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Diagnosis-centered versus situational approaches to therapy
Much has been said about the stigma surrounding mental illness. As emotionally-loaded as the phrase “mental illness” is, little is often understood about it. Scientists are only beginning to understand the complex interaction between mind, body, the social environment, parental influences, and genetics that underlie human behavior. Categorizing this complex phenomenon as a mere biochemical anomaly does little to shed light on the multifaceted nature of this problem, and does more to fuel existing prejudices surrounding people with mental illnesses.
Mental illness can be thought of as a social and environmental phenomenon as much as a biological one. It is in reality impossible to separate MI from its wider context. The notion that simple genetics and biology determine human behavior is as simplistic as the assumption that one’s preference for a certain type of music over another, or specific political belief over another is simply the result of the random dance of molecules in the brain, devoid of anything else such as previous experiences, education or peer influences.
The so-called symptoms that underlie various diagnoses of MI, whether it be depression or Bipolar disorder, are not static conditions that can be neatly placed in specific cubbyholes that offer insightful guidelines for effective treatment. In fact, rarely is this the case. MI is one of the many aspects of human experience that most if not all people experience over the course of their lifetime. Grief is a normal reaction for someone who has just experienced a loss. PTSD is a perfectly rational psychosomatic response to sexual assault.
Taken this way, an episode of schizophrenia or other types of psychosis may be considered a response to a personal crisis, and in some cultures a rite of passage in one’s development toward maturity. Supporting a person undergoing such a crisis free of stigma or prejudice may produce a far different outcome from one which results in ostracism, hostility, hospitalization, and drug treatment devoid of any other form of care.
The problem is, those that have not been previously diagnosed with MI are often told that an “episode” is a situational thing and not an enduring phenomenon, while those diagnosed with MI are far too often given a label used to justify and explain their aberrant behavior. The label can often feed upon itself, perpetuating a cycle of internalized stigma that is then reinforced in treatment, as well-intentioned as it might be.
Panic attacks preceding a job interview or a graduate school entry exam may be considered extreme for some, but everyone has some sort of vulnerability or another that can bring out “symptomatic behavior”. Calling this “panic disorder” or generalized anxiety disorder as a pretext to prescribing anti-anxiety medication may be the right thing to do, clinically-speaking, but it is difficult to assess the psychological damage to the patient over time caused by bearing a label of psychic pathology, attacking the symptom without delving into underlying causes.
Medical practitioners must consider their role in relation to the patient. This is not to negate the fact that indeed, biological influences play a huge role in manifesting symptoms of MI. Nor does this negate the important role that psychiatric drugs may play in alleviating symptoms of MI, so that other treatments such as talk therapy can kick in optimally. Diagnosis should only be a beginning – a road map if you will, and not the end of treatment, as if administering the “correct drug regimen” is all that is required for success.
Being human, psychiatrists and clinical psychologists are liable to make biased judgments like anyone else, but as they act in their professional capacity, there is far more at stake. Studies have shown that unconscious biases or stereotyped perceptions on the part of the mental health professional may have adverse effects upon the patient’s recovery process. Biases may communicate themselves in subtle attitudes or behaviors that elude superficial detection, making them a much more pernicious and pervasive influence than previously thought.
“How people with mental disorders are viewed by treatment providers and the general public can have a significant impact on treatment outcomes and the quality of life of clients,” writes Dr. Bruce Link, professor of epidemiology and sociomedical sciences at Columbia University.
According to statistics 1 in 5 Americans have some form of mental illness, yet, the statistics can be higher, as many individuals simply do not seek treatment. Certainly cultural attitudes may predispose individuals against seeking therapy or for professionals themselves to factor in cultural biases in diagnosing them, resulting in misdiagnoses. Repression rather than acceptance of MI for example is prevalent in East Asian cultures, further obscuring the true inicidence of MI across the world.
Nor do the stats take into account the fact that diagnoses in the DSM are not restricted to people with so-called “mental illness” diagnoses. Symptoms can be thought of as points on a continuum, with everyone falling somewhere, which all of us, at one time or another, may find helpful in order to identify the problem in order to devise an appropriate plan for action – whether it be treatment, medication, or simply some form of therapy. It need not be a source of stigma. Instead it can be a ready tool used to find common ground in treatment for both “normal” and “mentally ill” alike.
