Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.

The model muddle

I’ve already written posts on several therapy models (gestalt, Rogerian, Transactional Analysis, Freudian psychoanalytic), so it’s time I examine what models are: their utility, their strengths, and their limitations. First off, models are ways of organizing and framing ideas in a way that serve as a guide. A good model is like a good map: it helps you accomplish something you set out to do, to get where you wanted to go.

But the map is not the territory; it’s merely a helpful representation. I’ve known people who were so dedicated to a model that they couldn’t see its limitations, and were blind to alternative formulations, viewing everything through the lens of their fixed beliefs. No model is perfect and complete. Each one has its flaws and limitations.

I first started thinking about models as a young mental health professional, when I read Miriam Siegler and Humphrey Osmond’s Models of Madness, Models of Medicine, in which they compared the medical model to eight other models related to the care of mentally ill persons. After examining each model (moral, impaired, psychoanalytic, social,  family interaction, etc.), the authors – both MDs – conclude that psychiatry is the only way to go. Holistic, shmolistic..

Psychiatry is the medical model’s approach to treating mental illness, usually with medications. The medical model is a scientific model. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to a specific treatment. The medical model is very good at what it’s good at, such as mending broken bones, and doing surgery, and treating many physical ailments. But its self-promotion as the only game in town for the care of the mentally ill has been challenged by many, notably Dr. Thomas Szasz and R.D. Laing.

No model is a perfect fit for all occasions, and many MDs have come around to believing in the benefits of a holistic approach to health care. Although I still believe that psychiatric treatment has its place and can be of benefit to many people with what are known as “psychiatric disorders,” like all models the medical model has its limitations. There are other valid approaches to health care that don’t rely on symptoms > diagnosis > treatment as their primary focus. The medical model is mostly focused on what to do after you exhibit symptoms, not so much on how you got there. Some medical traditions are more focused on wellness than on treating (sometimes preventable) illnesses. No model has all of the answers.

One of the limitations of the medical model as regards the care of mentally ill people is that the criteria for a differential diagnosis were determined by a committee of psychiatrists, to be applied to a unique individual. Unlike most physical disorders, there are no identifiable biological markers to distinguish what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psycho-diagnosis is not rocket science, because mental illness isn’t precisely measurable. At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

A model I’ll be writing about in a future post is the Recovery Model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” chronic substance abusers, but did it apply to the chronically mentally ill? I think (hope) that many or most mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers in some cities that aren’t run on the medical model. You might want to check out <> to learn more.

Treatment models compete in the marketplace, and there’s money to be made. For instance, the Pentagon has paid millions for training in Positive Psychology. With modern marketing in the mix, we find ourselves in the midst of a model muddle. More about this down the road.