Ending Harm from Psychiatric Diagnosis
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Excerpted from the Introduction of
Bias in Psychiatric Diagnosis
Edited by Paula J. Caplan, Ph.D & Lisa Cosgrove, Ph.DClinicians often ask what they can do to try to insulate patients from negative consequences of receiving a diagnosis. Clinical judgments are always involved in the process of diagnosis, whether in psychiatry or other fields. In some cases, the patient clearly meets the requisite number of criteria for one of the official diagnostic categories. However, there are cases in which questions arise about which is the most accurate diagnosis, and in those cases, clinicians might take particular care to consider the effects of their diagnoses on clients' lives outside of treatment, as well as of the treatment implications of giving a patient one diagnosis rather than another. For instance, insurance companies often provide reimbursement for more therapy sessions for patients with certain diagnoses than with others. It is important to select a label that seems accurately to represent as many of the patient's difficulties as possible and does not misrepresent any dangers or increase the potential risk to the patient or others. When there is any question about which diagnosis is most appropriate, the clinician can record which labels besides the chosen one were seriously considered and whether or not they were ruled out. Whatever diagnosis one gives a particular patient, it is important to be aware that diagnoses can be helpful but not infrequently have negative effects on patients' rights to child custody, employment, health insurance, or the right to make decisions about their lives.
Clinicians who feel in a given case that it is consistent with their clinical assessment and judgment to do so can write on the patient's chart next to the diagnosis such statements as, "The fact that this patient has received this diagnosis does not in and of itself indicate that the patient lacks such capacities as the ability to be a good parent, caretaker of others or employee or to make decisions about their medical and psychological care, their legal affairs, or other important aspects of their lives." Some therapists offer to give their clients letters in which they make statements about the diagnosis that are relevant to the particular person's life situation and needs. For example, a therapist who had diagnosed a woman as having Chronic Adjustment Disorder gave her a letter in which he stated that her disorder was a result of severe, ongoing crises in her life and that it was likely, if the crises abated, that she would be employable and that she would not necessarily always have the disorder and be mentally ill if her life circumstances improved.
It is wise for clinicians to make sure that their words and actions are consistent with the ethical standards of their respective professions and to check with attorneys about how best to choose to protect both the patient and the clinician.
Clinicians should also fully inform patients: (1) that they have to give them a diagnosis, (2) the reason that they have to do this (most often because required by their place of work and/or required for reimbursement by insurance companies and because diagnoses are used in treatment planning), (3) that there are potentially negative consequences of receiving a diagnosis and what these can be, and (4) what the clinician is doing—or will do in the future, if relevant—to try to protect the patient as much as possible from those consequences.
Finally, it is important to initiate and engage in ongoing discussions with colleagues and consultants about the various potential and actual positive and negative consequences of diagnosis, and it is important to educate the public about these matters, to make the realm of diagnosis more transparent to all.
Slightly adapted from:
They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal
by Paula J. Caplan, Ph.D pages 284-288Therapists might consider thinking less about how to classify and label their patients than about such clearly relevant questions as how they are feeling and why, as well as what their strengths and resources are and whether or not they are able to care for and take care of themselves and others. Former mental patient and current activist/organizer Judi Chamberlin says, "People who have been patients know from their own experience that warmth and support . . . were helpful and that being thought of and treated as in?competent were not."
There are encouraging signs even within the realm of psychoanalysis, which has long been split, Janus-like, into its helpful concentration on detailed, careful listening to what patients say and its attitude that therapists know better than patients what is happening to the patients. Psychoanalyst Evelyne Schwaber, for instance, writes about the importance of the analyst's being open to considering how she affects her patient and to hearing the patient's perspective rather than maintaining a position as the only arbiter of truth.
