Like an overbearing partner, a diagnosis sometimes stops the patient finding a voice of their own
An important Lancet Psychiatry paper has just come out. It is the largest review looking at service user, carer and clinician experiences of mental health diagnosis. For some people, psychiatric diagnosis was helpful, and the problem was that it was not given early enough. For others, a diagnosis was deeply oppressive.
The tensions between these camps frequently threaten to ignite social media. This dynamic, which causes significant distress, is only likely to increase as social media gives a platform to those who have negative experiences of diagnosis at the same time as more and more people identify as having a mental illness as a consequence of changing public ideas around mental health. To drain something of the charge in these inflaming dynamics, it is important to confute the idea that psychiatric diagnosis is a single thing.
Some diagnoses are more useful than others. Diagnoses such as obsessive-compulsive disorder and depression, for example, are more likely to be experienced positively, validating suffering and giving people a platform from which to speak about distress and access help. Yes, there is stigma, but not the rampant sticky, staining discrimination one gets with diagnoses associated with serious mental illness. With the latter, diagnosis can produce what the philosopher Miranda Fricker has called “testimonial injustice” – an inbuilt prejudice that gives less credibility to the diagnosis.
The diagnosis of borderline personality disorder, for example, is experienced commonly as a character slur, a “dustbin” diagnosis that makes many clinicians turn away from people in pain and take communications such as that someone wants to kill themselves less seriously, to often deadly cost. The diagnosis of schizophrenia can confer with it a clinical gaze that situates those with the disorder as lacking insight and being delusional. This set of ascriptions has meant psychiatry is only now beginning to hear the devastating experiences of trauma so often core to experiences such as voice-hearing and dissociation. It is difficult to say anything pro or against psychiatric diagnosis per se when different diagnoses have such wildly different effects on one’s capacity to be taken seriously as a speaker.
Second, even within diagnostic categories, some people find diagnosis more useful than others. As the Lancet paper makes clear, the context in which a diagnosis is given is crucial. If a diagnosis is offered carefully, with time for discussion, clear information and hope, it is more likely to be experienced positively. How a psychiatric diagnosis is experienced is also mediated by an individual’s life experience and their cultural identities. For example, someone who identifies as LGBTQ might have good cause for suspicion of diagnosis, given that homosexuality was diagnosed as a mental disorder until the 1970s. Diagnosis is also taken up and put down as an idea depending on the goals of conversations we are in. For example, in family therapy, patients who generally reject their diagnosis often take up this idea as a discursive move if relatives start to attribute cause to their poor parenting skills.
Elsewhere, the difficulties lie with the point at which we start to view experiences that lie on a spectrum as problematic. Here, it is important to critique the pernicious, shaping influence of psychiatric expansionism and big pharma on how we view our inner worlds.
Given diagnosis can be both a structural violence and a life-saving explanatory tool, what to do? A frequent response is that patients should be free to choose. However, it is questionable whether one can make an informed choice about having, say, one’s entire personality invalidated. Or if it is possible to choose freely when diagnosis can be like an overbearing partner, taking up all the discursive space, limiting the possibility of thinking differently, and gaslighting understandable reactions to painful events in a life.
Instead, we need to create space for new ways of speaking about distress that foreground the effects of trauma and the socio-political context on the psyche and body, and that recognises that difference becomes disability at the point that society tries to squeeze people into one-size-fits-all boxes. We must place the power to dictate the thrust of speech firmly with the person of most importance – the person in need. This can only occur if we hold a more tentative relationship to the diagnostic system, binning ways of diagnosing that slur the speaking credibility of certain patient populations, and ensuring access to resources such as benefits are dependent on severity of illness rather than acceptance of diagnosis.
In an era where speech is more and more polarised and combative, with devastating effects on our mental health, open dialogue is key. Far from being an “everybody has won and all must have prizes” response to the diagnosis wars that have plagued psychiatry since its inception, such an approach demands a radical rethink of power relations in psychiatry to place patients’ voices where they belong – centre stage.