When Psychiatric Labeling Hurts

When Psychiatric Labeling Hurts
By B. Imei Hsu, BSN-RN, MAC-LMHC, Artist

Our culture is moving towards a much needed health kick. After decades of being introduced to processed foods and new products sporting the “latest in scientific research and technology”, it is no surprise how often I find myself in conversation with those who have developed a skeptical eye mixed with a little paranoia about the health benefits and consequences of ingesting, integrating, or otherwise experimenting with new products. I observe more people flipping processed food boxes over, looking for ingredients like partially hydrogenated oils, excess sugar and sodium, and mono sodium glutamate (MSG). This kind of interest and investigation into what you are ingesting is a welcome health consciousness I wish everyone would adopt! Yet there is another kind of label of which people should be aware. And this one may be coming directly from your doctor’s office.  There are times when psychiatric labeling hurts, and you should learn as much as you can about it in order to make informed decisions about your mental health.

What Is A Psychiatric Label?

Psychiatric labeling, aka psychiatric diagnosis according to one medical model proposed in the Diagnostic Statistical Manual (DSM), has become par-for-course in the American medical setting. All licensed practitioners of psychology and psychiatry, including this author, are required to receive education on the use of the DSM codes describing all known psychiatric disorders in reference to billing a client’s insurance, prescribing or recommending medication, sharing client information with a mutual helping professional, and dialoging in a shared language about evidence-based treatment options for a particular diagnostic specifier. What most people do not know is that DSM labeling and diagnosis in the currently accepted medical model is not the only model available. It is, however, the only model third-party payers accept.

Why is this so?  According to an article credited to John R. McHugh, MD (professor of psychiatry, John Hopskins University):

“The medical model is convenient, it provides the practitioner with a clear-cut approach to handling individual situations, but most of all, it has been used by the psychiatric world in a way that leads to labeling and subsequent prescribing of psychiatric drugs. The typical procedure for the medical model of mental health involves identifying symptoms, assigning an appropriate label, and administering what is deemed appropriate drugs.

Sounds fine, doesn’t it? If a person is labeled mentally ill, shouldn’t they receive medications that may relieve their most mind-altering and disruptive symptoms? If a person is suffering from terrifying and disruptive hallucinations, shouldn’t she or he be offered a prescription (along with a care plan) for haloperidol or clonzapine? Absolutely. No argument there.  A label, such as schizophrenia, along with a prescription for medications to reduce the troubling symptoms associated with a schizophrenic mental framework, can be a part of compassionate and effective treatment. But sometimes, labels are stigmatizing, shameful, and often permanent in a way that does not help the client. In some cases, the labels used in the DSM are simply not appropriate in light of other models of psychiatry that are more positive. And worse, some of them appear fabricated, with little evidence to back them up.

When Is Labeling Harmful?

Psychiatric labeling is harmful when its used:
1. at the convenience of the practitioner, with little benefit for the client
2. in a way that “sticks” to the a person, preventing health care professionals from “seeing” the client’s true content instead of diagnostic indicators from a book
3. creates shame on the part of the client that does not promote integration, growth, or other positive outcomes
4. as a means to aggressive marketing of pharmaceuticals

What if you were to theoretically reject the DSM as a book proposed by a potentially biased group of individual “experts” who created a list of under-vetted diagnoses followed by a checklist of symptoms? While the growing list of contributors to the DSM have impressive credentials, the reality of psychiatry is that it is a young medical field.  The DSM-V [check out Dr. Kaplan’s article on his rejection of being a part of the DSM-V reviewing committee] is about to be revised and released to the public in May 2013, and the process of categorization is not open to public scrutiny. Why the secrecy? And can’t most of us guess what is coming: a slew of additional predictive categories for pre-existing conditions to be labeled as mental illness? Relational disorder, with recommendations of psychotropic medications for couples in relationship crisis? Racism as a mental disorder rather than an individual’s problematic social outlook?

The acceptance of DSM coding as the “bible” for psychiatry is controversial, and you can hear practitioners grumbling about it. Why grumble? Because I believe the mental health of a person shifts and changes, constantly adjusting and readjusting to the changes in a one’s environment and ability to adapt, change, and grow. Disorders can be invented from any behavior, deemed abnormal, and then codified. If you don’t believe that, remember it was not so long ago that homosexuality was labeled a paraphilia (sexual disorder).   Sometimes, all we might accomplish in labeling someone with a psychiatric disorder is put a blinder on one’s self-awareness, blocking him or her from seeing anything but the diagnosis and all its debilitating outcomes.

