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Chapter 2

Avoid Diagnosis (except for insurance companies)

Today's psychotherapy students are exposed to too much emphasis on diagnosis. Managed care administrators demand that therapists arrive quickly at a precise diagnosis and then proceed upon a course of brief, focused therapy that matches that particular diagnosis. Sounds good. Sounds logical and efficient. But it has precious little to do with reality. It represents instead an illusory attempt to legislate scientific precision into being when it is neither possible nor desirable.

Though diagnosis is unquestionably critical in treatment considerations for many severe conditions with a biological substrate (for example schizophrenia, bipolar disorders, major affective disorders, temporal lobe epilepsy, drug toxicity, organic or brain disease from toxins, degenerative causes or infectious agents) diagnosis is often counterproductive in the everyday psychotherapy of less severely impaired patients.

Why? For one thing psychotherapy, consists of a gradually unfolding process wherein the therapist attempts to know the patient as fully as possible. A diagnosis limits vision, it diminishes ability to relate to the other as a person. Once we make a diagnosis, we tend to selectively inattend to aspects of the patient which do not fit into that particular diagnosis, and we correspondingly over-attend to subtle features which appear to confirm an initial diagnosis. What's more, a diagnosis may act as a self-fulfilling prophecy. Relating to a patient as a "borderline" or a "hysteric" may serve to stimulate and perpetuate those very traits. Indeed, there is a long history of iatrogenic influence on the shape of clinical entities, including the current controversy about multiple personality disorder and repressed memories of sexual abuse. And keep in mind, too, the low reliability of the DSM personality disorders category (the very patients often engaging in longer term psychotherapy.)

And what therapist has not been struck by how much easier it is to make a DSM-IV diagnosis following the first interview than much later, let us say, after the tenth session, when we know a great deal more about the individual? Is this not a strange kind of science? A colleague of mine brings this point home to his psychiatric residents by asking: "If you were in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?" (C. P. Rosenbaum, personal communication, Nov. 2000)

In the therapeutic enterprise we must tread a fine line between some, but not too much, objectivity; if we take the DSM diagnostic system too seriously, if we really believe we are truly carving at the joints of nature, then we may threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture. Remember that the clinicians involved in formulating previous, now discarded, diagnostic systems were competent, proud, and just as confident as the current members of DSM committees. Undoubtedly the time will come when the DSM - IV Chinese restaurant menu format will appear ludicrous to mental health professionals.