Imagine: your partner breaks up with you. You feel sad and exhausted and find it difficult to carry on with your normal life. Friends suggest you find someone to talk to.
You went to find a psychotherapist. It takes a few months, but eventually you will find someone. You have five sessions to get started. Things are going well – you’re learning about yourself and liking the ability to talk without feeling like you’re overwhelming the other person with sadness.
After the five sessions are over, your therapist asks you to go to the doctor to fill out some forms. You must submit a contract for your health insurance company to finance your treatment. Along with the forms from your doctor, your therapist should include their own analysis of your condition: Diagnosis.
Your therapist diagnosed you with “major depressive disorder.” And it’s true – you feel sad. You don’t sleep well, you can’t pay attention at work, and you’ve lost interest in your hobbies.
You’re still conflicted. Part of you is relieved: You like the fact that you can put a name to what you’re feeling, that it’s something millions of people have felt before, and that now that your problem has been identified, you can start trying to fix it. allow .
But another part of you wonders if your bad mood is simply due to circumstances. Sure, you feel depressed – but who wouldn’t in your situation? The diagnosis sits uncomfortably in the back of your mind for the next few weeks.
Pathologizing normal distress
In Germany, the US, Finland and many EU countries, to receive therapy that can be reimbursed by public health insurance, people must receive a diagnosis. As the number of people interested in accessing mental health treatment has skyrocketed since the start of the COVID-19 pandemic, many are left asking: Where is the line between habitual depression in response to some type of triggering environment and major depressive disorder? ? What role does diagnosis play in our understanding of ourselves?
Many psychiatrists and psychologists criticize insurance companies’ need for a diagnosis, arguing that it forces them to pathologize normal distress.
Peter Kinderman, professor of clinical psychology at the University of Liverpool, said this led to a kind of “mistranslation of human experience”.
“What’s happening is our partners are cheating us,” Kinderman said. “We get depressed. We go to get help, and they say, “No, you’re wrong. It’s not like what you’re experiencing is the normal, understandable, age-old experience of depression for perfectly understandable reasons. You are actually wrong – this is major depressive disorder which I will now be treating and billing your insurance company for.
In many countries, patients in therapy can only access care if they accept the diagnosis, Kinderman said. But he stressed that just because they’re diagnosed with a disorder doesn’t mean they’re sick, or that they’ll always be sick, or that there’s something wrong with their brain.
“It has nothing to do with your suffering or the practice of psychotherapy or the nature of the world,” he said. “These are commercial decisions made by people who want to distribute services in a certain way.”
Spanish psychiatrist Eduardo Vieta, an expert in the neurobiology and treatment of bipolar disorder, agrees with Kinderman that a diagnosis is not always necessary – in cases of mental stress that is not extreme.
When dealing with non-serious conditions, requiring a diagnosis can lead mental health providers to “medicalize a normal reaction or situation that doesn’t need a label,” Vieta said.
However, Vieta considers the diagnosis “extremely important” when it comes to more serious mental stress.
A diagnosis can allow people to better evaluate their care
Vieta said that for conditions like bipolar disorder or schizophrenia, the diagnosis can work as a kind of quality control. Once people receive a diagnosis, they may go online to read about other people with the same illness or ask another psychiatrist or doctor for a second opinion on whether they agree with the diagnosis and subsequent treatment suggested by their original provider.
Vieta added that although some psychiatrists disapprove of it, he doesn’t see much harm in patients researching their diagnosis on the Internet.
“People have a right, and that’s a good thing, unless it becomes a bit obsessive,” he said. “But otherwise, it’s good for people to be informed and try to find answers to the questions that arise when you have a certain type of suffering.”
The diagnosis provides a streamlined way to refer people in severe psychological distress to treatment — either through targeted psychotherapy or medication or both, Vieta said.
Till Wykes, a clinical psychologist at the University of London, agreed that the diagnosis can offer a useful explanation for a person’s suffering.
“It gives some people an opportunity to think carefully about how to adjust their lives and think about themselves and how to live with the diagnosis or prevent the worst parts of the diagnosis,” said Wykes, who specializes in treating patients who experience episodes of psychosis, such as hearing voices.
But Wykes said people should not be required to receive a diagnosis before being allowed access to ongoing treatment.
Stigmas surrounding the diagnosis can be barriers to therapy
Vieta noted that while the practice of diagnostics can be useful in theory, it doesn’t always work in practice. Public stigmas about certain diagnoses—such as schizophrenia or bipolar disorder—can cause people to reject or avoid treatment.
“The diagnosis is helpful,” Vieta said. “And if it was stigma-free, it would be essentially fine.”
Wykes said the stigmas surrounding certain diagnoses have caused some mental health providers at early intervention clinics to change their practices.
“Some [clinicians] never say the word schizophrenia because they think that will scare the person,” said Wykes.
Wykes added that in the UK, where a diagnosis is not necessary for people to access treatment, therapists can support people who may not meet the threshold for a diagnosis of schizophrenia or psychosis but clearly need help for a range of other problems.
For them, Wykes said, treatment can prevent or delay the onset of actual schizophrenic disorder. Or “it can engage them in services so that when the disorder starts, they more readily accept services and help.”
This type of support is not possible in states where diagnoses are required to access care, which can lead to people rejecting it altogether for fear of receiving a diagnosis they don’t feel comfortable with.
“People will try to avoid them as much as possible. And then families try to avoid them as much as possible,” said Wykes. “If you can’t access health care without a diagnosis, you’re really stuck. Because if you don’t want a diagnosis and you just want help, you’re not going to go to the services if they give you a label.”
Editing: Zulfiqar Abani