diagnosis
The term mental illness is misleading. Although so-called mental illnesses involve physiological changes the causes are largely social and interpersonal rather than physical. And most centre around emotions rather than thoughts.
Individuals don't fit neatly into any of the diagnostic systems that have drifted in and out of fashion over the centuries. Many subtleties of mood and thought are overlooked and most of the person is missing. For instance anxiety and depression are diagnoses for persistent emotional states but persistent anger has not found a place. Aggression is not a diagnosis in most systems.
A diagnostic system is part of the packaging that maintains the image of authority and expertise of professions. It survives once its diagnoses get official recognition as billing categories for government subsidies and health insurance. Health providers get paid when they find an accepted diagnosis. However there little evidence of effectiveness of specific psychotherapy treatments for diagnoses whereas there is for treatments for individuals.
symptoms
Diagnosis of a mental illness by symptoms looks at parts rather than at the whole person and creates expert tunnel vision while diverting attention from the overall picture and causes and complicating factors.
Many symptoms of mental illness are similar to those of infection, poisoning, nutritional deficiencies, traumatic experiences, metabolic disorders, hormonal dysfunction and prescribed and recreational psycho-active drugs so misdiagnosis is not uncommon.
People with sensory or other impairments especially the deaf and blind are vulnerable to a misdiagnosis of mental illness. When my after hours crisis team went on strike our director stood in and on her first night certified and committed a man who was deaf and dumb as schizophrenic. This was quickly spotted and he was released the next day. Not so fortunate was a lady who spent 20 years confined as a catatonic schizophrenic in a mental hospital. The longer she stayed the more she fitted in, confirmed the diagnosis and became a part of the scenery. She was discharged before I started there after a visitor started a conversation with her in her native tongue - the only language she knew. She came from a culture where it would not be easy for her to look at strangers. These kind of errors would probably not be made by beginners.
dis-empowering
Many Psychiatric diagnoses merely restate symptoms in a way only understood by professionals and reflect their assumptions and values.
Being told who what are or you should be can be bewildering especially in an unfamiliar medical environment. An expert is offering a judgment which is often a first step towards taking over some decisions. It might not be correct or complete and you can't know exactly what it means or where the treatment that follows will lead.
A diagnosis can be reassuring for anyone who respects authorities particularly if it helps make sense of a distressing situation and a cure is offered.
A diagnosis can be self-fulfilling if it lowers a persons expectations of themselves. They may be treated using treatment protocols instead of as people. Vague and poorly understood labels like depression, dementia, schizophrenia, cerebral palsy are used to interpret behaviour and unnecessarily lower or extinguish the expectations of others. Conversation is often restricted and opportunities are withheld even when there is no significant impairment or the person is capable of functioning above average in some areas of their life.
When I worked on acute psychiatric admission wards I helped patients work through how to do things rather than do things for them as far as possible. I have found that everyday challenges and empowerment helps people re-orientate and get on their way. Staff estimation of the capacity of patients was usually lower than their potential. I was assigned a patient with complex problems with his welfare payments who was said to be a delusional, hallucinating and aggressive schizophrenic. I was always able to talk with him but had no idea of his capacity to manage his affairs. The ward refused to let me take him to the welfare agency offices to sort out his benefits. I had to go to the director to over-turn this decision but had to accept personal responsibility if anything went wrong. He got out of the car strode ahead of me through the entrance went to the front of the queue, explained the problem and what he wanted and asked the counter service clerk firmly, clearly and politely to fix it. She happily complied and we left in a few minutes. I would have taken an hour get that result if I was lucky and would have stressed. The instant we returned to the ward he resumed “delusional” and hostile interactions with staff.
stress disorders
The stress disorders including PTSD are diagnosed in the DSMIV according to causes rather than symptoms and so are for my purposes as a therapist more clearly defined and grounded in reality than most of the rest.
assessment
Risk and liability driven assessments are now common in the personal social services. Many agencies mostly or only assess and refer. Some assessments take an hour or more to administer and record.
Compulsory formal tick-box assessment protocols ensure uniformity so that nothing is missed. They cover staff and agency against liability. If the boxes have been ticked everyone has done their job. Some agencies spend most of their resources ticking boxes, completing forms and maintaining databases.
Formal assessment protocols introduce judgments, concepts and values that dictate the logic, language and even the direction of therapy. They often sideline or override a client and postpone or derail therapy. They are time consuming and ultimately increase risks by overriding clinical judgments with assessment checklists. In crisis situations they interrupt or deny emergency care and emotional first aid.
The most useful assessments are the moment to moment clinical judgments arising out of observation and intuition. Most assessment could easily arise out of therapy rather than replacing it. Staff satisfaction and productivity increases when they are actively involved instead of being at the bottom of a micromanaged hierarchy of protocols.
labelling
Once someone attracts a diagnosis of a mental illness it usually follows them around whether or not it still applies, particularly after a senior practitioner endorses it. Routine behaviour that would pass unnoticed in anyone else become a symptom.
Psychiatric diagnoses encourage professionals to ignore the person and treat their diagnosis instead. Dangerous medications can be prescribed without thinking beyond a diagnosis. Often prescribing and then not following up for weeks or months at a time.
So far diagnostic systems are not sound enough to rely on as a central focus of mental health which is for the most part not really either mental or medical in the first place.
copyright (C) John Brasted 2008
updated 28. Dec. 2011
