Imagine that you got upset. Is it very remarkable that I can “diagnose” that you are upset? After all, you are clearly upset. What expert thing did I accomplish by agreeing with you that you were upset? Or imagine that you are angry. Is it very remarkable that I can “diagnose” that you are angry? After all, you are clearly angry. Have I added anything meaningful by saying “I diagnose that you are angry” instead of “You seem angry”?
“You look upset” is the simple, truthful thing to say and “I diagnose that you look upset” is a piece of self-serving chicanery. By adopting that circumlocution I’ve tried to turn an ordinary observation into a pseudo-scientific marvel. If this is the way I’m operating, I dearly hope that you won’t notice my little game.
By contrast, let’s say that you explain to me that you’ve been having hallucinations. You describe the look of your hallucination and you also describe to me your recent history, other physical symptoms, and so on. Taking that information together, I have a strong hunch that you’re suffering from early Parkinson’s. I then run tests to confirm or disconfirm my hypothesis. I didn’t “diagnose” your hallucination—you handed me that. I diagnosed your Parkinson’s.
Why do we have so much trouble understanding this difference: the difference between “diagnosing a symptom” and “diagnosing a cause”? The second is what medicine legitimately does. The first is what the mental health establishment illegitimately does. It is not real diagnosis for me to “diagnose you with an anxiety disorder” because you told me you were anxious. That is chicanery and not diagnosis.
You don’t diagnose symptoms. You diagnose causes. To diagnose a symptom is only to say, “Yes, I agree, you have a rash.” Everyone who looks at you knows that you have a rash! What we want to know is what sort of rash is it? What’s causing it? You observe the tumor and you diagnose the cancer. You observe the bump and you diagnose the concussion. You observe the fever and you diagnose the influenza. You don’t observe the anxiety and diagnose the anxiety. That is wrong.
You observe a symptom, you interpret a symptom, and you make use of a symptom as part of your efforts at diagnosis. But the symptom isn’t the diagnosis. You observe a symptom and then you diagnose a cause. You don’t observe anxiety and then diagnose anxiety. It isn’t okay to call this “diagnosing.” It isn’t okay to turn a report of anxiety into “an anxiety disorder” just by saying so. Yet this is what is done all the time nowadays.
The challenge for any contemporary psychotherapist who wants to retain an ability to “diagnose and treat” is simple to describe: give me an example of your updated diagnostic system. Tell me how you would test to confirm your diagnoses and how you would distinguish one cause or source of a problem from another cause or source of a problem. Give me your taxonomy—your naming system and your rationale for using it—and let’s hold it up to scrutiny. If you want to continue diagnosing, put up the names of your “mental disorders” and let’s look them over. And don’t forget to clearly indicate what you are counting as causes! If you don’t take causes into account, you still aren’t really diagnosing. You are merely inappropriately cataloguing.
I think that we will discover, if we are truthful and if we are acting in good faith, that it is impossible to retain the idea of “diagnosing” when it comes to human experiences. We should stop “diagnosing symptoms” right now, as that is a completely illegitimate enterprise that is annually adding millions of people, many of them children, to the rolls of the “mentally disordered.” This should stop today. But we should also let go of the idea that “diagnosing and treating” makes any sense in the context of human experience. It is this simple: we have adopted the wrong model. It is past time to discard it.
As to whether there is perhaps some way to retain the idea of “diagnosing,” let those who want it retained describe what their taxonomy might look like and let us see if we believe them. I don’t think we will believe them, because it is folly, and always will be folly, to “diagnose the human condition” when we have no way of knowing what counts as cause-and-effect in human affairs. Are we to “diagnose” personality differences, changed circumstances, stray and odd thoughts, and every single human thing, from war breaking out to a month of cloudy days? Such an enterprise makes no sense.
We do not know what caused Jim or Mary to become anxious, say; and while we can investigate their situations with them we can’t arrive at the sorts of conclusions that in medicine are called “diagnoses.” To announce that we can arrive at such conclusions or that such conclusions are warranted by our investigations is to lie. We can help Jim or Mary a lot—and we will help Jim or Mary a lot more if we stop “diagnosing” him and simply start helping him. That should be our rallying cry: “Lots of help and no more diagnosing!”
A doctor is not engaged in idle investigating. He is trying to succeed in his investigations. We do not think that a doctor has been successful who engages in one surgery after another to find out “what is wrong with us.” In that unfortunate set of circumstances, he has not reached a conclusion yet and so he can’t make a diagnosis. If there ever was a way to “diagnose” in human affairs—and there never will be—we would need to set the bar exactly that high: we would need to be successful in our investigations and we would need to be able to say, “This is clearly causing that.” That time can never come.
A diagnosis is a conclusion about cause and effect. “You need new spark plugs” is a conclusion about cause and effect. “You say you are anxious so I will say that you are anxious” is not a conclusion about cause and effect. It is a travesty. It is time for society, in the form of its legislators and watchdogs, to end this travesty. Millions upon millions of adults and children are receiving “diagnoses” that make no earthly sense. And these “diagnoses” stay with them forever. Mention that you are sad to the wrong person and you will carry a “clinical depression” label with you everywhere.
It is time we placed a moratorium on this illegitimate “diagnosing.” It is likewise time that we thought twice about encouraging any new system of “diagnosing” to replace the current mayhem. No new system will prove legitimate because we do not actually know what “causes” individual human experiences like sadness and anxiety. It is simply improper to turn human experiences, even of the most painful and the most unwanted sort, into “disorders.” Let us help with the pain; let us really help Jim and Mary. And let us leave “diagnosing” to car mechanics and their faulty carburetors and to medical doctors and their heart diseases and cancers.
* * * * *
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.