Given the numbers of people suffering from serious and sometimes life threatening mental illness, is this humor fair?
Diagnostic categories provide useful shorthand to describe and then treat a set of psychological symptoms. They help clinicians and insurance companies speak to one another without unnecessary repetitions. Individuals can find comfort in that fact that enough other people have experienced the same symptoms to warrant a category.
Diagnostic misuse arises when psychological evaluations don’t observe symptoms in a relational context. Family, friends and colleagues function like a network around every individual. These networks implant themselves within societal organizations. Societal organizations embed themselves in environmental systems.
Every behavior connects to a large set of interdependent variables. Those variables determine a behavior’s meaning. Only its meaning can signal whether it is problematic or an ordinary extension of being a person.
Providing a “flat” evaluation – one that doesn’t include contextual information – functions like a quick look at a painting on a wall. You can know what it looks like but not what it means. A person who has a hard time concentrating, extreme distractibility and a tendency to zone out will easily receive a diagnosis of ADD. The treating clinician will then recommend a treatment based on this description.
Yet doesn’t the description only tell part of the story?
A “dimensional” evaluation, akin to viewing paintings alongside other paintings along with a brief historical summary, analyzes the origin of behaviors and how they function in a person’s world. Therefore the person who can’t concentrate could easily be a person with worries, with a temperament not suited to detail oriented work, or with a trauma (even a small one) weighing upon their countenance.
Dimensional evaluations take time and energy. They can’t often be summarized with a DSM code. Their complexity defies simple classification.
Given the 11% of kids and increasing number of adults being diagnosed with ADD, the Onion’s critique becomes particularly poignant. Flat evaluations lead to an indiscriminate use of diagnostic categories and a tendency to over-treat leading to dire consequences, like the tragic stories of Richard Fee and David Gup.
Flat diagnosis can lead to flat treatments like the use of medication without the necessary mentors who can actually teach and support a person to manage their challenges.
Ted Gups, David Gups’ father, writes: “I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.”
Medication helps. But it isn’t the only solution. Climbing a mountain, playing with friends outside under a torrent of cool summer rain as well as deeply bonding with other people who care can also make a difference.
Sometimes pushing a person to dig more deeply into life can be a better alternative than medicating a symptom away. The vigorous confrontation of vulnerabilities can strengthen people and communal bonds.
Sometimes solving a behavioral difficulty might mean challenging social mores.
Being a person comes with hardship because humanity is inexorably linked to the wide expanse of the natural world – a place of uncertainty, sadness and failure as well as clear paths forward, unprecedented joy and unimagined accomplishment. We are imperfect beings hoisted into life with individual tool kits well designed for some situations and horribly inadequate for others.
Instead of flatly delineating how a person falls outside the random definitions of normality, diagnosis might better describe contexts that can make the best use of any individual’s diverse self.
Or diagnosis might focus the fine skills of interpretation on social conditions that routinely transform underlying vulnerabilities into dangerous behaviors.
Maybe contextualized diagnoses can also define the types of relational interventions that can galvanize the best medicine – love, compassion and guidance – into the service of humanity.