Current practitioners in the field of counseling take a categorical approach to diagnosing mental illness. Pathology is viewed from a lens similar to that of organic medicine, in which presenting symptoms that commonly co-occur are grouped together into syndromes; these are the diagnostic units of psychiatry. This conceptualization is referred to as the medical model of mental illness (Frances, First, & Pincus, 2005). Unlike organic medicine though, psychiatry does not necessarily assume that a given syndrome corresponds to a single underlying pathology. There is, in fact, significant symptom overlap across many disorders. For example, insomnia, fatigue, and poor concentration are phenomena common to both major depressive disorder and generalized anxiety disorder, while marked weight loss can occur in the context of anorexia nervosa as well as a depressive episode (American Psychiatric Association, 2000).
|The Medical Model of Mental Illness: Ethical and Practical Implications for Diagnosis|
|Jonathan Whittenhall, Springfield College |
Categorical diagnosis of mental illness stands in contrast to a dimensional approach. Rather than conceiving of specific mental "disorders," such an approach profiles an individual in terms of the full spectrum of symptoms she is experiencing, noting the intensity and pattern of occurrence for each. Such a formulation implicitly recognizes that mental health exists on a continuum and that there is overlap between syndromes. It is important to note that, while the mental health community recognizes this continuum in theory, in practice it relies upon a notion of separate and distinct mental disorders.
However appealing it may be for mental health practitioners to adopt the diagnostic model of organic medicine, there are important differences between the two disciplines that make it illogical and unwise to do so. Organic medicine deals with anatomy and physiology of the human body, the mechanisms and variations of which have been extensively studied and are often well understood. Thus, the physical diseases and pathologies that are the province of organic medicine often present with typical symptom sets and follow mostly predictable courses. In contrast, mental health practitioners deal with human personality and behavior, which vary widely from person to person and whose underlying mechanisms are not well understood. Into this realm enters mental illness—the appearance, dynamics, and course of which is rarely typical or predictable.
There are several major practical issues that arise when adopting a medical model of mental illness. A large component of standard diagnostic procedure is the intake interview—essentially a client's self-report of her symptoms. These reports are vulnerable to several dynamics which tend to decrease their accuracy (as well as the validity of any resulting diagnoses). Taking a categorical approach to diagnosing mental illness may exacerbate these flaws. For example, fearing the stigma accompanying a label of a "mental disorder", clients may minimize or withhold sensitive information. Embarrassment about certain symptoms can have a similar underreporting effect. Meanwhile, some clients may endorse or exaggerate the intensity of certain symptoms in order to be helpful and agreeable, or to gain needed sympathy. There are also problems with memory and attention; for example, some clients may be so accustomed to living with certain symptoms that they forget to mention them. Even language itself is problematic; clients may be unable to find words to accurately and fully describe their symptoms, and word usage may vary between client and counselor. Finally, with a certain diagnosis in mind, clinicians may unintentionally ask leading or suggestive questions that trigger false positives. These flaws in the information-gathering process can result in inaccurate symptom lists that are rife with under- or overreporting.
Diagnosing clients with distinct mental disorders can oversimplify and misrepresent their actual mental health profile and experiences. The process may leave out related problems or symptoms that are important but do not fall into the diagnoses made for a given client. Likewise, it fails to describe how an individual's problem develops and evolves—how symptoms may come, fade away, or change in intensity. Further, it encourages clinicians to compare one client's problems to another's on the basis of a "same" diagnosis.
Adopting the medical model can also lead to problems with treatment. Clinicians may tend to treat the disorder and not the client, for example by unduly focusing on "typical" symptoms and ignoring other issues or concerns. They may recommend or apply particular treatment techniques based on the diagnosis. Even if their decisions are guided by empirical results (of treatment effectiveness), the studies that produce such results must by definition also rely upon these diagnostic constructs. If the constructs are flawed, then so are the empirical results. Clinicians may unwittingly choose inappropriate treatments and rule out potentially beneficial ones.
Labeling individuals with mental disorders also opens the door for stigmatization. A comprehensive nationwide survey conducted in 1996 confirmed the existence of a strong and persistent set of negative attitudes toward those experiencing mental illness. Significant numbers of respondents associated psychiatric illness with mental deficiency, violent or socially deviant behavior, poor life skills, and even bad character. Persons labeled with mental illness often share these negative attitudes, and their self-image can suffer accordingly. They may also experience social stigma and marginalization: A large percentage of study respondents admitted they would likely avoid persons with schizophrenia in a variety of public and private settings (Pescosolido et al., n.d.).
