Benefits and Challenges of Diagnosis in Mental Health
Benefits and Challenges of Diagnosis in Mental Health
Currently there is some debate as to how useful the medical model of diagnosis is, including the reliance on diagnostic manuals. In this document we explore the benefits and challenges of mental health diagnosis and consider alternative ways of thinking about the experiences people have.
For some people, a diagnosis can be a welcome relief and provide them with hope, access to support and clarity about their situation. It can empower individuals and help them to feel listened to and understood. Sometimes it can also help people to have a better understanding of themselves, their diagnosis and their symptoms. It can provide validation, and knowledge that what is happening to them is not their fault.
However, it is important to recognise that this is not the same for everyone and that alternatives to diagnosis need to be explored. For some individuals, a diagnosis can be a distressing and difficult experience that makes the person feel as though they are not included in the process, that they are not listened to and/or their experiences are not validated. It can feel labelling and disempowering.
There is increasing literature now suggesting a move away from the medical model of mental health and diagnostic labelling to thinking more about a person’s experiences, and what has happened to them instead.
Making a mental health diagnosis
Doctors will look at a variety of things to help them diagnose a mental health condition. Among these will be:
- Your experiences (your physical symptoms, your feelings and your behaviours)
- The length of time you have been experiencing these symptoms, feelings and behaviours
- The impact your problem is having on your life
For issues that are quite common like anxiety and depression, a GP will be able to give you a diagnosis after a couple of appointments. If your issue is not as common, you will be referred to a specialist like a psychiatrist. This person will probably want to see you a few times, over a long time period before they give you a diagnosis.
The two tools that are used to support a diagnosis are:
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
This is a manual that is used to diagnose mental health disorders and psychiatric illnesses. It is a compilation of the work of many hundreds of mental health experts from around the world over the period of a decade.
It is also used to see what treatments are recommended for different disorders. This manual does not have a theoretical basis, but rather contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders.
It also contains statistics concerning who is most affected by different types of illnesses, the typical age of onset, which gender is most often affected by an illness, the effects of treatment, common approaches to treatment and treatment effects.
Diagnostic manuals such as the DSM were created to provide a common diagnostic language for mental health professionals and an attempt to provide a definitive list of mental health problems, including their symptoms.
World Health Organisation International Classification of Diseases (ICD)
Is a diagnostic tool that is used by clinicians. It is a publication that is managed by the WHO (World Health Organisation). Originally, it was designed as a classification system for health care that consisted of diagnostic codes to help classify diseases. It includes a variety of symptoms, signs, complaints, abnormal findings, external causes of diseases or injuries and social circumstances.
The International Classification of Diseases is used across the world for mortality and morbidity statistics as well as automated decision support for health care. It is a system that is designed to help promote comparability across different nations in classifying, processing, collecting and presenting statistics.
De Silva (2017) suggested that, due to the nature of subjective observation, diagnosis is open to interpretation and may change throughout an individual’s life, depending on who is involved in their care and treatment. There is a risk when diagnosing mental health conditions of minimising personal experiences and situations, so individuals fit into boxes based on symptoms rather than the cause of those symptoms. For some people, the experience of trauma, abuse or neglect may not be considered.
The benefits and challenges of a diagnosis – BENEFITS
- Having a diagnosis can be useful, many people will feel relieved that there is a name for what they are experiencing, and they might not feel so alone as others experience it too. The diagnosis can enable people to connect to other individuals facing the same type of problem, which can provide a shared understanding of experiences and empower them to talk about what is happening.
- Receiving a diagnosis can help to strengthen relationships with health professionals, and support communication between different practitioners seeking treatment options. It makes things easier when communicating with professionals and once a person gets a diagnosis, it can help him/her to access some services, or it can also make finding information on specific problems easier.
- Having a name for the experiences or problems can be beneficial for some. This gives them a sense of knowing, allows them to make sense of their symptoms and helps them to explain to friends and family what they are experiencing. It becomes easier to explain the problem to others and professionals when you know the definite name of the complication.
- Labelling your feelings can help someone recognise that their condition is a real one. It gives hope and reduces anxiety of the unknown.
- It gives insight into the problem. Individuals get the idea of the issue rather than think of themselves as crazy. A diagnosis may also reduce stigma by explicitly acknowledging the presence of an illness.
CHALLENGES
- Some individuals may not agree with their diagnosis or feel fully involved or supported in the process of receiving their diagnosis (Double, 2019). For some people, stigma plays a big part in this. This can impact how they are perceived by health and social care services and society, how interactions/interventions by professionals are carried out and, ultimately, whether – when struggling to find the appropriate help – they feel understood and respected.
- Mental health diagnosis can be subjective and open to interpretation (De Silva, 2017). This can mean at times, an individual’s symptoms may not fit into one specific diagnosis, limiting their access to the care and treatment they need. It also may mean misdiagnosis or multiple diagnoses, which can leave them feeling confused and frustrated (Munro, 2021). It can also result in confusing treatment and support and individuals being bounced from service to service with no agency taking responsibility for care.
