What's in a Diagnosis?
These two 'giants' in the field of Diagnosis were speaking at the 2010 Annual Conference of the Royal College of Psychiatrists. Sir David Goldberg I have heard once before. Thomas Szasz I had never heard and was delighted that he was being invited to speak at a Conference like this. He is somewhat controvertial!
Professor Thomas Szasz has been Professor Emeritus of Psychiatry at the State University of New York Health Science Center in Syracuse, New York. He is a well-known social critic of the moral and scientific foundations of psychiatry, and of the social control aims of medicine in modern society. He is well known for his books, The Myth of Mental Illness (1960) and The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (1970) which set out some of the arguments with which he is most associated.
His position is essentially that if you can see it under a microscope then call it a brain illness and get a neurologist involved. If not, then it is entirely subjective. Whilst there may be people called psychiatrists who offer advice, they should never attempt to constrain, define,control - because their point of view is no more valid than anyone else. He quotes Victor Frankl, who said that when may [in a concentration camp in Frankl's case] is prevented from committing suicide he has lost his last libery and may as well die anyway! He believes we should never lock people up because of 'mental illness' [brain illness yes, undefined mental illness no] and that the body of psychiatrists [mainly to him the American Psychiatric Association] should not define these purely social constructs and in doing so abuse people in the name of acting in their best interests; after all, we did that to the slaves!
He is engaging to listen to, albeit in aged 90 and 50 years since his core work, the Myth of Mental Illness [wiki-link], was published. He was funny, blunt, had piercing arguments and unsettled me. I was convinced - almost.
Sir David Goldberg is Professor Emeritus and a Fellow of King’s College London. He sits on the Advisory Boards of both the World Health Organisations ICD-11 [to replace the International Classification of Diseases Edition 10, 1990] and the American Psychiatric Association's DSM-V [to replace the Diagnostic and Statistical Manual of Mental Disorders Edition VI].
He is taking a lead in the Primary Care version of ICD-11 which aims to make simple descriptions of mental illness available to developing world practitioners. He sometimes wonders if the larger and more complex psychiatrists' version will be too complex and be in danger of trying to please too many people. But he is concerned that DSM-V is a more worrying tool of social construction. DSM is largely used by American Insurance Companies to diagnose disease with a view to paying out [and calulating] insurance premiums. As such, it will tend to overdiagnose, settle for extensive comorbidity [when in fact one diagnosis is better] and also be used mainly in the private sector and not the developing world. However, DSM has brought a financially-driven rigour that has been welcome in planning and research settings.
So when is a diagnosis helpful? In my book it is first when it acurately describes the problem and leads to some kind of direction in treatment; and secondly when it helps the person realise they are not alone, not 'going mad' and not helpless - people have travelled this road before. It should also never be manualised or based on a tick-box exercise, but should be given my someone who has seen a lot of patients and has seen stuff like this before. In those hands a diagnosis can be empowering, directing and even partly curative.
But then I am with Szasz on some aspects. I wonder sometimes if it is my view vs theirs. I may be the expert by training, but they are the expert on the basis of their lived experience. I may want to help them and keep them alive, and they may thank me later - but sometimes they don't and their lives are truly miserable and all I did was take away their autonomy.
Lord, help me offer diagnoses where they are helpful, offer my humble advice where they are not; and help me balance my responsibilities to person, state and family where they seem to contradict. Amen
Rob Waller, 28/06/2010