What therapists—as well as family and friends—can also do is to refuse to produce knee-jerk interpretations of people's problems that consist of forcing human suffering into categories like "masochism" or "codependency." Labeling increases the likelihood that therapists—and patients themselves—will force the patient through the often-deforming mold of a diagnosis, thus misunderstanding much about the patient and overlooking the way that therapists' own blind spots and problems shape their views of their patients. Some therapists can combine careful listening to troubled people with a minimum of preconceptions, with what is suspected or known to help people with certain kinds of problems. Although this approach will not lead to the eradication of all psychological problems or pain, it certainly does not hurt and will probably be of some help. Indeed, one would think it would be the sine qua non of all people who claim to serve others, but often, it is not. In fact, some therapists are so dazzled by or preoccupied with the scientific-seeming DSM, as well as with various "treatment" techniques, such as drugs, electroshock, and hospitalization, that they replace a caring approach with instant engagement in choosing a diagnosis and medical treatments, rather than combining a caring approach with responsible consideration of the range of possibly helpful options and their dangers.
Therapists need to know how to think "scientifically," which really means knowing how to evaluate properly what has helped whom and when and under what circumstances, and how to show respect and warmth for their patients. There needs to be a balance between being an evaluator of information from research and being a thoughtful, caring listener, between thinking about general issues and about the individual before you who might or might not be helped by your knowledge of the general. The best way to do the scientific thinking would be t: conduct careful research on a large scale, taking account of the important complexities of human behavior and need. The DSM people have not done that, nor, for the most part, have other mental health professionals and researchers. Much remains a mystery.
The danger is that people will believe that the DSM is the solution to the mystery. This is dangerous for a number of reasons, not the least of which is noted by psychiatrist Joel Kovel, who writes that the handbook exists to serve the needs of therapists, not of their patients. Kovel's perceptiveness is illustrated by Allen Frances's statement that DSM categories must come from a long clinical tradition (that is, other therapists have to regard the problems in question as mental illnesses) and from the description in the DSM of the aim of producing a document that is acceptable to professionals from various theoretical orientations and in various settings. Kovel opines that this would be no problem if therapists could be counted on to do what is best for their patients, but he argues that this becomes less likely when patients are seen through the objectifying lens of the DSM. He goes on to say that as soon as people are given diagnoses of mental disorders, they are "secured into a system of social relations and power." Instead, he suggests, the focus should be on "the person and his/her relation to the world—instead of being located in the false abstraction of mental disorder."
As therapists, we know so little about what helps people in extremes. It seems to me that, as we struggle to find ways to bring people relief from suffering, we at least ought always to be honest about the possible benefits and possible dangers of what we recommend and about the degree to which what we do is based on science, hunches, or a combination of the two.
And what do I wish the DSM people themselves would do? Both as individuals and as a profession and a mental health enterprise, I would urge them to admit that their work is not yet very scientific and reflect that in the title of their handbook. Perhaps they could rename the DSM something like A Proposal for Defining and Classifying Emotional Problems. They might say that much of what they do is more like art and intuition than like science, and they could promise to handle with loving care, thoughtfulness, and honesty the people who seek help from them—and then do it. Of course, there is every reason also to continue to use scientific research to try to find answers. It is not the doing of research that is the problem. It is the doing of inadequate or bad research and then acting as though it is definitive.
In one American Psychiatric Association publication there is this claim:
"The process of diagnosis begins with the patient interview. Psychiatrists will order or conduct a careful general medical examination of each patient to assess his or her general health. They will request their patients' medical records from other physicians who've treated their patients. They will carefully question their patients about their past history and the symptoms of their disorder, the length of time they've had the symptoms, and their severity. If it seems warranted, the psychiatrist will also specify a period of observation. It is only after this careful assessment process that a psychiatrist to the DSM-IV."
Often, steps of that careful process are skipped. Psychiatrists and all mental health professionals know that, for a variety of reasons, we do not always do everything we should do. To know that but to make public statements that cover up our fallibility is dishonest.
Kirk and Kutchins have pointed out that members of the professions enjoy special privileges, such as being allowed to govern themselves, to control who can join their professions and what kind of training they need, and to regulate the practice of their members. "In return" for all of this freedom, professions are supposed to "abide by their codes of ethics, to protect the interests of their clients, to practice in a disinterested manner, and to use their substantial knowledge for the betterment of society." I wish that the American Psychiatric Association, and all professionals who use psychiatric labels, would act accordingly.
"He who sees a need and waits to be asked for help is as unkind as if he had refused it."
- Dante Alighieri (1265-1321)