Not Diagnosing Jim
Let’s look at a hypothetical fellow, Jim. Jim has looked a certain way his whole life: he has been recognizably himself for as long as he or anyone can remember. If you are his mate or his friend you are pretty much certain how he’ll react if, say, you offer him a second beer, ask him if he wants to climb a mountain, ask him to play a board game, and so on. You know his likes and dislikes, his habits, his characteristic expressions, pretty much everything.
Jim goes away for a week and comes back different. This is a classic plot in fiction, where a character goes off for many years, say to war, and when he comes back his wife is certain that he isn’t the same man but an impostor, even though he looks the same, has all the right memories and information, and can pass any test on being himself. However his wife just knows that he isn’t the same man. Let’s say that Jim, who has never seemed particular anxious previously, comes home highly anxious.
He looks anxious. He says he’s anxious. His anxiety is keeping him from sleeping. The question isn’t “Is Jim anxious?” Of course he is. The question is, “Why is Jim suddenly anxious, so much so that he doesn’t even seem to be the same person?” To “diagnose” Jim with “an anxiety disorder” is child’s play: he is clearly anxious. That is no diagnosis at all. That’s like diagnosing Jim with “lump-itis” if he comes in with a baseball-sized lump on the side of his head. “Lump-itis” won’t do. Nor will “anxiety disorder.” To do that is to just to mint money.
We want to know the following three things: 1) Why is Jim anxious?; 2) What might we suggest to help Jim, given the particular source of his anxiety?; and 3) What can we suggest to help Jim whether or not we’re able to discern why he is anxious? Mental health providers skip 1 and 2, because Jim may not cooperate in their investigation, because those “causes” are too hard to discern, and/or because those “causes” are frankly unknowable. They go directly to 3. They say, “Let’s treat that anxiety!” They say, “Let’s treat that symptom!” The pills appear; talk of a certain sort commences. No real investigation begins as steps 1 and 2 are assiduously skipped.
Let’s imagine that the following ten things occurred in Jim’s life during the week that he was away:
1. On the flight home his plane encountered engine trouble and had to be diverted to Amarillo.
2. He started an affair with a woman half his age and half his wife’s age, an affair that he would like to continue even though he feels guilty about betraying his wife.
3. He took certain street drugs for the first time.
4. He had a memory that he couldn’t shake about a test that he failed miserably in fourth grade and how his teacher humiliated him when she handed out the test results.
5. He experienced certain physical symptoms, including heart palpitations and sudden sweats.
6. He received an email and learned that he was about to be audited.
7. He had a nightmare in which he saw himself being drawn and quartered for his unpopular beliefs.
8. He received an email from his sister saying that she was unwilling to continue taking complete responsibility for caring for their demented mother.
9. He began wondering if misplacing his hotel key and his car keys were signs of his own early dementia.
10. He reread a portion of a novel he had once written, discovered that he still liked it, and began to wonder if he should resume writing it.
Whether or not any of these “caused” Jim’s sudden anxiety, doesn’t each feel suggestive and something like a potential clue? Wouldn’t you want to know these things if you were tasked with helping Jim reduce his experience of anxiety? Forgetting for a second about how you might actually discern which of these, if any, was causing Jim’s sudden onset of anxiety, don’t we suspect that even just getting them named and “on the table” might have some salubrious effect on Jim? Doesn’t all therapy that isn’t caught up in “diagnosing and treating mental disorders” rely on this central idea, that making the unknown known helps people reduce their experience of distress?
We’d certainly like to possess that information about Jim’s week. Let’s add another wrinkle. What if Jim reports that he believes the anxiety is the result of him being followed all week by a certain suspicious stranger—a man Jim is sure was there but who in fact wasn’t. In this scenario Jim may be suffering from an actual organic syndrome—and a feature of this organic syndrome may be that Jim will not believe you when you try to explain to him, if you are in a position to do so, that the stranger does not exist and could not have existed.
For example patients with Anton’s syndrome, which can arise in blind individuals with cortical damage, may “see” exactly such strangers as Jim feels he is seeing—and they can’t be talked out of the belief that they are hallucinating. Oliver Sachs explained in Hallucinations, “A patient with Anton’s syndrome, if asked, will describe a stranger in the room by providing a fluent and confident, thought entirely incorrect, description. No argument, no evidence, no appeal to reason or common sense is of the slightest use.”
This possibility should further highlight what investigating looks like. You can’t learn this vital information if the transaction plays itself out in the following way, as it almost certainly will between Jim and a chemical-oriented psychiatrist:
“So, Jim, you’re anxious,” says the psychiatrist, looking at the intake form.
“Excellent! Shall we diagnosis you with generalized anxiety disorder?”
“Great! Done! Now as it happens today I have yellow pills, orange pills, and blue pills. Let me tell you about these miracle workers … ”
“Can’t wait to hear!”
It should be perfectly clear that “diagnosing the symptom” (“You’ve got anxiety!”) and then “treating the symptom” (“Here’s a pill!”) is simply the path of least resistance. We can see why it is so tempting to engage in this shortcut and this illegitimate process, since it appears well nigh impossible to know whether Jim is anxious because his anxious nature, dormant “forever,” suddenly kicked in, whether a single idle memory, say of that fourth grade humiliation, caused “all this emotional fuss,” whether the affair, the audit, or the near plane crash provoked this new anxiety, and so on. Rather than admit that he doesn’t know what is causing the anxiety, probably can’t know, and doesn’t really care one way or the other, a chemical-oriented psychiatrist simply proceeds to “diagnose and treat the symptom.”
