Psychiatric Diagnosis Part 1: a guide and caution for the weary

This post seeks to give an overview of how upsetting or distressing human experiences can be viewed and categorised as illness, disease, defect, disorder or dysfunction requiring the special expertise of specific treatments, therapies, interventions and pharmaceuticals for effective ‘cure’.  It is not my intention to devalue the choices exercised by patients who elect this treatment route for their mental distress, nor to assume that all mental distress is psychological in origin (some may be accompanied by medical evidence of an organic or toxicological cause, for example).  Simply to offer some clarification on how the psychopathology model of mental distress – used by psychiatry, medicine, clinical psychology, CBT, Social Services and other fields – is, in fact, a social construct that is seldom if ever rooted in scientific, biological or medical evidence of disease processes.  It then becomes apparent that other approaches to mental distress and wellbeing can be taken as an alternative to the pathology model with absolutely no requirement of a diagnosis as a precondition for effective treatment.

The Medicalisation of Mental Distress

Many people who experience distress, emotional and mental disturbance, anxiety, and a whole range of unpleasant or difficult experiences unwittingly seek medical help via the NHS or other healthcare settings. There may or may not be anything medically wrong with them, but they do so with little or no awareness that they are submitting themselves to a process that entails their distress being pathologised and labelled, even when no bio-physiological cause has been determined. Psychiatric labels can sometimes offer emotional relief, and give patients access to treatment, but can also sometimes be stigmatising and stay on a patient’s medical record permanently.  Alternatively, it is also possible to seek help from practitioners who do not apply or use psychiatric labels, and who don’t view human distress in medical terms.  More on that later.

Psychiatry is a branch of medicine that attempts to systematise human distress in clusters of commonly observable and reportable phenomena.  In other words, psychiatric diagnoses are based on interpretions of an individual’s speech and behaviour as measured against prevailing social norms. As a branch of medicine naturally psychiatry uses the illness model to formulate these diagnoses, based on these interpretations and descriptions of behaviours and speech.  As such it uses a paradigm of understanding founded upon ways of conceptualising physical ailments – with discreet signs, symptoms, pathology, progression, differential diagnosis and treatment.  This adopted paradigm then categorises behaviours, sometimes alluding to underlying neurochemical and psychological ’causes’ of such behaviours without evidence in support of such allusions.

Unfortunately, emotional and mental distress and disturbance in human beings are not amenable to the same framework of understanding used in clinical medicine to treat physical ailments.  This is because ‘mental illness’ is not characterised by the degree of predictability of outcome, progression or causation as physical illness.  Nor has it been shown to have any organic basis in biophysiology or neurochemistry as one would expect with our conventional understanding of ‘illness’ in the physical sense.  This has not prevented psychiatry, clinical psychology, medicine, CBT and a range of therapies that have aligned themselves with psychiatric diagnoses from adopting (and thus legitimising) the psychiatric diagnostic viewpoint, assessment and labelling process, all of which are socially normative in their approach. The fact that social mores and customs change and vary both over time and across cultures is one criticism of the normative function of professions which use psychiatric diagnoses to understand, label and control individual citizens. And there is a clear history of previous diagnoses that have become defunct due to changes in these social norms: homosexuality, being one of several that may have once been considered an ‘illness’ but is no longer.  Conversely, the number of new psychiatric diagnostic labels has increased exponentially over the decades.

NOTE: If you are about to commence psychotropic medication for any form of mental distress, please carefully read the information that accompanies such drugs. Anti-depressants, for example, can cause an increase in suicidal thoughts in the first few weeks or months of taking them.  Many others cause other significant negative side-effects.  Some older pharmaceuticals originally prescribed for mental distress have been repurposed by drug companies for other things e.g. for sleep, pain relief etc.  It is always wise to educate yourself on the benefits and risks before taking such medications.

Mental Illness is Not Disease

‘Mental illness’ is not disease, in the way that physical illness can be classified in disease terms.  However, this has not stopped medicine from attempting to classify human distress in disease terms – referred to as ‘disorder’ – as it attempts to understand difficult and distressing human experiences and behaviours in a systematised form within the medical framework.  The DSM – the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – is a handbook (now in its fifth edition and more closely resembling a major city phonebook) that attempts such systematisation as a reference guide for diagnosing mental distress according commonly observed clusters of ‘symptoms’ or unwanted experiences and behaviours.  It can be useful in forming a rudimentary understanding of a patient’s presenting difficulties, finding words and phrases to describe those difficulties in a way that allows both patient and others involved in his or her care to share that rudimentary understanding for the sake of reference and with the potential for consistency of care.


