The Self-fulfilling Prophecy of Diagnoses
Bearing in mind some of the key issues mentioned above, it is perhaps not surprising that psychiatrists frequently disagree about what constitutes a correct diagnosis.2’10,18,25’36 Moreover, as well as questionable validity, it raises potential problems of stigmatising those given abstract biomedical labels that other them.25 A considerable number of studies have found that attributing mental health problems to biology is associated with negative public attitudes, such as the belief that people are dangerous or unpredictable and, through fear, keep their distance.10 Mental illness is frequently felt to be a shameful or dirty word with a stigma that is allpervasive and hard to challenge. People come to be aware of the label and the need to have strategies to fight or resist it and to counter the ways in which some people’s reactions to them change once they become a ‘disordered’ person.37
Psychiatric labels can give people identities. They artificially separate them from other people and, rather than have them understood as people reacting in meaningful ways to life histories and challenging circumstances, both recent and distant, labels separate them as sufferers of a biological illness. They are different, deviant and defunct. They often enter a world of labels, pills, ‘shrinks’ and powerlessness becoming what Ridgway has described as a ‘nothing in a no-world’, and for some this is like entering a world of suspended animation where their access to the normal rhythms of community life lies in the hands of a group of professionals and their invalid diagnoses.38
Moreover diagnoses, as well as being subject to professional disagreement often on a case-by-case basis and rendering people subject to stigmatised suspended animation, can also lead to a self-fulfilling prophecy. Here, miserable people, through their contact with powerful and publicly legitimised mental health professionals, become entrained into careers or chronicity,38 inducted and supported into the entrapping niches of the status of chronically ill mental patients and party to the social segregations that accompany this. In such cases, as we know only too well from our personal and professional experiences, struggling people and their families learn how to perform the roles of mental patient and carer, and come to know what performances are required to gain certain privileges.39
Indeed, people come to interpret their experiences as symptoms, as illnesses, and to do so can bring currency and value in certain settings. This can absolve people from blame and responsibility,16 provide access to time off work, financial benefits, space and sympathy. Moreover it can give people a framework to make sense of the maelstrom of pain, confusion and misery, the bizarre embodied changes, to make sense of a world that seems to be falling apart and relationships that are suddenly under profound duress. It provides a framework to allow for thinking about cures and recoveries and the promise of ‘being better’ through professionals, and doctors and institutions who hold, through their diagnoses and treatments, the magic keys to escape from where they currently are. It is at present not only the dominant framework but largely the only conceptual framework that people with misery have at their disposal. And this is partly why one of the authors of this book repeatedly tries to get David to a doctor.
We have other close relatives, colleagues and friends who have long histories of severe distress. As with many who share these experiences, they have found themselves party to a range of diagnoses, treatments, medications, incarcerations and periods of wellness. One of our close relatives, let’s call him Paul (and he’s agreed that we can write about this in our book), has a mental health history that has been variously diagnosed as bipolar, schizophrenia, major depression, generalised anxiety disorder, obsessive compulsive disorder and Asperger’s, often at the same time. He has experienced being sectioned on a number of occasions and has taken a range of medications over the last 25 years. These vary from atypical antipsychotics, which brought about substantial weight gain and type II diabetes, to almost every antidepressant known to humankind. Some of the labels above have been useful in the sense that they allowed him access to time, space, to feel numbed and allowed access to sympathetic and understanding professionals. Other times they have contributed to stigma, entrained passive docility, caused confusion and rarely overall have they contributed to his feeling better.
Last year Paul experienced a period of crisis. His behaviour was chaotic, disorganised and hyper. Thus followed a period of two years where his behaviour transitioned to what he described as depressed, low and very anxious all of the time. For Paul, his family regularly set up what can best be understood as an amateur ‘drug procurement team’. That is, they work together to help this relative to get the drug that he believes he needs and that has intermittently been helpful in the past. This is the case despite the fact that no one in the family has much faith either in the psychiatrists that the relative visits or indeed the medications he receives. Paul’s supporters are all well aware that research40 has shown that often they work by placebo. They are also well aware of their sometimes startlingly disabling side effects and know that the profits of companies who make them are intimately tied up in the naming of disorders and prescribing practices of GPs.
Our amateur drug procurement team try to get these despite the fact that they know that he experienced recent and or distant life experiences that related directly to his misery. They do this despite their knowledge that nobody yet has a biological marker for the condition that his misery has been called, and despite the fact that previous visits to psychiatrists have left him (and the team) with a nagging feeling that they have little understanding of what embodied distress actually is. These do not stop our drug procurement team’s visit to the office to get hold of medication.
Over a nine-minute duration the doctor finds out that Paul is profoundly unhappy, is eating poorly and is occasionally prone to suicidal thoughts. The doctor thumbs through his monstrous 25-year mental health file that is littered with psychological therapies, Selective Serotonin Reuptake Inhibitors (SSRIs), atypical neuroleptics, lithium bicarbonate, serotonin syndrome, adverse reactions and gaps in time. Will it have side effects? The doctor is unsure. Will it make him better? The psychiatrist, with a degree of unsurprising certainty and authority, says that it will, as long as he keeps taking it. Off they go then with a prescription that may, if Paul is lucky, make him feel less miserable.
The biomedical discourse has become so dominant in the west that it is the framework through we have access to knowing misery, even for those with little faith in it. And so, three people who are writing a book find themselves repeatedly sitting nicely in the psychiatrist’s or psychologist’s office, each party playing their role in the mental health consultation play.