“The moment a little boy is concerned with which is a jay and which is a sparrow, he can no longer see the birds or hear them sing.” – Eric Berne, M.D., Games People Play (1964)
In modern psychiatric and psychotherapeutic education, diagnosis is one of the first things a trainee is taught to do. In clinical practice, it is a requirement for reimbursement by the insurance companies and a process thought to help structure and guide the treatment. But it wasn’t long ago that psychiatric diagnosis didn’t count for much; prior to the publication DSM-III, many psychiatrists and therapists never formally conferred a diagnosis. Categories were limited to “neurotic” and “psychotic,” with little attention paid to any further delineation.
While things have changed vastly in the past forty years, some analytically-minded psychiatrists and psychotherapists still see diagnosis as an unnecessary impediment to treatment.
The first thing to realize is that psychiatric diagnosis is, by its very nature, an imprecise endeavor. There are no x-rays, blood scans, or MRIs that can aid psychiatric diagnosis, despite popular media claims to the contrary. Even amongst skilled clinicians, disagreement over diagnosis is common. I find that diagnoses tend to clump around certain providers: one may have a penchant for bipolar disorder diagnosis, another may call everything schizoaffective disorder (while others never diagnose it), another may diagnose borderline personality disorder in every patient he sees, etc. This gives weight to the idea that psychiatric diagnosis often says more about the provider than the patient.
The sheer number of psychiatric diagnoses has increased from a mere 10 or 12 one hundred years ago to over 300 in the latest iteration of DSM. The seemingly endless array of mental disorders enshrined in DSM speaks to the rapid medicalization of human suffering in the 20th and 21st centuries. And this is rather unique to psychiatry. No other branch of medicine has seen even near-comparable numbers of new disorders in the past hundred years.
Another vital fact for the clinician (and for the patient) to understand is that what we call psychiatric disorders are not discrete disease entities. Despite common misconception, there is no known brain lesion or chemical imbalance causing mental illness. Some brain abnormalities are found in some patients diagnosed as psychiatrically ill, but it is entirely possible that these abnormalities are the result rather than the cause of the problem. In some cases, these changes have been shown to be the result of long-term medication treatment.
Even the chair of the American Psychiatric Association’s DSM-IV Task Force, Allen Frances (2013), has acknowledged that mental disorders are social constructions and not diseases. This is not to say that they are entirely useless constructions. Rather, in my opinion, psychiatric disorders are metaphors that can be useful in helping a patient understand the nature of their problems—so long as the metaphors are understood as metaphors and not taken literally.
Frequently, a patient in psychotherapy or psychiatric treatment will come to identify so closely with his or her diagnosis that it becomes a major barrier to recovery. The famed psychiatrist Eric Berne (1964) used the term “wooden leg” to describe a posture assumed by the patient in which the individual resists improvement as a strategical method. “What would you expect from a person with a wooden leg?” the question goes, or, in this case, “What would you expect from a person who is mentally ill?” The all-too-frequent answer: not much.
Unfortunately, patients have no trouble finding therapists and psychiatrists who will play along with this game—the result always being a worsening in the patient’s condition. Usually, it ends with the patient going on disability.
Another problem with psychiatric diagnosis is the tendency of some clinicians, particularly biologically-minded psychiatrists and other adherents to the biological paradigm, to see psychiatric symptoms as mere manifestations of the patient’s underlying disease process, completely devoid of any meaning or symbolism. The richness and idiosyncrasy of psychiatric presentations is ignored, the symptoms explained away as the mere consequence of disease.
From this perspective, it makes no sense to understand why a person is suffering the way that he is—it only makes sense to suppress or treat the symptom, usually with a drug. Meaning is ignored. The patient is left feeling misunderstood, or not understood at all.
This phenomenon is beautifully captured by Berne’s quote, “The moment a little boy is concerned with which is a jay and which is a sparrow, he can no longer see the birds or hear them sing.” Once a psychiatric diagnosis is applied to an individual, there is a tendency for clinicians to see only that diagnosis and not the richness and complexity of the individual experience. Depression is seen as the result of a chemical imbalance rather than a psychological reaction to adverse events, hallucinations as mere symptoms rather than reflections of the patient’s internal life, etc.
While psychiatric diagnosis can do a lot of good when applied judiciously and contractually (and with proper explanation), the limitations of diagnosis cannot be ignored. As the psychiatrist Thomas Szasz pointed out frequently, words have consequences. This is perhaps most true in the case of psychiatric diagnosis.
Berne, E. (1964). Games people play: The basic handbook of transactional analysis. New York, NY: Grove.
Frances, A. J. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY: HarperCollins.