A Conflict Of Interest?
If psychiatric diagnosing is so effective, efficient, and compassionate, I wouldn’t be writing to you about a strong and ever-growing movement some refer to as the “anti-psychiatry” movement. To be clear, the anti-psychiatry movement, which started in the 1960’s, is not against all forms of psychiatric care, and it should not be equated with the Anti-Psychiatry Coalition, who proposes that all forms of psychiatric care are implicitly harmful. Many mental health practitioners, including myself, claim to be a part of the anti-psychiatry movement because of the alarming trend of labeling and medicating people with mental health issues according to diagnostic indicators found in the DSM, instead of taking the time to observe the content of a person’s life before presenting all current and alternative choices for treatment.

Medical practitioners are often placed in a conflict of interest with their agencies as pharmaceutical companies rise and fall based on the popularities of their drugs, and those companies are financially enmeshed with our hospital systems. It doesn’t take a rocket scientist to figure out how advantageous it is for Pharma to sell drugs — and psychotropic drugs are a big seller — to hospitals and clinics, while its physicians are paid and retained according to their ability to treat as many clients per day as safely as possible. If each billable hour is full of prescriptions … well, do I need to describe to you why your 15-20 minute doctor’s appointment might include ten minutes of discussion about a medication, and very little to no information about other treatment options?

Before I rub any MD’s out there the wrong way, I am not saying that all physicians and prescribing professionals are “in it” for the money. Most of us entered the medical field because we sensed a strong calling to heal, and a similarly strong desire to serve others.  Yet not one of us can say we have never felt the pressure or received “the lecture” on our responsibility towards the financial health of our Employer, including a message about diagnosis, scripts, and schedules. It’s tied to part of the reason we often aren’t allowed to refill a prescription without asking the client to schedule an appointment, even though we have the data to make a safe and effective decision on behalf of a client. [BTW, whatever happened to standing orders? Understand?] At the end of the day — and it sometimes pains me to say this — it is about money, isn’t it?

The World Beyond the DSM
While I am not saying that the DSM has no value, I am advocating that there is a world beyond the DSM for those looking for help, and the DSM should not be allowed to be the know-all, end-all answer to mental health issues. There are other treatment options that do not require noxious and shameful labeling, such as Positive Psychology, Buddhist Psychology, and Integrative Medicine strategies that focus on the positive content found in a person’s life. Instead of focusing on “what goes wrong” and what is broken, there are others treatment options that support the client’s growth in a positive and collaborative manner. These can be offered when a person is not in substantial mental crisis or in danger of harming him or herself.

An integral part of one’s experience at Seattle Direct Counseling is that you are seen as a whole person, and not a biochemical imbalance with arms and legs. We’re not just treating your “disorder”; we’re interacting, collaborating, and creating with you. Many of the people who come to my office are not stereotypically “crazy”;  they simply deal with the maddening effects of every day life, and they want to develop ways of being and responding that lead to greater understanding, happiness, equanimity, dignity, and courage.

Part of informed consent means that you should be presented with not only the current standard approach to care (which in the western world is the DSM, evidence-based medicine, and psychiatry), but you should also be offered other points of view that work with your concerns for your benefit, which may include (but aren’t limited to) physical therapy and massage, movement and exercise, vitamins and supplements, social support, spiritual activities, and peer-run support organizations. While psychotropic medication might be one of your options, it shouldn’t be the only one. And you shouldn’t be slapped with a diagnosis and left to “deal” with it alone.

Now it’s your turn. If you were going through a difficult time in your life, such as the death of a loved one, the end of a long-term relationship, the loss of an important job, and you noticed you were having a hard time getting out of bed or taking care of yourself, how would you like to be treated by your doctor or helping professional? Does it help you to know you have a DSM category diagnosis? Why or why not? What else might help you understand what is happening to you, and what you can do about it while you’re feeling miserable? Do you think a healthy skepticism towards DSM categorizations and labeling might help you make a more informed choice about your care? Do you feel the your practitioner spends enough time understanding your situation before a diagnosis is applied? If not, how does this make you feel?