Psychologists are trained to assess and diagnose problems in people’s thinking, emotions and behaviour. Yet in practise, many psychologists resist the use of diagnosis and may even be critical of it, seeing it as being within a ‘medical paradigm’. In this article we explore the dilemma of diagnosis and the considerations for psychologists.
Psychologists are frequently confronted with questions related to the mental health of their clients. Dilemmas then inevitably arise as to whether psychologists should consider diagnoses when assessing their clients’ mental health. There are very important criticisms of diagnosis practices that all psychologists need to be aware of and consider carefully. Despite the limitations and constraints that this consideration will raise, there are many benefits to diagnosis that also need to be taken into account.
On balance, most psychologists have concluded that diagnosis is an important undertaking that can offer valuable advantages to psychologists who take the time and care necessary to complete comprehensive diagnostic work-ups with their clients (Evans, et al., 2013).
What is diagnosis?
Diagnosis is the process of identifying a specific type of problem by examining its features, both those common with similar problems and those that are unique to this particular presentation. It also requires the consideration of the circumstances in which the problem is occurring. The word has Greek roots that roughly mean, “to know through distinctiveness”.
For example, a car mechanic might diagnose a problem of an engine failing to start by considering the common features of all examples of ‘failure to start’ that is encountered, and isolating the unique factors and circumstances in which the failure occurred, to identify the particular problem in this instance. With mental health conditions, the diagnostician will consider the signs and symptoms that are reported by the client, and perhaps by others such as partners or parents, as well as the circumstances in which these indicators have occurred. To give a common example, a person who has just been retrenched might report moderate loss of interest and pleasure, some sleeping and appetite difficulties, and so forth. An appropriate diagnostic judgement, after considering all of the other information required, might be to conclude the person is experiencing an adjustment disorder with depressed mood.
Diagnosis of mental health conditions is usually performed within a diagnostic framework, particularly those provided by classification systems such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), or International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10). Classification systems group symptoms into disorders with the aim of understanding the person’s difficulties and guiding decisions about optimal care. Both of these frameworks are vulnerable to the criticisms, which are reviewed briefly below, and do not offer magical solutions to the question of accurate and reliable assessment. They need to be applied with expertise and intelligence, and psychologists must bring these abilities to the task if they are to reap the potential benefits that diagnostic thinking can afford.
Legality of making diagnoses
The legal status of diagnoses offered by psychologists depends very much on the context in which that opinion is offered. It varies considerably between jurisdictions and settings. For example in Victoria according to the Mental Health Act (2014) a suitably qualified and authorised psychologist working in the mental health field can be one of two health care practitioners to recommend that an individual be formally assessed by an accredited psychiatrist. It is important to note that a typical medical practitioner in general practice could also be one of those two professionals, but would not be in a position to make the final decision. In this regard, suitably qualified psychologists are thus in exactly the same position as medical practitioners.
In other settings, the diagnostic opinion of psychologists is more directly acceptable as evidence that a specific condition should be attributed to an individual. For example, within the education system, the diagnosis of autism spectrum disorder issued by a suitably qualified psychologist can contribute to a multidisciplinary team assessment and the student in question might become eligible through the school for additional material and financial support from the government.
Given these differences, it is incumbent on psychologists to establish the particular rules and precedents that apply in their own areas of practice. It is also important that psychologists consider the appropriate capabilities and attributes that are required to practise in that field. The Psychology Board of Australia expects psychologists to be suitably equipped for practice if registration criteria are to be satisfied, and future course accreditation standards might well specify that competency in diagnosis is a core capability of graduates from psychology degrees.
Regardless of the legal status a particular diagnosis might incur, it can be argued that psychologists should routinely undertake thorough mental health assessments of their clients (where appropriate to do so) and comprehensively document their decision-making processes and diagnostic judgements.
Accurate and comprehensive diagnoses can inform other health care practitioners and assist them to better understand the individual...
Exploring the criticisms
For many decades, critics of mental health diagnoses have pointed to the weaknesses, and indeed the dangers, associated with the practice (e.g., Timimi, 2014). The list is long and it will not be possible to do justice to it in this article. However, mentioning some of the main criticisms and considering their implications can be instructive. For example, researchers have documented how diagnoses can serve as ‘labels’ that concretise non-normative differences and produce stigma. Once labelled as ‘schizophrenic’, for example, an individual can have great difficulty escaping from potential prejudice and discrimination. Using diagnostic terminology is also criticised because it indicates the adoption of a medical model of conditions of living, and introduces unconscious biases that may lead others, including health practitioners, to categorise many innocuous or reasonable responses of the diagnosed person as evidence consistent with their alleged ‘illness’. A famous example is of a patient who was thought to be hallucinating a ‘black devil’ that he could not escape, when actually he was talking metaphorically about the mood that enveloped him.
Others criticise the epistemological frame that diagnosis entails. Problems of living, such as having to deal with poverty, are transformed from social harms to individual differences, and the everyday miseries created by social constructions of the person are converted to symptoms that are real and that reside within the person. Just as a patient with a liver problem has an enzyme deficiency that can be corrected through medication, so too a person who has been sexually abused can suffer from a chemical imbalance in the brain, producing depressed mood, which can be rectified by administering the correct neurotransmitter to rebalance the brain chemistry. The lived experience of the client is excluded in such diagnostic processes.