While the concept of "normal functioning" used in organic medicine is biologically based, that used by psychologists is socially derived. Any diagnosis of mental illness is based upon some conceptualization of "normal" or "healthy" human behavior, with reference to the larger society in whole or in part (Kupers, 2005). Such an assessment is difficult at best. First, it is problematic even to demonstrate deviation from the behavioral mean of a given population, because the client and counselor may have differing and/or inaccurate understandings of what the mean is. It is difficult or impossible to avoid referencing personal or societal values when defining what is "normal" behavioral deviation from the mean. Furthermore, the distress and impairment that clients experience (as part of their mental illness) always occur within a particular societal framework; this begs the question of whether the "illness" lies with the individuals or with the society in which they live. It is not too far a stretch to view the practice of mental health "treatment" as a mechanism of social control—encouraging conformity to a society's norms or values.
As described above, there are a number of risks involved when employing the medical model in diagnosing mental illness. There are problems of assessment—missing information and misinformation—which can lead to a misconception of a client's true clinical picture. These issues can overflow into treatment by directing the counselor toward techniques that may not be appropriate or best for a particular client. There is the problem of stigma that comes with labeling of mental illness. Finally, there is the larger issue of bias—personal and societal—that can skew a clinician's judgment about what constitutes "normal" behavior. No doubt in part because of these issues, the American Counseling Association Code of Ethics (American Counseling Association [ACA], 2005) clearly recognizes the ethical significance of diagnosing mental illness. For example, it requires that the implications of diagnosis be explained to clients (Sec.A.2.b.). It also advocates sensitivity to the client's cultural background (Sec.E.5.b.) as well as an awareness of the counselor's own social or historical prejudices that may come into play during assessment (E.5.c.). Counselors are also ethically obligated to be aware of how their own personal values may effect how they diagnose and/or counsel a client (Sec.A.4.b.). Above all, counselors should "act to avoid harming their clients... and to minimize or to remedy unavoidable or unanticipated harm" (Sec.A.4.a.; ACA, 2005, p. 4). In this vein, counselors are urged to refrain from diagnosis if doing so would likely cause a client harm (E.5.d.).
The ACA ethics codes cited above hint at a tension—perhaps even a polarity—within the field of mental health. On one side is the growing trend in the direction of the medical model, with a push toward pharmacological treatments and research into the biological underpinnings of mental illness. Yet there is also a strong awareness among professionals of the limitations and negative consequences of the categorical/medical approach to diagnosis. It is up to individual practitioners to remain alert and informed of these tensions, and to use proper judgment on a case-by-case basis in order to provide the best possible outcomes for their clients.
American Counseling Association. (2005). ACA code of ethics. Retrieved May 10, 2006, from http://www.counseling.org/ Resources/CodeOfEthics/TP/Home/CT2.aspx
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Frances, A., First, M. B., & Pincus, H. A. (2005). DSM-IV: Its value and limitations. In R. P. Halgin (Ed.), Taking sides: Clashing views on controversial issues in abnormal psychology (pp. 4-7). Dubuque, IA: McGraw-Hill/Dushkin.
Kupers, T. A. (2005). The politics of psychiatry: Gender and sexual preference in DSM-IV. In R. P. Halgin (Ed.), Taking sides: Clashing views on controversial issues in abnormal psychology (pp. 16-25). Dubuque, IA: McGraw-Hill/Dushkin.
Pescosolido, B. A., Martin, J. K., Link, B. G., Kikuzawa, S., Burgos, G., Swindle, R., et al. (n.d.). Americans' views of mental health and illness at century's end: Continuity and change. Retrieved March 15, 2006, from Indiana University, Indiana Consortium for Mental Health Services Research Website: http://www.indiana.edu/ ~icmhsr/amerview1.pdf
|Jonathan Whittenhall is a second year student in the Clinical Mental Health Counseling masters program at Springfield College. He has worked as a clinical intern in both outpatient and crisis counseling at the Carson Center for Adults and Families in Westfield, MA, and is planning to pursue licensure as a mental health counselor following graduation. He received an BA from Amherst College with a major in law, jurisprudence, and social thought. His professional interests include mental illness prevention, the relationship between vocational life and mental health, and the roles of developmental milestones and issues of meaning in psychological well being.|
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