In the previous post I said a lot about why people who are suffering might want to embrace a diagnosis of a mental health problem. In the next post I will say more about why practitioners may be wedded to this way of working with distress. Here I will outline some problems with diagnosis in general.
As I mentioned, for people who are struggling, diagnosis is often seen as the only option other than seeing themselves as totally 'to blame' for their own distress. Also, it may be the only way to access support and community, and to be taken seriously by employers and others whose understanding they may need as they are struggling. Given that this is the world we currently live in, it is important for those who are critical of diagnosis not to impose that on others. Rather we might explore, with them, the potential losses and gains of taking on a diagnostic label (something explored in the Open University counselling module). Common losses which people express are that no label fits them perfectly, that – if they do embrace a label - they feel trapped by it (that this is all that they are are all that they'll ever be), and that they are treated differently by other people.
Irving Yalom points out this problem with diagnosis, that it easily fixes people (the way that a kiln fixes a pot) and can prevent us from treating people as whole, complex human beings. Rather, it is easy for professionals to see people as a 'bipolar' for example, or as a 'borderline personality disorder' (assuming that that category is all that they are, and that this person will be the same as other people in that category). Actually there can be multiple diverse meanings for people who fall into the same category which it is vital to explore. Take agoraphobia, for example, which involves fear of being outside the home. This could be about a fear of social contact, a sense of shame about oneself, an oversensitivity to noise, a genuine concern around violent attack (racist or homophobic, for example), an inflated concern over the risk of crime, superstitious fear of an accident happening, worry over one's own capacity for anger and violence with others, or many other things (and combinations of things).
The point about fixing people is supported by the famous Rosenhan study 'on being sane in insane places' which was conducted in the 1970s. He got a group of people to present to psychiatrists. They didn't wash for three days and said that they heard the word 'thud'. All were admitted to hospital and all were diagnosed with schizophrenia (except one who presented to a private clinic who was diagnosed as manic depressive, which is telling about class and diagnosis). Once admitted, the people said that they were fine and didn't report any further symptoms. Nonetheless they were kept in for weeks at least and their behaviours were still read as ill or disordered. For example, queuing up for lunch early because they were bored was labelled 'oral acquisitive syndrome' and making notes was labelled 'compulsive writing behaviour'. Science writer, Lauren Slater, repeated the study in the early 2000s herself. She didn't get admitted, but was diagnosed and medicated by everyone she presented to, reflecting shifts in understanding and treating mental health problems.
Clinical psychologist, Richard Bentall, has pointed out the incoherence of many diagnostic categories: It is possible for two people, categorised in the same way, to have completely different clusters of symptoms. Some symptoms which are generally seen as signs of mental illness, such as hearing voices, are experienced by many people and are not always viewed as problematic.
Also, there are issues with the cultural and historical specificity of diagnosis. The classic example of this is the fact that homosexuality was included as a disorder in the DSM until 1973 and in the ICD until 1992. Other consensual sexual behaviours which are considered 'outside the norm' (such as fetishes, sadomasochism and transvestism) are still listed despite lack of evidence linking them to distress and calls for them to be removed.
This raises the question of to what extent diagnosis of disorder represents individuals being in conflict with the norms of society rather than a genuine pathology. There are many other examples of this. For example, the 'sexual dysfunctions' are categories for people who don't have the amount, or type, of sex that they are expected to have by wider society. Categories of 'premature ejaculation' and 'vaginismus' suggest that 'proper sex' involves penile-vaginal penetration.
We might also think about what things are classified as addictions and what are not (in relation to what is socially acceptable), or what forms of self-harming are pathologised (cutting and burning oneself, but generally not smoking, drinking to excess, risky sports or driving, or cosmetic surgery).
Many have argued that the high levels of diagnosis of depression in women (and the greater likelihood that distressed men will be criminalised as 'bad' whilst women will be pathologised as 'mad') are related to cultural expectations around femininity and masculinity. Also, black and minority ethnic people are more likely than white people to be diagnosed with 'severe' mental health problems and to be hospitalised and treated with drugs, arguably due to the western norms inherent in the diagnostic categories, as well as experiences of racism and social injustice.
Going back to Rosenhan's study we may regard the world that we currently live in as rather an 'insane place' (particularly given the current economic and ecological situation) and question what it means to respond 'sanely' to this. Winnicott famously said, of depression: 'The capacity to become depressed, to have reactive depression, to mourn loss, is something that is not inborn nor is it an illness; it comes as an achievement of healthy emotional growth...the fact is that life itself is difficult...probably the greatest suffering in the human world is the suffering of normal or health or mature persons...this is not generally recognised.' In recent goals for everybody to be 'happy' there is a danger that we pathologise, even more, quite reasonable forms of distress.