I never used to find making a psychiatric diagnosis particularly difficult. Actually that’s not true. Sometimes it wasn’t straightforward deciding which diagnostic category best matched the particular collection of symptoms that were presented. But once decided, it wasn’t usually difficult to convey the diagnosis to a patient and record it as clinically required. It was automatic, part of the job of a doctor, a practice and skill learnt throughout medical training. It was a task expected of me by mental health services and by most patients. I was relatively comfortable getting on with it.
That was how it was over 25 years ago when I stepped into the role of a psychiatrist, accepting that making, or rather giving someone, a diagnosis was one of my core functions, along with prescribing psychiatric drugs. But over time something changed. This aspect of psychiatric practice, rather than providing professional satisfaction (and perhaps bolstering a sense of status), began to weigh heavily on me. Simply, I came to see psychiatric diagnosis (in the sense of categorising disorders using classification manuals) as an aspect of psychiatry and mental healthcare that is deeply flawed and limited, for reasons I will explore.
What hasn’t changed though, is that making a diagnosis still is a core part of the job of a psychiatrist. It is still expected, more so than ever. There are probably many reasons for the increased diagnostic demands, not least that in the minds of many, a diagnosis will lead to treatment and support. And surely with all the scientific advances over the last century, curative treatments are now available and services will provide them. Won’t they? There is also an ever increasing range of diagnostic categories to choose from, as evidenced by the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) (American Psychiatric Association, 2013). Furthermore, with many diagnostic thresholds lowered, more people will meet the criteria for one diagnostic category or another.
But how often does a psychiatric diagnosis actually lead to helpful treatments? It certainly can, and does, lead to a range of responses and benefits. But how much is actually helpful? And what is meant by treatment, for that matter? Over the years these kinds of questions increasingly nagged me, along with the notion of making the ‘right’ diagnosis. The scientific validity and reliability of psychiatric diagnosis has bedevilled psychiatry for decades and still does. The notion of making the right one is, therefore, to my mind, spurious. Although please don’t misunderstand me. I am not saying it is not important to know about a person’s mood, thoughts, perceptual phenomena and any other mental experiences unique to them.
Nevertheless, diagnosis is a powerful driver of the healthcare system, enabling efficient organisation and delivery of services, for example, being integral to care pathways and other attempts to standardise care. It is the basis for research into treatments and therefore treatment guidelines. It is communication shorthand for professionals, enabling easier and quicker exchange of clinical information. And it is necessary for insurance-based systems of care. Quite simply, at the current time, it is the main gateway for help and support from health and social care and many other services.
One thing is certain then, psychiatric diagnosis does not lack utility. In other words, it services a purpose — in fact many. Is this why it is so hard to counter the forces and arguments that insist it remains at the heart of psychiatric and mental healthcare? Despite a number of criticisms and critiques of psychiatric diagnosis, I find it hard to imagine that, at the present time, these will do much to sway the pro-diagnostic preoccupations of the psychiatric profession in particular.
So why not just be pragmatic and accept that whatever the flaws and limitations of psychiatric diagnosis (such as the fact that it tells us nothing about causes or indeed much about the actual nature of mental disturbance), it is still worth using in order to achieve a greater good?
Here lies my main concern and unease. Does psychiatric diagnosis ultimately achieve a greater good? How often does it lead to effective treatments — whether the ‘right’ drug or ‘right’ type of psychological therapy? Over the years what I have observed and experienced is that people can recover in spite of the diagnosis they have been given. What I have also come to believe is that the diagnostic enterprise, as currently practised, involves the neglect of an important aspect of being human — subjective meanings.
When someone is given a psychiatric diagnosis, while it actually explains nothing about any assumed underlying pathology, it is nevertheless powerful because it means something to the person who has been given it. In fact it can mean many things, positive and negative, and often a mixture of both for any one person.
Positive meanings first. Giving something a name (or label) seems to bring it into existence – ‘it’ becomes real, concrete, an entity. For many people, receiving a psychiatric diagnosis is to experience validation and recognition of their suffering and provides a sense of being taken seriously. It may relieve some people from feelings of shame or that it is their ‘fault’. It can bring a sense of hope that, as mentioned earlier, treatment or particular support will be provided. It can provide a sense of order and clarity to a hitherto confusing tangle of mental experiences. For some it may shape a sense of identity or role in a way that is experienced as beneficial, perhaps linked to a variety of social consequences such as being exempt from particular responsibilities or employment, or gaining access to benefits and other system of support.
However, I have heard far more some of the negative meanings that recipients of a psychiatric diagnosis attach to it. The most obvious one is the way in which it leads people to view themselves as disordered, defective and as having something wrong with them or ‘in’ them. Along with this people may identify themselves as weak or a failure. Such a self-concept can leave people feeling ‘marked’ and in this sense a psychiatric diagnosis may feel like a mark of shame (which is the meaning of stigma). This in turn may result in discrimination in many areas of social life, creating ‘them and us’ or sense of being ‘other’. For some people, receiving a diagnosis may be disempowering or lead them to reluctantly (or readily) hand over control and responsibility to others, for example, medical or other experts. It may affect the exercise of personal agency. Other meanings or psychological effects include feeling objectified or that something of one’s personhood has been interfered with or lost – that one becomes more an object and less a person. It can create a sense of separateness and alienation. It may also close down possibilities for self-directed growth and recovery with preference given to relying on expert applied, technical treatments such as psychiatric drugs.
All these potential meanings and psychosocial consequences are powerful in many ways, not least in how they shape a person’s identity — their sense of who they are. Yet how often is this considered when someone is given a psychiatric diagnosis? I was not encouraged to explore subjective meanings in my psychiatric training. Does it make the clinical encounter too complex? Does it make too many demands on empathic listening? Is this something psychiatrists simply don’t have time for, even if they wanted to take it seriously?
Yet it is the failure to pay attention to this array of potential meanings, and both the short and long-term psychosocial consequences of psychiatric diagnosis, that in my opinion represents a gross inadequacy and neglect at the heart of psychiatric practice. For these reasons I found it increasingly difficult to give someone a diagnosis. But if the arguments asserting the importance and necessity of psychiatric diagnosis continue to hold out, at least for the foreseeable future, then can there at least be more transparency and recognition that psychiatric diagnoses are little more than culturally shaped judgements and social constructs? They are not scientific facts. Can there not be more honesty permeating the landscape of psychiatry and mental healthcare?
Should a psychiatric diagnosis be necessary to receive effective care and treatment? After 25 years of psychiatric practice, my conclusion is that it should not be. At the end of the day, it is how one is listened and related to that probably, in most cases, has the greatest beneficial impact.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed) (DSM-5). Washington, DC: American Psychiatric Publishing.