People often need a mental health diagnosis to access ongoing therapy. Some psychiatrists and psychologists say the requirement is pushing them to pathologize normal distress or diagnose stigmatized conditions too early.
Imagine: Your partner breaks up with you. You feel sad and exhausted and find it hard to carry on with normal life. Your friends suggest you find someone to talk to. You set out to locate a psychotherapist. It takes a few months, but eventually you find someone. You are given five sessions to start. Things are going well — you are learning about yourself and you like the ability to talk without feeling like you are overwhelming your conversation partner with sadness.
Once the five sessions are over, your therapist asks you to go to the doctor to fill out some forms. You have to file a contract for your health insurance company to fund your treatment. Along with the forms from your doctor, your therapist has to include their own analysis of your condition: A diagnosis.
Your therapist diagnoses you with a “major depressive disorder.” And it’s true — you are feeling sad. You aren’t sleeping well, you can’t pay attention at work and you’ve lost interest in your hobbies.
Still, you’re 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 solve it.
But another part of you wonders whether your low mood is merely due to the circumstances. Sure, you feel depressed — but who wouldn’t in your situation? The diagnosis sits uncomfortably in your mind over the course of the next few weeks.
Pathologizing normal distress
In Germany, the US, Finland and many countries across the EU, in order to receive therapy that can be reimbursed by public health insurance, people have to get a diagnosis. With the number of people interested in accessing mental health treatment skyrocketing since the start of the COVID-19 pandemic, many are left asking the question: Where is the line between regular depression in response to some kind of environmental trigger and a 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 into pathologizing normal distress.
Peter Kinderman, a professor of clinical psychology at the University of Liverpool, said it results in a kind of “mistranslation of the human experience.”
“What happens is that our partners cheat on us,” said Kinderman. “We become depressed. We go to seek help, and they go, ‘No, you’re mistaken. It’s not the case that what you’re experiencing is the normal, understandable, centuries-old experience of depression for perfectly understandable reasons. In fact, you’re wrong — this is major depressive disorder, which I shall now treat and bill your insurance company for.'”
In many countries, therapy patients can only access care if they accept a diagnosis, Kinderman said. But he stressed that the mere fact they are diagnosed with a disorder doesn’t mean they are sick, or that they will always be sick, or that there is something inherently wrong with their brain.
“It’s nothing to do with your distress or the practice of psychotherapy or the nature of the world,” he said. “These are commercial decisions made by people wishing to ration services in a particular way.”
Spanish psychiatrist Eduard Vieta, an expert on the neurobiology and treatment of bipolar disorder, agrees with Kinderman that diagnosis isn’t always necessary — in cases of mental distress that are not extreme.
When dealing with non-serious conditions, a diagnosis requirement can push mental health care providers to “medicalize a normal reaction or a situation that doesn’t need a label,” Vieta said.
However, Vieta does consider diagnosis “extremely important” when it comes to more serious mental distress.
Diagnosis can allow people to better evaluate their care
Vieta said that for conditions like bipolar disorder or schizophrenia, diagnosis can work as a kind of quality control. Once people receive a diagnosis, they can go to the internet to read about other people with their same condition, or ask another psychiatrist or physician 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 do not condone it, he doesn’t see much wrong with patients researching their diagnosis on the internet.
“People have the right and it’s a good thing, unless it becomes something a bit obsessive,” he said. “But otherwise, it’s a good thing that people are informed and try to find answers to the questions that come up when you have a certain sort of suffering.”
Diagnosis provides a streamlined way to lead people under severe psychological distress to treatment — either through targeted psychotherapy or medication or both, Vieta said.
Til Wykes, a clinical psychologist at the University of London, agreed that diagnosis can offer a helpful explanation of a person’s distress.
“It enables some people to think carefully about how to adjust their life and to think about themselves and how to live with the diagnosis or prevent the worst parts of having a 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 get a diagnosis before allowing them to access ongoing treatment.
Stigmas can be roadblocks in therapy
Vieta noted that although the practice of diagnosis can be beneficial in theory, that’s not how it always works in practice. Societal stigmas about certain diagnoses — such as schizophrenia or a bipolar condition — can lead people to reject or avoid treatment.
“Diagnosis is useful,” Vieta said. “And if it was free of stigma, it would be essentially good.”
Wykes said that stigmas surrounding certain diagnoses have led some mental health care providers in early intervention clinics to alter their practices.
“Some [clinicians] never say the word schizophrenia, because they think it will frighten the person,” said Wykes.
Wykes added that in the UK, where diagnosis isn’t needed in order for people to access treatment, therapists can support people who may not reach the diagnosis threshold for schizophrenia or psychosis, but clearly need help for a range of other problems.
For them, Wykes said, treatment can avert or delay the onset of an actual schizophrenia disorder. Or it “might engage them in services so that when there is an onset of the disorder, they are then more easily accepting of services and help.”
That type of support isn’t possible in countries where diagnoses are required for access to care, which can result in people rejecting it altogether due to 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,” Wykes said. “If you can’t get access to 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 approach services in case they give you that label.”