagnostic enterprise when pursued sensitively and with adequate training: One, its usefulness for treatment planning, Two, its implications for prognosis, Three, its contribution to protecting consumers of mental health services, Four, its value in enabling the therapist to convey empathy, and Five, its role in reducing the probability that certain easily frightened people will flee from treatment. In addition, there are fringe benefits to the diagnostic process that indirectly facilitate therapy.
By the diagnostic process, I mean that except in crises, the initial sessions with a client should be spent gathering extensive objective and subjective information. My own habit is to devote the first meeting with a patient to the details of the presenting problem and its background. At the end of that session I check on the person's comfort with the prospect of our working together. Then I explain that I can understand more fully if I can see the problem in a broader context, and I get agreement to take a complete history during our next meeting. In that session I reiterate that I will be asking lots of questions, request permission to take confidential notes, and say that the client is free not to answer any question that feels uncomfortable (this rarely happens, but people seem to appreciate the comment).
I am unconvinced by the argument that simply allowing a relationship to develop will create a climate of trust in which all pertinent material will eventually surface. Once the patient feels close to the therapist, it may become harder, not easier, for him or her to bring up certain aspects of personal history or behavior. Alcoholics Anonymous meetings are full of people who spent years in therapy, or consulted a bevy of professionals, without ever having been asked about substance use. For those who associate a diagnostic session with images of authoritarianism and holier-than-thou detachment, let me stress that there is no reason an in-depth interview cannot be conducted in an atmosphere of sincere respect and egalitarianism. Patients are usually grateful for professional thoroughness. One woman I interviewed who had seen several previous therapists remarked "No one has ever been this interested in me!"
PSYCHOANALYTIC DIAGNOSIS VERSUS DESCRIPTIVE PSYCHIATRIC DIAGNOSIS
PSYCHOANALYTIC DIAGNOSIS VERSUS DESCRIPTIVE PSYCHIATRIC DIAGNOSIS
Even more than when I wrote the first edition of this book, psychiatric descriptive diagnosis, the basis of the DSM and ICD systems, has become normative-so much so that the DSM is regularly dubbed the "bible" of mental health, and students are trained in it as if it possesses some self-evident epistemic status. Although inferential/contextual/dimensional/subjectively attuned diagnosis can coexist with descriptive psychiatric diagnosis, the kind of assessment described in this book has become more the exception than the rule. I view this state of affairs with alarm. Let me mention briefly, with reference to the DSM, my reservations about descriptive and categorical diagnosis. Some of these may be quieted when DSM- Five appears, but I expect that the overall consequences of our having deferred to a categorical, trait-based taxonomy since nineteen eighty will persist for some time.
First, the DSM lacks an implicit definition of mental health or emotional wellness. Psychoanalytic clinical experience, in contrast, assumes that beyond helping patients to change problematic behaviors and mental states, therapists try to help them to accept themselves with their limitations and to improve their overall resiliency, sense of agency, tolerance of a wide range of thoughts and affects, self-continuity, realistic self-esteem, capacity for intimacy, moral sensibilities, and awareness of others as having separate subjectivities. Because people who lack these capacities cannot yet imagine them, such patients rarely complain about their absence; they just want to feel better. They may come for treatment complaining of a specific Axis One disorder, but their problems may go far beyond those symptoms.
Second, despite the fact that a sincere effort to increase validity and reliability inspired those editions, the validity and reliability of the post-nineteen eighty DSMs have been disappointing. The attempt to redefine psychopathology in ways that facilitate some kinds of research has inadvertently produced descriptions of clinical syndromes that are artificially discrete and fail to capture patients' complex experiences. While the effort to expunge the psychoanalytic bias that pervaded DSM-Two is understandable now that other powerful ways to conceptualize psychopathology exist, the deemphasis on the client's subjective experience of symptoms has produced a flat, experience-distant version of mental suffering that represents clinical phenomena about as well as the description of the key, tempo, and length of a musical composition represents the music itself. This critique applies especially to the personality disorders section of the DSM, but it also applies to its treatment of experiences such as anxiety and depression, the diagnosis of which involves externally observable phenomena such as racing heartbeat or changes in eating and sleeping patterns rather than whether the anxiety is about separation or annihilation, or the depression is anaclitic or introjective-aspects that are critical to clinical understanding and help.
Third, although the DSM system is often called a "medical model" of psychopathology, no physician would equate the remission of symptoms with the cure of disease. The reification of "disorder" categories, in defiance of much clinical experience, has had significant unintended negative consequences. The assumption that psychological problems are best viewed as discrete symptom syndromes has encouraged insurance firms and governments to specify the lowest common denominator of change and insist that this is all they will cover, even when it is clear that the presenting complaints are the tip of an emotional iceberg that will cause trouble in the future if ignored. The categorical approach has also benefited pharmaceutical companies, who have an interest in an ever-increasing list of discrete "disorders" for which they can market specific drugs.
Fourth, many of the decisions about what to include in post-nineteen eighties DSMs, and where to include it, seem in retrospect to have been arbitrary, inconsistent, and influenced by contributors' ties to pharmaceutical companies. For example, all phenomena involving mood were put in the Mood Disorders section, and the time-honored diagnosis of depressive personality disappeared. The result has been the misperception of many personality problems as discrete episodes of a mood disorder. Another example: If one reads carefully the DSM descriptions of some Axis One disorders that are seen as chronic and pervasive, it is not clear why these are not considered personality disorders.
Even when the rationale for including or excluding a condition is clear and defensible, the result can seem arbitrary from a clinician's perspective. From DSM-Three on, a criterion for inclusion has been that there has to be research data on a given disorder. This sounds reasonable, but it has led to some strange results. While there was enough empirical research on dissociative personalities by nineteen eighty to warrant the DSM category of multiple personality disorder, later renamed dissociative identity disorder, there was very little research on childhood dissociation. And so, despite the fact that there is wide agreement among clinicians who treat dissociative adults that one does not develop a dissociative identity without having had a dissociative disorder in childhood, there is (as I write this in twenty ten) no DSM diagnosis for dissociative children. In science, naturalistic observation typically precedes testable hypotheses. New psychopathologies, such as Internet addiction, especially to pornography, a version of compulsivity unknown before technology permitted it, are observed by clinicians before they can be researched. The dismissal of clinical experience from significant influence on post-nineteen eighties editions of the DSM has created these kinds of dilemmas.
Finally, I want to comment on a subtle social effect of categorical diagnosis: It may contribute to a form of self-estrangement, a reification of self-states for which one implicitly disowns responsibility. "I have social phobia" is a more alienated, less self-inhabited way of saying "I am a painfully shy person." When its patent on Prozac expired, Eli Lilly put the same recipe into a pink pill, named it Serafem, and created a new "illness," premenstrual dysphoric disorder. Many women become irritable when premenstrual, but it is one thing to say "I'm sorry I'm kind of cranky today; my period is due" and another to announce "I have PMDD." It seems to me that the former owns one's behavior, increases the likelihood of warm connection with others, and acknowledges that life is sometimes difficult, while the latter implies that one has a treatable ailment, distances others from one's experience, and supports an infantile belief that everything can be fixed. Maybe this is just my idiosyncratic perspective, but I find this inconspicuous shift in communal assumptions troubling.