- A lot of people find having a diagnosis problematic because it might not fit the individuals’ experiences completely and risks putting people in a box.
- Some people feel that having a label is permanent, especially when it comes to mental health conditions. This can result in discrimination and stigma impacting on the individual’s future employment, education, and health prospects.
- At times, reliance on a diagnosis may reduce professional curiosity about the person’s specific and individual experiences. This may mean for example that experiences of trauma, abuse or neglect are not heard or considered as potential underlying causes. This could result in an over-medicalisation of normal experiences.
- Diagnosis risks the oversimplification of human experiences and behaviour. A diagnosis may also ignore other factors that might be contributing to the problem.
- Due to diagnosis being reliant on subjective judgement, it can be unreliable and open to different opinions and perspectives.
RECENT RESEARCH
A study led by researchers from the University of Liverpool, involved a detailed analysis of five key chapters of the latest edition of the widely used Diagnostic and Statistical Manual (DSM), on ‘schizophrenia’, ‘bipolar disorder (manic depression)’, ‘depressive disorders’, ‘anxiety disorders’ and ‘trauma-related disorders’.
The main findings of the research were:
- Psychiatric diagnoses all use different decision-making rules
- There is a huge amount of overlap in symptoms between diagnoses
- Almost all diagnoses mask the role of trauma and adverse events
- Diagnoses tell us little about the individual patient and what treatment they need
The authors concluded that diagnostic labelling represents ‘a disingenuous categorical system’.
Lead researcher Dr Kate Allsopp, University of Liverpool, said: “Although diagnostic labels create the illusion of an explanation, they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.”
Professor Peter Kinderman, University of Liverpool, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria. The diagnostic system wrongly assumes that all distress results from disorder and relies heavily on subjective judgments about what is normal.”
Professor John Read, University of East London, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”
Trauma can adversely affect all areas of life and prevent the early development of key emotional and cognitive skills. Complex trauma can lead to individuals displaying behaviour that meets diagnostic criteria for several different psychiatric disorders. Unless these behaviours are recognised as adaptive responses to extreme adversity, individuals may be labelled with one or more inaccurate psychiatric diagnoses. Such diagnoses may lead to inappropriate drug or behavioural interventions rather than an effective relational response to help children or adults recover.
ALTERNATIVES TO DIAGNOSIS
Gabor Mate, Bessel Van de Kolk, Bruce Parry are especially known as leading Doctors in the field of trauma that have been advocating application of a non-diagnostic approach to trauma for many years.
In the UK, Johnstone et al (2018) argue that mental health practice is too heavily dependent on diagnostic classification and the use of psychopharmacology. This approach suggests that services should focus on cultural, social and economic contexts. It moves from the medical and biological dimensions of the person to an understanding of the whole person encompassing the physical, psychological, emotional, social and spiritual aspects of their life. The focus is on the individual and what has happened to them, instead of the specific diagnosis, and offers a solutions-focused approach around the patients’ strengths as well as their vulnerabilities (Munro, 2021).
POWER THREAT MEANING FRAMEWORK
The Power Threat Meaning Framework aims to serve as an alternative to receiving mental health diagnosis. It argues that distress is understandable in the context of our relationships and social circumstances, and the wider structures, norms and expectations of the society and culture in which we live (Johnstone et al, 2018).
The approach is summarised in four questions that can apply to individuals, families or social groups:
- What has happened to you? (How is power operating in your life?);
- How did it affect you? (What kind of threats does this pose?);
- What sense did you make of it? (What is the meaning of these situations and experiences to you?);
- What did you have to do to survive? (What kinds of threat responses are you using?).
These questions help to change the focus from “what is wrong with you?” to “what happened to you?” This framework creates narratives about the reasons for an individual’s distress that are not based on psychiatric diagnoses and finds ways for individuals, families, social groups and whole societies to move forward.
SUMMARY
Individuals vary in their responses to receiving diagnosis in relation to their mental health. As we have seen, some people find this a positive experience and others find it a negative experience.
It is important that as professionals working within human services that we understand the complexities of this discussion and seek to ensure that our focus is on the individual and supporting that person’s unique and specific situation.
As such, ensuring that we continue to be curious about what has happened to someone that may be contributing to their behaviour or presentation and that we guard against a reliance on medical diagnosis only.
We must provide opportunities for discussion, hopes and fears of the individual and ensure that their own unique experiences are validated, listened to and acknowledged.
References
De Silva P (2017) How to improve psychiatric services: a perspective from critical psychiatry. British Journal of Hospital Medicine; 78: 9, 503–507.
Johnstone L et al (2018) The Power Threat Meaning Framework: Towards the Identification of Patterns in Emotional Distress, Unusual Experiences and Troubled or Troubling Behaviour, as an Alternative to Functional Psychiatric Diagnosis. British Psychological Society.
World Health Organization (2021) International Statistical Classification of Diseases and Related Health Problems (ICD). WHO.
Munro M (2021) Mental health diagnosis: looking at a grey area through a critical lens. Nursing Times [online]; 117: 10, 18-20.