Psychiatric diagnosis is the foundation upon which the psychiatric death machine is built. I know something about this, given that I was a practicing clinician and practicing mental patient for many years of my life. I suppose it is possible to say I was a really great clinician and a really horrible patient, for whatever the subjective value judgements on those roles are really worth in the context of a human being’s life. In the present context, one thing we know for sure is that H.R. 2646 targets some of the most vulnerable individuals in our society: children; elders; those who are differently abled cognitively; minority communities; and, those who are socioeconomically disadvantaged, among others. Please see my piece, H.R. 2646 (Murphy Bill): What does it mean? A survivor’s perspective, for additional details with regard to this dynamic.
What is diagnosis, really? Many in the community of survivors who fight for human rights won’t even use the term. They refer to it as labeling. I prefer this language myself, but acknowledge, in the course of my life as a whole, the word “diagnosis” carries a meaning that is part of the fiber of my humanity, and that, as much as I might try, I can never really make it fall away. It is an extremely limited and limiting concept.
First, diagnosis is subjective. People who have taken the time to educate themselves on the topic know that there is no scientific evidence or medical test to determine or confirm diagnosis. Murphy (or perhaps it would be better to say the Treatment Advocacy Center people, who are responsible for authoring his bill) know this too. Section six of H.R. 2646 is a small part of the bill, and easily overlooked. Yet, this section provides 40 million dollars per year for the years 2016 through 2020 to fund the Brain Initiative at the National Institute of Mental Health. That is 160 million dollars—a bigger allocation of funds than is provided by any other section of the bill. The Brain Initiative has two primary purposes: to look for determining factors for self and other directed violence and to advance research in neurotechnologies. This huge monetary allocation is hard evidence that even the authors of this bill know that the evidence for psychiatric diagnosis does not exist.
This complete lack of any hard evidence leaves diagnosis as a concept that is completely subjective and culturally bound. I recall quite clearly giving a presentation on the history of diagnosis with one of my early clinical mentors who was a psychiatrist of the Humanist School, in his eighties at the time. He actually had on hand the earliest version of the Diagnostic and Statistical Manual. It resembled nothing as much as a large Master’s thesis, or perhaps a rough draft of a Doctoral dissertation. This document was just post World War II, and was a response to the issues of soldiers returning from combat with huge amounts of distress.
In addition to the complete subjectivity of diagnosis, it is also important to note that it is completely bound up in culture. The later expansion of that early, thin document cannot be extracted from the development of various pharmaceuticals intended to treat such diagnoses. As more drugs became available, and profitable, the DSM grew from a thinnish document to the DSM V we have today that has hundreds of pages and the weight of several standard bricks. We also know diagnosis to be limited culturally, based on some diagnoses that have been removed based on changes in dominant cultural attitudes. Perhaps most notable was the complete removal of “homosexuality” as a diagnostic category in 1986. I don’t believe I have ever heard of a scientifically based diagnosis being removed from the International Statistical Classification of Diseases (ICD) because many people within a given culture had decided it was no longer a pathology.
These facts about the subjectivity of psychiatric diagnosis bring me to the second major point of this essay. Diagnosis can, and regularly is, manipulated by clinical types to increase revenues. Of course, the easiest populations to manipulate are those that are disempowered. Again, it would be possible to return to the H.R. 2646 and find multiple examples of how marginalized populations are the targeted. Here, I will give one example from my personal experience in clinical practice.
A few years ago, I was a Licensed Independent Social Worker in the state of Ohio. Please don’t hold it against me. At one point, I decided to leave the agency work I was doing with individuals who are differently abled cognitively, largely because of ongoing and severe clinical abuses that were heaped on what I consider to be one of the most powerless populations in our society (and marginalized within the context of the movement for survivor rights a well). These abuses included psychiatric labeling, drugging, and aversive behavioral programming, among others. What I saw in that context would easily make another complete essay. But, coming back to my point, I decided to start a dissident practice that became the Kent Empowerment Center. One of the ways that I was able to do this was by taking on a large behavioral health nursing home as a client. Without this client, finding enough revenue for a start up practice would have been virtually impossible. The story I want to tell here is about the diagnostic manipulation within that nursing home, as it impacted the elderly and differently abled individuals who resided there.
