What's Wrong With Psychiatric Diagnoses?
Psychiatry’s critics often take aim at psychiatric diagnosis. They think labels like “depression,” “bipolar disorder,” and “schizophrenia” generally do more harm than good. The non-profit organization A Disorder for Everyone! even uses the slogan “Drop the Disorder!” to give voice to their critical stance.
On the surface, it’s hard to see what’s so bad about these labels. After all, many mental health professionals think of them as useful shorthands for a list of symptoms. Diagnoses can facilitate communication and guide treatment. They give service users tangible benefits like access to valuable social support. They also give service users the intangible benefit of feeling like they finally have an explanation for their distressing thoughts and feelings. Who but an “anti-psychiatrist” would object to these benefits?
The Core Social Meaning of Diagnosis
In order to understand the problem, we have to look more closely at how diagnoses receive their meaning and power. The act of giving a diagnosis has what I’ll call a core social meaning that it draws from the ordinary practices in which lay people are most likely to encounter them.
Think about the meaning of a specific action: a man kneels down in front of a woman and holds a small jewelry box up to her. What is he doing? We understand exactly what he is doing, because this act has a core social meaning: he is proposing to her. If he did not, in fact, intend to propose, we would find his action inappropriate, and even malicious.
So, what is the core social meaning of giving a diagnosis? To understand it, we should look to a rather paradigm scenario in which people are likely to get one. Suppose I am coughing up colored mucus. I want to know what’s wrong so I can get better. I go to a doctor. After careful examination, the doctor says, “you have chronic bronchitis.” Among other things, the doctor prescribes a bronchodilator. What are the elements of this scenario?
Three Functions of Diagnosis
Philosophers and other theorists who have studied the nature of diagnosis have identified at least three main functions that paradigm diagnoses like chronic bronchitis have.
First, they have a descriptive function. They point to a typical set of outward symptoms and signs. In this regard, they work like a useful shorthand.
Second, they have an explanatory function. A diagnosis works like a name for a special inner cause of those symptoms: inflammation of the bronchial tubes.
There's a third one that hasn't received the same amount of attention, but it's in the background of the discussion. A diagnosis presents that inner cause as a pathology. It presents it as a way of “something going wrong.” That's why it sounds strange to “diagnose” somebody with pregnancy, racism, or grief.
These three functions of diagnosis are part of standard dictionary definitions, such as Merriam-Webster’s, which defines diagnosis as “the art or act of identifying a disease from its signs and symptoms.”
At least according to this core social meaning, then, a diagnosis – as lay people ordinarily encounter them in somatic medicine – is not an innocent label for a cluster of symptoms. It is a way of presenting my suffering as the outcome of an inner, pathological cause.
If some mental health professionals intend to use diagnosis in a different sense, say, as nothing more than a convenient shorthand for a special pattern of thoughts and feelings, they should be aware that they are running against this core social meaning.
Diagnosis and the Pathologization of Distress
Now that we have a view of the core social function of diagnosis, we can see exactly what makes it problematic. The problem is not that the pathological cause of, say, depression is unknown. True, we still don't know what causes depression, nor do we know what causes bipolar disorder or schizophrenia. That is not a good reason for rejecting psychiatric diagnoses. After all, we don't know the cause of many bodily illnesses either, like migraines, chronic fatigue, or discogenic back pain.
Rather, the problem is that the act of diagnosis has a core social meaning that lay people are likely to carry over into the psychiatric context, where it can prove harmful.
The problem is not just one of stigma – which I think is serious enough. More importantly, it might lead us to overlook the possibility that my thoughts and feelings are a coherent response to a life problem, not a pathology. It might also lead us to overlook the possibility that my thoughts, feelings, and personality traits represent ordinary, non-pathological variation between people.
I've written in other places on how conditions as diverse as depression, personality disorders, and even the delusionsassociated with schizophrenia, can often be viewed as coherent responses to crises. I've also written on how dyslexia is probably best thought of as ordinary cognitive variation rather than pathological variation. Of course, these theories might be wrong, but they shouldn't be ruled out in advance.
More generally, I think psychiatry is on the precipice of a paradigm shift, one from what I call “madness-as-dysfunction,” which sees mental disorders as medical problems, to “madness-as-strategy,” which sees function, adaptation, and purpose in mental illness.
Of course, sometimes diagnoses are pragmatically useful to help people get the social support that they need, such as educational benefits or unemployment compensation. Here, what may be called for is an open conversation between the mental health professional and service user about the pros and cons of having a diagnosis. Even if the client and provider agree that a diagnosis is beneficial, the service user might choose not to identify with the diagnosis.
As I see it, the purpose of organizations like A Disorder for Everyone! isn’t to eliminate, entirely, the use of diagnosis, but to point to its unacknowledged harms and seriously contest its primacy in psychiatric care.
Justin Garson is Professor of Philosophy at Hunter College and The Graduate Center, City University of New York. He writes on the philosophy of madness, evolution of the mind, and purpose in nature He has two new books: Madness: A Philosophical Exploration (Oxford University Press, 2022) and The Biological Mind: A Philosophical Introduction, 2nd ed. (Routledge, 2022). Justin also writes for psychologytoday on alternative paradigms of mental health https://www.psychologytoday.com/us/blog/the-biology-human-nature https://www.justingarson.com