I have written here about my reservations about the diagnostic system we use in mental health. I have problems with the lack of theory to support it, with the proliferation of categories, with the way it is used by third party payers to control who can and cannot receive treatment. And I have doubts about the applicability of the medical model for most of the people most of us who practice outpatient psychotherapy see. Problems in living just do not equate to illness for most of our patient population.
So I have been thinking about a post made by Stephen Diamond last week on what is a mental disorder. He and I are in radical agreement on the difficulty in finding the line between normal and abnormal. But we find less common ground here:
"...as Freud famously observed, we are all at least a little neurotic. And existential frustration, anger, sadness, despair and anxiety are feelings every person experiences at some point. Just because someone doesn't meet the criteria for a diagnosable mental disorder only makes him or her "normal" insofar as mental suffering will always be an inescapable part of the human condition. Psychopathology is always relative. Receiving a psychiatric diagnosis does not necessarily mean the cause or etiology of the disorder is known or agreed upon. It doesn't necessarily mean one has some "brain disease" or "biochemical imbalance." Nor does it typically necessitate pursuing one particular type of treatment or therapy over another. However, refusal to diagnose by clinicians can be a kind of naive denial, resulting in not taking someone's suffering sufficiently seriously to intervene--sometimes with catastrophic consequences. When that mental suffering--whatever its source may be--manifests in debilitating, intolerable psychological and/or physical symptoms or destructive behaviors, a psychiatric diagnosis formally recognizes the need for additional support and possible professional treatment. Which of these two options is truly more humane?"
Borders and boundaries are devices we use to order the world. We make lines on a map and then find comfort in knowing that this is where our country ends and theirs begins. But boundaries are less lines than they are areas. Is there a clear line where the land ends and the sea begins? No, instead, we have wetlands that are neither wholly land nor sea, an area in-between. We might want to consider then, that there is an area of personality, present in all of us, which is between what we call sanity and madness, a borderline area.
It would be nice to imagine that there were some scientific way to determine diagnosis, but there is none. Absent biological or chemical tests to establish diagnoses, we fall back on consensus reality and struggle with the unevenness of such a standard. We look to mental health professionals to be in touch with society’s understanding of people and relationships between them, of relations between emotions and the self, and on local custom and ways of perceiving experiences. One outgrowth of this approach is the DSM IV. It is an attempt to develop, by consensus, descriptions of all disorders thought to be reflective of mental illness of one kind or another. Categories have been expanded and elaborated in the years since the first edition was published; yet, all but the rarest of categories still depends on the subjective judgment of the examiner. That a mental health patient might be diagnosed as bi-polar in one setting and schizophrenic while presenting the same symptoms suggests how primitive our ability to make distinctions really is. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.
That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible. A facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe are an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.
We imagine ourselves to be far more advanced than the ancient Greeks who relied upon consensus reality and collective roles to determine what was and was not normal. But is it really the case that we are as autonomous and individual as we want to believe?
It is generally assumed in medical circles that the examination of a patient should lead to the diagnosis of his illness, so far as this is possible at all, and that with the establishment of the diagnosis an important decision has been arrived at as regards prognosis and therapy. Psychotherapy forms a startling exception to this rule: the diagnosis is a highly irrelevant affair since, apart from affixing a more or less lucky label to a neurotic condition, nothing is gained by it, least of all as regards prognosis and therapy. C.G. Jung