These are just some of the objections to mental health diagnoses and there is no doubt that these are telling criticisms. Psychologists must take the potential pitfalls to heart, and be ever mindful of their tendencies to fall into these traps of social cognition (Barone, Maddux, & Snyder, 1997). Yes, humans are prone to perceive consistency with their pre-formed opinions and attitudes; they do seek confirmatory evidence when searching for solutions to problems; they are prone to unconscious biases that distort rational decision-making. Being prone to these cognitive errors does not mean we need to be captives of them. Careful training in and application of sound decision-making techniques can help prevent egregious errors and ensure psychologists remain open-minded and willing to change their views of clients and their mental health conditions (Stone, 2017).
Weighing the benefits
It is not possible to enumerate all of the benefits that diagnostics can offer in a brief article, but the main benefits can be noted (Evans, et al., 2013). Of most importance is the contribution a diagnosis makes to treatment decisions. When a psychologist makes a diagnosis they do so knowing this will guide them and other professionals in providing the most effective treatment based on research evidence. Another valuable contribution relates to their communication potential. Accurate and comprehensive diagnoses can inform other healthcare practitioners and assist them in understanding better the individual to whom the diagnosis is applied. A diagnosis can help flesh out a person’s experience, which otherwise might appear confusing, even to the person involved. It can assist in ruling out other possibilities, which might otherwise lead to unnecessary, unhelpful, or even harmful interventions. This is consistent with our professional obligations to treat others fairly. Acknowledging difference can be the first step in taking appropriate actions, ensuring the person is not handicapped by society as a result of unrecognised need.
A personal benefit to psychologists, it can be argued, is the greater expertise that they develop by exercising their diagnostic skills. Accurate and reliable diagnoses require deep knowledge of both the necessary decision-making processes and content that is involved. Thoughtful reflection on the processes being followed and the information considered in any specific diagnostic event can assist psychologists to be the very best practitioners they can, particularly if this reflection takes place with peers or supervisors. Those peers need to be ‘critical friends’, prepared to ask hard questions and place the psychologist on the spot. They have to ensure that qualities of empathy and perspective-taking are maintained, and the psychologist has to be prepared to revise and reconsider firmly held beliefs. If done intelligently and sensitively, diagnostic processes can keep psychologists focussed on providing the best possible care for their clients.
Diagnoses are not helpful in this way if they are superficial or non-informative. They indeed become more vulnerable to the criticisms outlined earlier. For example, it is inappropriate to ask a client to complete a short depression inventory, score the responses and decide that, because the total score exceeds a certain cut-off point, that the client must be ‘depressed’. That conclusion might not be drawn after following a careful diagnostic decision-making model and conducting a comprehensive investigation of all the relevant factors.
Furthermore, competing diagnoses need to be ruled out; a person can experience a severely depressed mood for a host of reasons, and it is imperative that those reasons be identified if intervention is to be tailored to the problem. The manifestation of a depressed mood will vary considerably depending on the personality style of the individual concerned. Psychologists, as part of their diagnostic investigations, can assess personality factors that might impinge on the expression of the current mood-state and adjust their intervention strategies accordingly. Similarly, there is a need to take into account physical health conditions which can have major implications for the manifestation and treatment of mental health disorders. Building these factors, as well as social, cultural, and spiritual aspects of the client’s experience into the diagnostic decision-making is essential to ensuring a sound understanding of the client and his or her experience.
Diagnosing in practice
Psychologists are required to be skilled and expert decision-makers in their field. If psychologists work with clients who experience mental health issues, it is incumbent upon them to ensure they have the capabilities to make comprehensive and informative diagnoses of those mental health considerations. While the legal status of psychologists’ diagnoses will vary from setting to setting, it remains an essential cornerstone of psychologists’ competencies to practice with such client groups. Capabilities are not developed easily or rapidly; psychologists are required by law to practice within their scope of competence and must ensure that their skills are ‘fit for purpose’. Advanced training in specific areas of practice – particularly endorsed areas of practice, such as forensic psychology – is necessary but not sufficient to ensure competence in a particular field.
Working with clients who have experienced multiple trauma in early years, for example, presents particular challenges for psychologists, who must ensure they do no further harm to their very vulnerable clients. Professional development in this specific field of practice is essential for any psychologists contemplating working with this client group. Theoretical content, such as diagnostic indicators, will be mastered and must then be complemented with rigorous supervision to ensure that service standards are developed and maintained. Supervision in such circumstances might be required for quite some time, and perhaps need to be ongoing, if the psychologist is to maintain the necessary standard of expertise and care provision.
A look to the future
While diagnostics is a cornerstone of expert psychological practice, the potential weaknesses of adopting and applying current mental health frameworks have been identified. Psychologists will need to be mindful of potential dangers, and remain vigilant to their own cognitive biases and propensities to label and stigmatise (Barone, et al., 1997). Alternative models of mental health diagnoses that help obviate these tendencies have been proposed, and members are encouraged to explore them. For example, the British Psychological Society has supported the adoption in the UK of an alternative to psychiatric diagnosis referred to as psychological formulation (see Johnstone, 2017). Whether or not this particular taxonomic system will be suitable to Australian contexts remains to be established, but it does highlight a key point of this article. Diagnoses and categorisation are inevitable, and denying that the often automatic processes of social cognition also apply to psychologists as well as other humans can lead to poor practice, as can egregious use of psychiatric diagnoses. Psychologists can acknowledge these constraints by undertaking the necessary preparation, reflecting on their decision-making processes, and remaining open to revising their diagnoses wherever necessary.
The author can be contacted at [email protected]