Sadly, I must start by drawing a distinction between the practice of diagnosis and that of formulation. I wish I didn’t have to. Formulation is about understanding. It is tentative, has a narrative component, includes strengths as well as difficulties, integrates the socio-political with the biological and psychological, and notices the all-important context that an individual finds themselves in. It reflects engagement and empathy. It is genuine, and genuinely holistic, in its aims and approach.
Personally, I think that “diagnosis” should mean pretty much the same. Instead, it has come to mean “attach a label”. Rather than attempt here to swim against the tide and rehabilitate the idea of diagnosis, I shall accept this as the new meaning. This is what reductionism does. By banishing nuance it leaves a husk of an idea which readily attracts negative connotations. Abuse, injustice, and pain are rampant and we are desperate for them to be contained in some way – in a brass lamp or Pandora’s box, if you will, or a tightly corked bottle at the bottom of the ocean. Enough people have been and have felt misunderstood, ignored, pushed around, and painted in colours of other people’s convenience by the diagnoses that they have been given, for this husk of an idea to be a deserving recipient. So be it. Diagnosis shall forever mean “the attachment of a label”.
Certain kinds of scientific research are required to be reductionist, to homogenise the sample, and to strip away confounding factors. Something akin to diagnosis can be useful there.
Even with this horribly narrow meaning, diagnosis may be useful in clinical practice if it points to a helpful explanation, beneficial intervention, or opens the door to resources. But there is a cost, and to provide informed consent to diagnosis, one needs to understand the cost. Working as a clinician in Child and Adolescent Mental Health, I have spent almost as much time actively avoiding giving a child a diagnosis as I have discerning or providing one.
I am lucky to work with children. Generally, they are wiser than adults. Saint-Exupery understood this, as have countless others. Mostly children are not very interested in diagnoses, in my experience, whilst pretty well everyone else is clamouring for one, ostensibly on their behalf. It may be the school, Social Services, the parents, or my own service. Each has their own agenda. Extra funding to the school or the provision of support beyond a certain level may be withheld unless a diagnosis is given. Children’s Services ask me, these days, for a diagnosis in a way that leaves me wondering if their purpose is to check out if I know what I am doing. Mental health services are themselves desperate for something official-sounding to justify the funding that maintains them. Parents are typically the most scared, and so deserve the least criticism for requesting a diagnosis which may not be in their child’s interests. Very occasionally, though, they are seeking ratification of their urge to locate the problem in the child, and this must be resisted.
Sometimes, of course, it is necessary to make a diagnosis. It can be essential to provide a clear opinion enabling an unambiguous clinical management plan.
What I would like diagnosticians, anyone who amateurishly throws around diagnostic labels, and anyone who demands a diagnosis for legal or other decision-making reasons, to bear in mind is the following:
Labeling (I shall use the word labeling)…
1) is not the same as understanding
2) is an exercise in power
3) has a meaning to the patient which must be explored. What does it signify or imply?
4) follows fashion
5) is an intervention
6) can harm as well as help
7) may be inaccurate or approximate
8) should therefore not be done unless necessary, helpful, and in a context and relationship in which the patient’s values and understanding can be explored, misunderstandings corrected, harm repaired, and informed consent is an ongoing and evolving understanding.
Because diagnosis is (or should be) integral to the process of treating/healing/helping it needs to be done with Therapeutic Attitude.
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