Psychiatric Diagnosis Limitations

However, due to the use of the physical illness paradigm in codifying common mental disturbance according to behaviours, thoughts and feelings reported or observed in so-called ‘clinical’ populations (essentially anyone who visits a psychiatrist or psychologist for ‘treatment’), the DSM and other diagnostic manuals’ cataloguing of human experiences naturally fails to provide in-depth or comprehensive understanding of the individual patient’s lived experience and unique meaning, unique causation and life circumstances, all of which are essential for a true understanding of the patient’s experience.  Because human experience – however anomalous it might be with the accepted social norms – is particular lived experience and a unique expression of individual needs, it cannot be legitimately classified in abstracted illness terms.

NOTE: You do not require a mental illness diagnosis to recover and heal from mental distress.  Psychiatric labels can sometimes be an aid to understanding, but are often not necessary for getting you the help you need.

Reducing a patient’s experiences to those that seem to fit with a psychiatric diagnosis is only useful in arriving at a conclusion about what label to attach to his or her expression of distress as it has been commonly and statistically observed in others.  In my view, this is where Psychiatric diagnoses in general stop being of service to the patient.  Because it is human experiences we are referring to, and each individual’s worldview, values, needs, understanding and meaning is a unique expression of that experience, specific ‘treatments’ that might be claimed for individual distresses are, in my view, often a step too far into the application of a medical framework upon non-medical phenomena.  Namely, phenomena that might be more appropriately understood in terms of their existential, emotional, social, spiritual and individualistic meanings.  ‘Labelling’ and ‘treatments’ in psychiatric terms typically take the form of behavioural restraints, legal and social controls, and social judgements on individual motivation (as in the use of the word ‘malingering’ for example), often for the purposes of individual and public safety, government and corporate agendas, and not the amelioration of causes of individual distress.  Pharmaceutical drugs that dull thoughts, subdue anxieties, blunt emotions, restrict extremes of emotion and behaviour, ECT (Electro-Convulsive Therapy), and physical, social and legal restraints are all forms of temporary containment of socially unaccepted behaviours, not treatment in themselves.  Indeed, such forms of treatment often work by causing iatrogenic harm to the patient on some level.


Doctor-centred Understanding versus Patient-centred Understanding

Psychiatric diagnoses are the medical establishment’s framework of understanding brought to the patient’s framework of understanding.  It is useful to the degree that it might offer clarity, concepts and nomenclature that can be shared between patients and care-givers.  However, to impose this framework upon a patient so that his or her individual experience, history of particular causes of distress and particular meaning are obscured or subjugated is where the psychiatric framework loses its usefulness as a tool for helping patients access real help.  ‘Therapies’ that simply reinforce the illness model by standardising patient experiences as ‘symptoms’ serve to stigmatise distress even further, obscuring or destroying the inherent meaning within distress itself.  Doing so blinds us to the fact that emotional and mental distress are, in fact, human expressions of human suffering and human need, not symptoms to be eliminated by any means necessary.  Emotional and mental suffering, as we all know in our common sense, tends to have their foundations in real world events for each particular person.

NOTE: Seeing an experienced psychotherapist who works from a non-labelling perspective can be a way to recover and heal from mental distress without the need for pharmaceuticals or stigmatising psychiatric labels.

Personal Responsibility Shift

One other significant effect of the expert-patient dynamic created via the pathology paradigm is the locating of responsibility for recovery in the ‘expert’ or ‘treatment’ and the patients compliance with them.  If a patient suffers from an ‘illness’ then his or her responsibility for recovery becomes limited to his or her degree of obedience to the ‘cure’ being offered.  This shift from personal responsibility to expert responsibility can create a sense of disempowerment and dependence upon compliance to treatments that keep the patient ‘down’ and the practitioner ‘up’ hierarchically.

Distress as Human Expression, Not Medical Symptom

However, with few exceptions, emotional and mental distress are thus often caused by the world and our responses to it, not disease pathogens or toxins in the environment.  These causes are typically social and economic in origin: other human beings, economic and social conditions that give rise to suffering either immediately or eventually following their adverse influence.  For example: the stresses and strains caused by poverty, relationships, poor parenting, over-work; bullying and other malignant interpersonal behaviours; sexual assault, harassment and abuse, social pressures in dysfunctional work and educational environments upon senstive individuals; traumatic events, warfare, and a whole range of other toxic social, economic and psychological influences acting upon individuals to the point of overwhelm. In such cases ‘symptom management’ as stand-alone ‘treatment’ can be a further insult to the suffering person as the means by which he or she reveals and expresses his or her suffering to the world is silenced or subdued.