Drugging is used as a form of social control in settings such as these. Perhaps this nursing facility could even be viewed as a contained metaphor for the general issue of drugging as a form of social control. The manipulation of diagnosis was central to the drugging. As was standard practice, I conducted a diagnostic assessment for each of the individuals in the facility for whom I was contracted to provide services. I “found” a whole variety of things going on, and termed them in all the standard ways I had been taught: Generalized Anxiety Disorder; Major Depressive Disorder; Adjustment Disorder, and so forth. Not surprisingly, it was hard to find anyone who was not having a hard time adjusting to this particular environment.
As I compared my completed assessments with the existing charts, an odd pattern started to emerge. Many of my diagnoses were completely different from that of the treating psychiatrist. Over and over, I placed assessments into charts that contained ONLY ONE diagnosis from that psychiatrist, and it was ALWAYS THE SAME. Schizoaffective Disorder. I was puzzled by this, and attempted to ask the psychiatrist about it. He was initially extremely defensive, stating that he “only talks medical stuff with the medical people”, but later relented, stating that he did not care if my diagnoses went into the chart, as long as his diagnoses remained primary. At that time, he also told me that he had OVER 3000 CASES.
It was clear to me, early on, that many of the diagnoses of Schizoaffective Disorder were incorrect. What I could not understand was: why? While there are many incompetent psychiatrists at large out there, it still felt very odd that this one always defaulted to the SAME incorrect diagnosis. As I watched the operation of the facility and thought about the meaning of Schizoaffective Disorder, the diagnostic manipulation became clear.
Schizoaffective Disorder has two major components. The first is psychotic, with a presentation of some kind of hallucination, paranoia, delusion and so forth. The second component is affective, meaning something with the the mood: anxiety, depression, lability, etc. I observed that drugging was one of the major interventions used in this facility; and, it was not uncommon for drugs to be switched up quite frequently, or for a PRN (extra) medication to be given when someone became simply “too difficult”. When drugging is used overtly by clinicians to control behavior, this is called a chemical restraint and requires massive amounts of documentation and oversight to implement. When drugging is used in response to a psychiatric diagnosis, it is simply treatment.
The diagnosis of Schizoaffective Disorder effectively justified the use of any class of psychiatric medication for any reason at any time. The psychotic aspect of the diagnosis would support any of the atypical antipsychotics such as Seroquel, or even the older antipsychotics such as Haldol. The affective portion of the diagnosis would support any of the antidepressants such as Zoloft or Celexa, as well as anti-anxiety agents such as Ativan or Buspar, and mood stabilizers such as Depakote. The diagnosis of Schizoaffective Disorder was used, in this setting, and I am sure in many similar settings, to justify a kind of medication roulette based on the convenience of staff and the ability to the facility to hold, maintain and bill the largest possible number of inmates at one time. These rapid fire medication changes, adjustments and additions could all be carried out under the umbrella of Schizoaffective Disorder without any of the pesky paperwork that would go along with changing someone’s diagnosis to match his or her actual presentation. After all, how would a psychiatrist with over 3000 patients manage any other way?
So, here we have just a small slice of the limitations of diagnosis, based on the subjectivity of the diagnosis itself and the subsequent likelihood of diagnostic manipulation in its role of turning the lives of completely disempowered people into nothing but the related billing code, with as little effort on the part of clinical providers as possible. I do not see anything redeeming in this completely broken system of labeling. It is corrupted beyond the point where it represents anything useful, or even anything real, yet it remains a part of the fabric of the humanity of many, like me, upon whom it has been imposed.