… or if it’s half right, which half?

Warning: If you want a rant, filled with gross generalizations about psychiatry, this isn’t one.

If you’ve ever given or received the gift of a psychiatric diagnosis, odds are there was something seriously wrong with it. Research has shown that many therapists have a poverty of diagnoses, and are prone to faddishly offer up their pet diagnosis. The players on the diagnostic landscape drive it’s nature with conflicting agendas. The managed care company wants to reduce costs. The provider wants to make a living. The client wants to feel better or get someone off their back. And everyone wants to be “right”, except for masochistic self-saboteurs who, ironically enough, no longer have a diagnosis in the DSM (where you find the diagnoses that have made it past the velvet rope of the American Psychiatric Association).

There are deeper flaws to the DSM, and they resemble going out on a limb, farther and farther, until it can’t support you. The diagnoses are based on observed patterns of behavior, including what people say about their feelings and thoughts, if anyone is listening. Odds are, if you know much about cars, you’re right when you diagnose your car. There are only so many parts, and your car’s symptoms have only so many possible sources. You even have the satisfaction of knowing you’re right. Replace the part and it goes!

With psychiatric disorders, you can’t even look under the hood nor do a biopsy. Brain scans are in their infancy, with very limited use in psychiatry. And if the client gets better, it isn’t always because of the treatment. So basing a diagnosis around generalizations about people who have similar behavior is already a stretch, especially since there are so many other qualities of the person that fall outside the diagnostic spotlight, yet influence the person’s response to treatment and their ultimate fate.

Next, there is prognosis or course of the disorder. We are challenged when it comes to predicting the course of a disorder. We don’t look so challenged when we appeal to statistics, because an average number is, well, a single number. Scatter, however, is the unwillingness of a statistic to bear much fruit in the real world. That’s why that test that rates your stress (Holmes-Rahe Stress Scale) can’t really tell you if you’ll get sick.

Then there is treatment. We must go even farther out on the limb, generalizing about what treatment will work for whom. Fortunately, research supports the notion that psychotherapy works for many people. Unlike the research on medication, there is no cunning, six-hundred-pound gorilla finding countless ways to interfere with the science and the justice system, as it is well documented when it comes to the pharmaceutical industry. Yes, there are well-known flaws to psychotherapy research, but not enough to undermine the conclusion that therapy works.

Psychotherapy succeeds, in part, because of diagnosis, but also because it can transcend diagnosis. The way most therapists talk about their clients shows that they see the person beyond the diagnosis. In fact, therapists that are preoccupied with pathology are likely to be mediocre at best, or even harmful. (To wit: the case of the supershrink vs. the subshrink as described in Core Processes in Brief Psychodynamic Psychotherapy: Advancing Effective Practice, by Denise P. Charman, and elsewhere.) At the same time, therapists who can focus on the desired result, rather than the rules, are able to come up with ideas that can dramatically improve the results of therapy. Milton Erickson is famous for being ahead of his time when it came to this, and, I suppose, most everything else.

In this transcendence of diagnosis and rules, we become light enough to manage being out on a limb. But we have to go out on the limb in the first place, by thinking diagnostically and in rule-based steps. This way, we can communicate with other clinicians by using our professional shorthand, we can scoop up ideas from research, and we can start off with the generalizations that help us formulate our first “map” of the client’s path to a better life.

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