Promises, Promises

For patients, psychiatric diagnoses can offer the beginnings of hope: the promise of recognition of suffering and validation of experience.  But many patients also express bitter disappointment at undestanding that never comes; medications that merely curtail clarity of thought and emotion or cause greater difficulties rather than helping; the implied promise of being heard, accepted and cared for that in reality becomes an effort to manipulate thoughts and behaviours in the service of social conformity and to the detriment of personal meaning; the stigma and refusal of access to therapeutic services, to insurance and employment.  This, in my view, is because psychiatric medicine and those allied professions who routinely use psychiatric labelling in the service of professional power – some psychologists, psychotherapists, CBT and other therapists, social workers, nurses and doctors – who have aligned themselves with the psychiatric framework have taken the application of this framework too far, applying a paradigm of understanding physical illnesses in the service of pathologising human experiences that is often inappropriate to the emotional, mental, and ultimately existential healing of the suffering person.  It is for these reasons that patients and professionals who wish to maintain a more human-centred approach to patient care can usefully approach psychiatric diagnoses with a degree of healthy scepticism and caution; accepting their usefulness as often arbitrary, rudimentary shorthand, but refusing to use a diagnostic category as a restricting lens through which the patient is narrowly viewed, as is often the case.  Where such labels are applied in the absence of meaningful, consistent, consensual care and support, they serve merely to stigmatise, serving no greater function than name-calling: legitimate where they assist in highlighting risk, vulnerability or danger.  Otherwise, it is crucial that patients who are given psychiatric diagnoses are fully informed about the limitations of such medicalised labelling so that they then retain the power to accept or refuse such labelling where it serves their best interests.


‘Specialness’ and Other Infectious Narratives

So often patients adhere to a psychiatric label simply because of its potential to validate their suffering in others’ eyes.  When a patient accepts a psychiatric diagnosis hook, line and sinker, he or she can unwittingly accept the restrictions associated with the psychiatric paradigm and the associated restricting narratives that suggest that ‘only this treatment has been approved or shown to work for this condition’.  Some ‘therapies’ and their proponents’ best marketing efforts have merely reinforced the illness model by making often spurious claims about effectiveness for particular conditions that only this or that therapy or specialism can legitimately address.  Patients, in their earnest efforts to have their suffering both recognised and alleviated can find themselves in a psychiatric labelling trap: having bound themselves to both diagnosis and marketing hype, reinforcing the marketing narratives that only this or that particular therapy is appropriate for this or that particular diagnosis.

Entire industries have been built upon the back of the shaky ground of psychiatric diagnoses and associated narratives about therapeutic efficacy, with vested financial and professional status interests involved in their perpetuation.  So often, however, a gift given by one hand can be taken away with the other, and the apparent validation given by a psychiatric label can also come with a flipside of de-validation, disempowerment and deep frustration or torment that can stay with patients for the rest of their lives as they invest in the notion that they suffer from an illness that only an expert can cure.  This is due in part to unrealistic expectations implicit in the idea that medical-sounding treatments promise a ‘cure’.  And in the absence of effective drug treatments, patients unable to access the ‘specialist’ therapy suggested as necessary by social media narratives and marketing campaigns can find themselves banging their heads against walls of institutional indifference when these ‘specialist’ treatments are not offered.  In reality, despite the efficacy claims that come and go, there is no convincing evidence to suggest that any one therapeutic model is more effective than any other.  Indeed, some claims of efficacy have since been proven to have the reverse effect to what was originally claimed, as in the case of CBT in the treatment of ME/ CFS, Fibromyalgia, depression and other conditions purported to benefit from this approach.


Personal Growth Versus Treatment of Pathology

The task of the psychotherapist then, is to see psychiatric diagnoses for what they are: sometimes helpful descriptions of features of mental distress clusters, and a basic reference guide for gaining limited insight or understanding prior to further investigation of the patient’s worldview.  Patients with a diagnosis may be under the impression that they suffer from an illness or disease in the orthodox medical sense and thus anticipate a ‘treatment’ administered by an ‘expert’.  The psychotherapist’s role is to help enlighten patients about their psychiatric label’s limitations in getting to the heart of personal experience and meaning, the centre of responsibility for recovery (a shift in responsibility for healing back to the ‘patient’), and the therapeutic work required for a meaningful recovery out of their suffering.  Reframing the psychiatric diagnosis as a medical way of viewing distress that lies within the spectrum of human experience allows patients to begin the process of leaving a psychiatric diagnosis behind as a temporary descriptor that was given for a short period of time and that, at best, may have allowed them access to effective help and in some cases, such as some ‘personality disorders’ excluded them from help*. Whilst some psychiatric diagnoses are successfully managed with pharmaceutical drugs (and to those patients wishing to adhere to this approach there is no criticism), many conditions can be successfully worked through to a resolution or better management in psychotherapy.

