System for Mental Health Diagnosis Is Corrupt, Some Experts Say

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As a therapist, I have always been careful to recognize that there is a vast gulf between diagnosable problems seen through the lens of clinical expertise and the essence and worth, strengths and hopes of the person before me.

Make no mistake: diagnosis can be clarifying, helpful, and even critical. Let us also be clear: we are not the diagnostic categories in which we find ourselves. Further, there is a great deal of confusion regarding not only our modern system of diagnosis–its purpose and limitations–but about the systems that undergird our diagnostic models.

I attended The Evolution of Psychotherapy conference in Anaheim, California, back in December, 2017, where psychiatrist and researcher Bessel van der Kolk decried,

"Our diagnostic system is shameful, horrendous... In order to do research, we had to have common diagnostic criteria back in the 60s and 70s... These are just lists of symptoms... They are horrendously inaccurate and not based in research... deeply corrupt... based in how we can bill and get reimbursement. We are now a profession who makes professional diagnostic decisions on the basis of how we get paid. We are deeply corrupt."

Also at that conference was one of the founding fathers of cognitive behavioral therapy (CBT), Donald Meichenbaum. During a session I attended titled, “Treatment of a Suicidal Patient with a Long History of Victimization: A Constructive Narrative Treatment Approach,” Don riffed,

"This is one of my greatest complaints of CBT: they get the whole catechism of labels and jargon about their pathology to take away, but they can't describe how it actually applies to them and their lives or what to do about it.”

None other than the great Carl Rogers, a father of humanistic psychotherapy, posed significant challenges to the practice of diagnosis when he—as a professor at the University of Chicago—helped establish a counseling center where he eliminated diagnosis altogether, finding the practice to be inadequate, prejudicial, and often misused.

Three years prior to arriving in Chicago—Rogers, in Counseling and Psychotherapy (1942), shed light on the pitfalls of information gathering and diagnosis in psychotherapy. He explained that, indeed, the field of psychology had gained a better understanding of human behavior, that psychotherapists understood more adequately the factors which underlie patterns. However, he instructed, “Then came the natural mistake of assuming that treatment was merely diagnosis in reverse, that all that was needed to help the individual was to explain to him the causes of his behavior (p 25)." He continued, "We do not change the client's behavior very effectively simply by giving him an intellectual picture of its patterning, no matter how accurate.” (p. 27)

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Renowned psychologist James Hillman (1967) warned—

"He then begins to look at himself as an object, to judge himself good or bad, to find faults and place blame for these faults, to develop more superego and ego at the expense of simple awareness, to see himself as a case with a label from the textbook, to consider himself as a problem rather than to feel himself as a soul." (p. 23-24)

But perhaps few modern experts in the field of mental health have spoken more loudly or incisively on the subject of mental health diagnosis than psychiatrist, former chair of the department of psychiatry at Duke University, and former DSM-IV Task Force chairman Allen Frances. In his important critique, Saving Normal, Frances (2013) quipped, "Nature picks diversity; we pick standardization,” and "Turning difference into illness was among the great strokes of marketing genius accomplished in our time."

Here are a few of my favorite tweets on the subject from Dr. Frances this past summer—

"To reduce mislabeling of normal distress as #mentalillness, we added ‘clinically significant distress or impairment’ criterion to each DSM-IV disorder. But this is tautological because there's no good definition of ‘clinical significance’. Boundary w normal is inherently fuzzy" -July 8, 2019

"In kids, psych diagnosis should always be written in pencil. Best way to protect them from cascade of harmful psych drugs is to protect them from rampant tendency toward over-diagnosis. Easy to write a diagnosis. Hard to erase it." -July 9, 2019

"I've worked with 1000s DSM experts over 40 yrs. They've made many mistakes creating loose definitions that over-diagnose. Cause: Intellectual conflict of interest- researchers love pet diagnoses/naive re risk in real world. They couldn’t care less about coding for clinicians." -July 10, 2019

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"We were amazed when DSM-III became a massive best seller in 1980. DSM popularity caused, but was also caused by, the more general medicalization of everyday life. Same cultural forces wildly expanded definitions of all diseases—so that now almost everyone is sick." -July 15, 2019

"There's no gold-standard defining ‘mental disorder’. Many DSM diagnoses don’t really belong— included only by historical accretion. It’s also hard to resist constant pressure to keep adding new disorders." -July 31, 2019

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Existential psychiatrist and former Stanford professor Irvin Yalom (2017) proclaimed, “I personally avoid diagnosis entirely… Diagnosis is a negative form. It plays no role in the treatment I’m providing to them.” Yalom clarified that this is not true of patients with psychosis or dementia but stated, “[Diagnosis]…with mildly troubled people is worthless.”

Our lives are bound into complexly interwoven ecologies of relationship, experience and meaning that evade compartmentalization. Diagnostic models of mental health conditions have limited usefulness and, in many cases, questionable origins. May we clinicians know well the models we must use, while doing so with a great deal of intellectual honesty and clinical humility.