To repeat: we understand the temptation. There are certainly no tests on earth to connect these possible “causes” in any direct or indirect way to Jim’s sudden onslaught of anxiety. For the most part, we simply can’t know. Nor can Jim, for that matter. Maybe he reads over his list and exclaims, “It’s the audit! That’s what’s doing it!” Do we trust Jim’s judgment on this score? Do we believe for a minute that Jim is accurately ascribing the right cause from among all these plausible causes? Do we believe that a certain feeling, insight or self-report on Jim’s part amounts to an “accurate diagnosis” of the source of his anxiety?
Not if Jim is the tricky, complicated, evasive creature he surely is—namely, not if Jim is a human being. Can we really trust Jim, especially once we discover that he doesn’t want to talk about how the new affair may be affecting him? Do we want to “diagnose” Jim with “audit-induced anxiety” because he’s cherry picked the audit off his list? No. We know better than to take at face value the often comfortable and self-serving explanations that human beings provide. We can’t rely on Jim, we can’t “test” Jim … and so, then what? Do we throw Jim to the chemical-oriented psychiatrist? No. Rather, we say to Jim, “You know, I wonder … ”
This “wondering” might sound like the following:
“Jim, you’ve picked the audit as the main source of your anxiety. But what about the affair you’re having and what about keeping the affair a secret from your wife? Isn’t that likely implicated? Don’t you think you might be suffering from a guilty conscience?”
“I don’t feel guilty.”
“Oh. But you said earlier that you did feel guilty.”
“I do and I don’t. The bottom line is, I don’t want to end the affair and I don’t want my wife to know. I want to get rid of the anxiety, not end the affair.”
“Oh. That is so interesting.”
This is a perfectly clear, characteristic and plausible exchange. Jim’s part of the exchange can be translated as, “I want relief from the symptom and I do not want to make any fundamental change in the way I’m operating. If you happen to have a pill handy, that would be lovely.” Jim may well pull for that pill! And what frustrated helper wouldn’t want to hand Jim the pill bottle and say, “Have it your way. This pill has strong effects that will quell your anxiety. I wash my hands of you and your nonsense. Let’s collude in acting like the anxiety is a ‘thing’ that blew in through the open window and that we have ‘medicine’ for it. Fine. Let’s play that game.”
However our human experience specialist, a new sort of helper I have in mind, or any psychotherapist who doesn’t feel obliged to “diagnose and treat symptom pictures,” doesn’t have to pull out the pill response. She can continue, one human being to another, “You want the affair, you want the lying, the hiding, the cheating, and all of that, and you don’t want the anxiety that may come from the lying, the hiding, the cheating, and so on? Have a got that right? Tell me, Jim—does that make any sense to you?”
You investigate, you suggest, you hypothesize … and you tell the truth. There is a world of difference between “diagnosing and treating” and investigating, suggesting, hypothesizing, and telling the truth. When a psychotherapist investigates, suggests, hypothesizes, and tells the truth, she is helping; when she “diagnoses the mental disorder of generalized anxiety disorder,” she is playing a game, illegitimately labeling, and creating a pseudo-patient who, like Jim perhaps, may prefer to be a pseudo-patient than deal with the turn his life has taken. When she does the former, she deserves a well-earned round of applause; when she “diagnoses,” she ought not to sleep well.
Consider the following. What if nothing unusual or provocative happened to Jim during his week away? Does that make Jim’s anxiety uncaused? Of course it doesn’t. It only means that we know even less about its source than if we had some obvious clues. In a certain sense that may even prove helpful, because without obvious clues we can’t leap to connecting up Jim’s sudden anxiety with some too simple “cause.” We would naturally presume that there are reasons for his heightened anxiety, reasons that we may never come to know, and even more adamantly invite Jim to collaborate in our investigation.
Let’s say that Jim does collaborate and that he lands on that audit as the source of his anxiety. We may not completely believe him; but should we dispute him or ignore his formulation of the problem? No: after we’ve said what we had to say, for example about his affair, we might then want to take Jim at his word and consider the possibility that the upcoming audit is indeed the primary source of his anxiety. Given that Jim has said so, we might take that as a working hypothesis. A working hypothesis is very different from a diagnosis. When a doctor says, “It might be this, it might be this, it might be this, or it might be this,” he is announcing his hypotheses. He hasn’t made a diagnosis yet. Nor should we as we begin our investigations. In medicine, you don’t diagnose until you can diagnose.
Will a moment come, in Jim’s case or in any other, when we can “make a diagnosis”? I think the answer is a clear no. What could such a diagnosis sound like? Audit-induced anxiety reaction coupled with denial-induced extra-marital affair-itis? Sudden Personality Change Syndrome caused by a plane’s engine catching fire? Unleashed Primal Lust For Younger Woman Syndrome with overtones of guilt and pleasure? These human events can’t and shouldn’t be “diagnosed” as if they were illnesses. Let us stop looking to diagnosis as a goal or as the Holy Grail. It isn’t either. Right now it is only a mechanism for turning human experience into mental health establishment profits.