How Important Is a Psychiatric Diagnosis?
A new study asks what a psychiatric diagnosis does, and doesn't, do.
Posted Jul 14, 2019
A young man came to consult with me after being diagnosed with Bipolar 1, which is generally considered the more severe form of Bipolar (formerly known as Manic-Depressive) disorder.
“I don’t know how to move forward in my life,” he said. “Do I tell people about this diagnosis? Do I hide it? What do I tell people at work, or when I apply for a new job? What if I fall in love and want to marry someone? When do I reveal that I have this diagnosis? I can’t just wait till after the wedding and say, ‘Oh, by the way, honey, I was diagnosed with Bipolar disorder years ago, but I didn’t want to upset you.’ But if I tell someone early in the relationship, won’t that drive them away? Or change their feelings about me, even if they want to stay?”
One woman diagnosed with Borderline Personality Disorder wore her diagnosis with pride. “It explains why I have so much trouble at work,” she said. “And why I have problems with friendships. I can’t help it when I blow up at someone. It’s my diagnosis!”
A man was diagnosed with Tourette Syndrome when he was 15. Tourette's is a neurological disorder in which an individual may have one or more uncontrollable tics, such as eye blinking, coughing, throat clearing, sniffing, and facial movements. The behavior may be irritating and/or disruptive, but it is often impossible to control. He told me that the day he was diagnosed was the happiest of his life.
“I had these tics that I didn’t understand,” he said. “My parents were always trying to make me stop doing them. And there were other things that I couldn’t stop doing, and everyone thought they were just signs that I was a bad kid who misbehaved for attention. When I got the diagnosis, I suddenly realized I wasn’t bad at all. This might seem really weird, but even though it’s a pretty severe disorder, it made me feel like I was normal: I have this diagnosis that explains my behavior, but behind it, I’m a good guy. I’m just like everybody else.”
The question of psychiatric diagnosis has long been a confusing one. In some cases, a diagnosis makes it possible to determine not only proper medication but also the most useful therapeutic approach for a particular client. According to NAMI (The National Alliance on Mental Illness), a diagnosis helps you understand and explains why you are having certain symptoms, and then “is simply a tool to help you and your doctor address those symptoms.”
But for many, the concern is that having a diagnosis makes an emotional or psychological difficulty sound like a disease. While we now understand that there are often physical underpinnings to emotions, the disease model does not always work best as a way of coping with our feelings.
Many psychotherapists have long expressed concern that a medical model for psychotherapy can actually interfere with a person’s ability to make the most of their strengths and manage their problems in the best way possible.
A new study now offers evidence that psychiatric diagnoses are actually not particularly useful tools for identifying discrete mental health disorders. According to one report, lead researcher Kate Allsopp, of the University of Liverpool, said, "Although diagnostic labels create the illusion of an explanation, they are scientifically meaningless and can create stigma and prejudice.”
The study found that the key problems with psychiatric diagnoses lie in four areas:
1. There are differences in how psychiatric diagnoses are made, depending on the person who is making the diagnosis.
2. There are significant overlaps in symptoms of different diagnoses, so that when a diagnosis is made, it may be simply a matter of personal opinion on the part of the diagnostician.
3. Diagnoses often mask the role of life events in the development of symptoms.
4. Making decisions about treatment based on a diagnosis means that an individual patient’s specific treatment needs may be ignored.
Diagnoses are often used for what is called “evidence-based” psychotherapy, which is defined as a treatment decision based on scientific research. Yet psychologist Jonathan Shedler, an outspoken critic of what he calls “manualized psychotherapy,” writes, “Empirical research actually shows that “evidence-based” therapies are ineffective for most patients most of the time.” Shedler provides research backing up his claim. It would seem that the research team in Liverpool offers more evidence that he is right.
So what do you do when you’ve been given a diagnosis? Perhaps the best answer is, consider it carefully. What does it mean to you? In what ways can it help you? And in what ways can it harm you?
What you do with your diagnosis is up to you. Whether it changes anything about how you live is also up to you. Sometimes a diagnosis can be useful, and sometimes it can be harmful.
For instance, the young man with Tourette’s found it incredibly helpful to know that he wasn’t being bad when he made odd facial movements. With the help of an excellent psychiatrist and a combination of talk therapy and cognitive behavioral therapy, he was able to have a productive and fulfilling life, even with the tics.
The young woman with Borderline Personality Disorder, on the other hand, used her diagnosis as an excuse for increasingly problematic behavior. Neither talk therapy nor Dialectical Behavior Therapy helped her manage her symptoms, which she explained as something she could not help because of her diagnosis.
And it turned out that the young man diagnosed with Bipolar 1 had been misdiagnosed. When there was no change in his symptoms after he took the appropriate medication for a reasonable period of time, his psychotherapist commented that she thought that the diagnosis might not be correct. She referred him to a different psychiatrist for evaluation, and with input from her and further assessment of the young man’s symptoms, this psychiatrist recommended that he go off the medication and work more intensively with his psychotherapist to understand the psychological meanings of the symptoms. Some years later, he was symptom-free.
Years ago I had a supervisor who said, “A diagnosis is nothing more than a working hypothesis. You use it to help you decide how to work with a client. If what you’re doing isn’t working, it could very well be that you’ve made the wrong diagnosis. But in fact, the diagnosis really isn’t what’s important. It’s how you deal with it.”
Her words echo the conclusion of the study. A psychiatric diagnosis can be a useful tool, but only if used wisely. When it becomes a way of identifying who a person is, of putting them into a specific category and choosing to provide therapy based solely on that category, then it becomes not just useless, but destructive.
LinkedIn/Facebook image: Kiwis/Shutterstoc
Jonathan Shedler, Ph.D. (2017) “Where is the Evidence for Evidence-Based Therapy?” https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf
Kate Allsopp, John Read, Rhiannon Corcoran, Peter Kinderman. Heterogeneity in psychiatric diagnostic classification. Psychiatry Research, 2019; 279: 15 DOI: 10.1016/j.psychres.2019.07.005