Diagnosis in therapy: The joke's on you

A new prisoner is escorted to his cell, on a block with a lot of old timers. A few minutes after lights out, one of them calls out, "17!" and the others roar with laughter. Moments later another cries, "41!." Laughter bellows through the cell block.

This continues sporadically for several minutes until, at a brief lull, the puzzled newcomer asks his cellmate, "I don't get it. What's so funny?"

His cellmate, still out of breath with laughter, politely explains: "You see, we've been tellin' the same jokes for so long that we've already heard 'em all, so instead of tellin' 'em again and again we just holler 'em out by the numbers."

Perplexed but eager to join in, the newcomer gives it a try. "26," he squeezes out. No one laughs.

The cellmate rejoins, matter-of-factly: "Some folks just don't know how to tell a joke."

Funny.

You want to know what's not so funny though?

It's that this sort of by-the-numbers banter is an awful lot like how psychotherapists and psychiatrists talk. Except instead of jokes, the numbers represent their patients' diagnoses.

Not funny.

What's the big deal about diagnosis in therapy?

Anytime you visit a health care provider, odds are, there's a diagnosis or two being generated. There's a diagnosis for strep throat, and for a broken fibula. It's a system that, in medicine, seems to work just fine. A medical provider assesses the situation, issues a diagnosis, and then proceeds with the treatment that his or her profession has deemed best for that particular diagnosis under those particular conditions. Those paying the bill (insurance companies) can get a quick idea of what the problem was and know that they're paying for the right (and necessary) solution.

At first glance, it might seem reasonable that things work this way in psychotherapy, too. But it's worth considering just what's different about physical illness in contrast to mental anguish.

What makes the prison joke work is the absurdity of the premise: Jokes, when distilled down to simple numbers, loose all of what makes them funny; some people are better at telling jokes than others, but that's all lost when numbers become fill ins for the content of the jokes. In just this same way, when human experience (sadness, turmoil, anxiety) is distilled to a mere code it betrays precisely that which it presumes to treat; it ceases to be human. This is fine (by me) for broken bones and stomach bugs, but just doesn't work when it comes to emotional life.

Who makes the rules?

The therapists' "bible," as some have called it, is the Diagnostic and Statistical Manual of Mental Disorders, published periodically by the American Psychiatric Association (the APA). This tomb (commonly referred to as the DSM for short) is a collection of literally hundreds of mental "disorders" as defined by the APA.

As publishers of this manual, the APA wields an enormous amount of power. In medicine (remember, psychiatrists are physicians, and therefore the model the DSM articulates is grounded in this medical approach) without a diagnosis, there's nothing to treat. In other words, if there's nothing broken, there's nothing to fix. For the APA, then, having the exclusive power to determine both the shape and existence of disorders in mental life allows them to quite literally determine what disorders exist and what psychotherapists and other mental health providers can treat.

Ontology, subjectivity and a human science

Ontology is a branch of philosophy concerned with the question of what does or does not exist, and which explores assumptions we bring to those questions. Within that frame, we might assert that an ontological premise of psychiatry is that we can understand and describe the existence or non-existence of mental disorders using the same conceptual and linguistic tools as those used in describing the existence or non-existence of physical disorders. We can see physical disorders (observing swelling, counting the number of certain kinds of cells observed under a microscope); therefore, we can see mental disorders by observing certain patterns of behavior (the frequency of certain kinds of outbursts or the reported severity of particular negative thoughts).

I'm not convinced this premise holds water. There is something fundamentally different about mental experience as distinct from physical experience, namely subjectivity. There is general (though not universal) agreement on what constitutes diabetes. While there might be disagreement over the details, or the exact course of treatment, these are largely objective disagreements. That simply isn't so in mental life. Sadness, anxiety, distraction, anger and so on are all words and concepts that vary wildly both across and within cultures. Some languages have no word for anxiety, while others have several. Some people understand these concept through the lens of spirituality, others through a social, familial or even sexual framework. The ontology on which our understanding of physical disorders is built simply cannot capture the diversity of these experiences. One cannot point to evidence of one way of understanding mental disorder in the same way that one can point to results of a blood test. An attempt to do so is to simply distort the very subject we presume to treat.

Fortunately, some psychotherapists choose to defy the authority of the APA and provide non-diagnostic therapy.

Suffering is real

My beef with the APA and the DSM is not meant to imply that the suffering they attempt to capture is not real. Depression, delusions and disassociation are all too real, but these experiences are as diverse as the people who experience them. A narrow enumeration of those experiences by equal measure narrows possibilities for intervening. In its very premise, the DSM makes the brazen assertion: "We are the sole authority that may define your mental anguish, it's limits, and the nature of how it might be understood and therefore the possibilities for how you might get help." The lofty position the DSM holds means that if you choose to access professional mental health care, your suffering must first be translated into a 5-digit code.

I guess some folks really can't tell a joke.