What I suggest is a shift away from a diagnosis-centered approach to identifying and treating mental illness and more of a situational or symptom-oriented approach. The situational or symptom-based approach focuses on the situation, or the underlying causes of current emotions of distress, rather than looking at the patient’s history or medical background. Looking into one’s detailed medical file is the most common way to guide future treatment, and this may be part of the problem, as it takes the focus away from the “patient” as an individual and places him/her in a category that is both impersonal and abstract – further obscuring any personal connection that may otherwise develop that is essential for effective treatment. A situational approach – in contrast – places the focus onto the client’s immediate and current experience, and works together with the patient to identify and mitigate the causes of “distress.”
A small and subtle difference to be exact, but the underlying premise is a marked contrast to the prevailing model which uses the patient’ diagnosis as a tool to guide treatment. Such a situational approach seeks not to view personal experience as pathological in itself, as every person’s experience – from an emotional and physical standpoint – is a valid one. It simply is. Seeing the patient’s personal experience as valid, and as potentially a reasonable emotional and or cognitive response to an external situation leaves room in the imagination for a rational alternative as a solution, and makes meaningful dialogue between provider and patient possible. Humanizing the patient is quite often the first step in guiding an effective therapy.
Michale C. Miller of Harvard University, suggests redefining diagnosis as a process that takes time, rather than a static and fixed initial stage in the treatment process. Seen this way, diagnoses are no more than educated “first impressions”, often prone to fallacy the same way any first impression can be. Seeing it this way, one sees that initial diagnoses are error prone and imperfect, something that can be and indeed must be refined by “careful consideration over time” in order to remain useful and provide a good model for action. Such effective diagnoses can only be made through careful and thoughtful interaction with a patent. Seen this way, re-humanizing the patient may have merits that are not merely humanistic, but scientific, in terms of delivering results in quality mental health care.
A dialogic approach to therapy is one which seeks to build a diagnosis that is a good albeit fallible and imperfect road map to appropriate treatment while recognizing with a respectable dose of humility that the multifaceted nature of the mind eludes simple static definitions and labels. The map is not the territory, but must be reinvented through collaborative dialogue with the patient. Only then can an accurate diagnosis be constructed, “accurate” being defined as one that is ultimately-empowering and wthat which provides a road map toward the realization of the patient’s human potential by seeing beyond the illness.
As far-reaching as the step may be, rethinking the prevailing practices around making diagnoses – and rethinking mental illness in general – is only an initial step in revamping a system that needs revamping on a systemic level. MI is as much a social problem as a biological one. The World Health Organization calls it the number one cause of occupational disability in the world, and in cultures throughout the globe, the dialogue around MI is laden with prejudice, misunderstanding, and dogma which underscores other social problems such as racism, sexism, and ethnocentrism. As with any kind of systemic change in institutions that are national, even global in scope, the dialogue must change in the healthcare community, and this dialogue must include the “silent minority” – the mental health care consumer as well as the provider.
On the side of mental health professionals whose medical opinions and evaluations are too human, considering the mind’s mischievous tendency to be unaware of its own bias while mistaking opinion for actual fact, the administration of mental health care for the consumer would be as much an exercise in humility as it is in leading one’s growth toward wholeness.
Dangers of biases (cultural and sexism) on the part of mental health professionals in diagnosing a patent:
•Uncritically interpreting information acquired in the artificial context of a clinic
•Making a decision about the normality or pathology of a patient on the basis of little information and little time spent with the patient
•Making a decision about the appropriateness of prescribing medication on the basis of very limited information
•More readily taking at face value what male patients say than what female patients say
•More readily judging a patient mentally ill if the patient is a woman and/or member of a racialized group and/or poor
•More readily judging women than men to be overly emotional, even dangerous
•More readily assuming that men need protection from women than the reverse
•More readily prescribing mood-altering medication for women than for men
•More readily offering men than women the option to take medication
•More readily assuming that women more than men need ongoing monitoring and treatment
•Tending to assume a higher-status role in relation to women patients than to men, including making male patients part of the decision-making process
Jeffrey Poland and Paula J. Caplan
04-266 Ch 02 6/18/04 6:20 AM Page 10
Dave Leon is the Founder and Director at The Painted Brain and a prolific author/contributor to Painted Brain News