*There are, in my opinion, cases where accurately assessed personality disorder diagnoses can be helpful.  Not least in those cases of what I refer to as ‘the toxic victim’ – those damaged individuals who go on to cause harm to other people whilst acting under cover of innocence or victimhood.  In such cases, personality disorder labels can alert us to the risks and dangers associated with dealing with such individuals, particularly as toxic victims are easily capable of harming people who have given them care, protection and support for months or years.

Pathology-Oriented and ‘Specialist’ Therapies

The term ‘specialist’, as mentioned, is another borrowed from the medical world and applied to pathology-oriented therapy models.  To the lay-person it suggests an elevated level of expertise, knowledge and competence.  When used within psychology and psychotherapies it largely functions as a marketing term used to suggest greater competence in a practitioner’s application of higher order treatment of specific psychiatric disorders.  However, since psychiatric disorders are constructs, ‘specialisms’ of this kind typically become yesterday’s snake oil in the therapy world as the self-aggrandising term ‘specialist’ becomes apparent as mere marketing vocabulary similar to the terms ‘upgrade’, ‘premium’ and ‘safe and effective’.  In a consumer culture, market competition also influences how ‘new and improved’ therapies are advertised and promoted in the manner of other products in their efforts to usurp the work of long-established psychotherapies and helping methods.  Patients unaware that the pathology model of mental distress is largely a construct used by psychiatry, clinical psychology, CBT (and derivatives), EMDR and others, naturally want what promises to work best, and so may latch onto a trending form of therapy marketed in such a way over others equally or more effective and often more easily accessed due to the simple matter if being long-established.

The most convincing long-term research concerning the effectiveness of any and all forms of psychotherapy is, contrary to marketing claims, not the specific therapy model, but the qualities the practioner is able to bring to the formation of a caring, understanding, accepting, empathic and well boundaried relationship of truthfulness, consistency and respect.  This evidence supports the reality that mental distress is a feature of the human experience, not necessarily disease, defect or clinical dysfunction.  It also runs counter to the technocratic gimmicks of ritual and protocol offered in more recent technique-driven helping models fuelled by vested interests.

In the end, whilst most people are sold the notion that their emotional suffering is a clinical or medical condition, some opt for and benefit from medical or technical interventions.  For those who wish to work through their experiences with a view to personal recovery and personal growth, psychotherapists and helpers who work from a non-pathologising perspective are in a position to educate and support suffering people through a process of personal development on a distinctly human, not medical nor technical, journey.  This is a humanising alternative to that of reinforcing a pathology narrative as promoted by practitioners and services who rely on psychiatric labelling and allied ‘specialist’ treatments that often serve the professional interests of practitioners more than the patients themselves, many of whom carry the stigma of mental illness diagnoses for the rest of their lives long after these treatments have come and gone.

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R. D. Laing – Blue Plaque – Ardbeg Street
Ronald David Laing was born in the Govanhill district of Glasgow on the 7th October 1927. He was a Scottish psychiatrist who wrote extensively on mental illness – in particular, the experience of psychosis. Later on Laing was seen as an important figure in the anti-psychiatry movement, although he never denied the value of treating mental distress. He challenged the core values of a practice of psychiatry which he thought considered mental illness as a biological phenomenon without regard for social, intellectual and cultural dimensions. (October 1927 – 23 August 1989)

5 Comments Add yours

  1. Wow, thanks for writing this!

    Liked by 1 person

    1. Stephen says:

      Thank you. Hope it was helpful.

      Liked by 1 person

      1. It was definitely helpful! 🙂

        Liked by 1 person

  2. Your compassion is evident. You are not alone in challenging the validity of psychiatric diagnoses.

    Liked by 1 person

    1. Stephen says:

      Thank you Anna. There has been a rising tide of dissent against psychiatry over the past few decades. Dr Peter Breggin, R.D. Laing, Thomas Szasz and many others have questioned the paradigm of medicalising, and thus pathologising, human emotional and mental disturbance and distress. That dissent seems to be escalating.

      Liked by 1 person

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