The ‘No Labeling’ Alternative
I believe it is morally wrong and intellectually shoddy to “diagnose” someone because he hates his job, finds his subjects in school boring, becomes paralyzed in the face of hard choices, or is made severely anxious by his lack of success. These and a million similar human experiences are not “symptoms of mental disorders” or markers of biological breakage. They really should not be “diagnosed” as if a medical event were occurring or as if an observer knew what was going on inside the person.
What then are the alternatives to “diagnosis” if the person is coming to us for help? Well, we could ask him what seems to be wrong and he might tell us. The simplicity of this transaction may seem “simplistic” or “superficial”—but why should it? Why should it seem simplistic or superficial to ask a person what he thinks is wrong, listen to his answers, and maybe make some suggestions based on what he tells us? If he fibs and doesn’t tell us the whole truth or even a portion of his truth, well, so be it. But he might tell the truth and we might have some good advice for him. Why is this an outrageous idea?
In this human-shaped scenario no “diagnosing” need go on. The straightforward alternative to “diagnosing” is not diagnosing and having a wise human interaction instead. Is this just not fancy enough to warrant payment and therefore a horror story to mental health professionals? Do they dread having to say that they do nothing but listen and respond, like a concerned friend might? Are they dismayed by the fact that their fancy reading, in attachment theory, brain scanning, dream analysis, or anything else, may have little or no real place in the actual practice of listening and responding? Is this just too darn unglamorous, to admit that what you do is to listen and respond?
As a mental health professional with objections to the current scheme you may still believe that there must be some alternative system that allows us to give reasonable names to what human beings present. You may deeply believe that there must be a way to create a taxonomy that at least allows us to be able to say the equivalent of “a dolphin and a human being are both mammals.” Mustn’t something along those lines be possible? Can’t we do even that minimum thing?
No, unfortunately, we can’t. When there are a million possible causes of a thing like a smile or a sigh, we can either lump everyone who smiles together and lump everyone who sighs together, creating categories of “people who smile” and “people who sigh,” or we can create a million individual “categories” for each person who smiles and for each person who sighs. Neither activity makes sense or is worth the effort. Rather, we take all those sighs and all those smiles as part of what the person across from us presents and we abstain from creating illegitimate or unnecessary categories. To create categories just for our own sake, so that we feel that we are doing something that resembles science, is to act in bad faith.
Imagine that a given person is sad because he has no life purpose, another person is sad because his best friend is doing better than he is, a third person is sad because his mate is cheating on him, a fourth person is sad because he can’t get over his childhood abuse, a fifth person is sad because he hates his government’s policies, a sixth person is sad because winter has lasted eight months, a seventh person is sad because he can’t get his novel written, an eight person is sad because she has become invisible to men, a ninth person is sad because he can’t find the wherewithal to announce his sexual orientation, and so on.
There are only two “naming” alternatives here, to create the category of “sad people” (which is what we currently do by turning “sad” into the “mental disorder of depression”) or to make all of the following categories: “people who are sad because their novel isn’t working,” “people who are sad because their mate is cheating on them,” and so on. Is either naming operation useful or sensible? Is it useful to lump all sad people together under one umbrella? Would it be sensible to create a million categories of sad people based on our guesses about what is making them sad? What would be the point to either naming operation?
Let’s take a second example. Let’s look at several unruly boys in school. One is unruly because he is bored, a second is unruly because he is being picked on, a third is unruly because his parents fight all the time, a fourth is unruly to gain attention, a fifth is unruly because he’s already a mean son-of-a-gun, a sixth is unruly because he finds math hard, and so on. To repeat, we can only do one of three things here with respect to naming. We can pin a single label on all these boys, using words like “defiant” or “oppositional” or “attention deficit disordered” and claiming they all have the same “mental disorder.” Or we can create a separate category for each “type of unruliness.” Or we can admit that these boys really have nothing in common except one observable behavior. Either we create an empty category, endless categories, or no categories at all. Only the latter is honest.
Many professionals who oppose the current labeling system nevertheless believe that there must be some alternative labeling system that makes sense. Whether they want to retain the fancy word “diagnosis” or whether they are willing to give it up, they have a belief that they can’t shake that there must be some legitimate categories into which to put human beings. Aren’t there really “hoarders” and “anorexics” and “alcoholics”? Aren’t there really “pedophiles” and “cutters” and “schizophrenics”? Aren’t these categories and many more like them reasonable, sensible, and useful categories? Isn’t that just obvious?
Well, no, it isn’t. What if a “pedophile” is also an “alcoholic”? What if a “hoarder” is also a “schizophrenic”? What if someone is “anorexic,” a “cutter” and also many other things, say “a fundamentalist,” “an incest survivor,” and a “classical musician.” Which thing is she “really”? The idea that these categories are reasonable, sensible and useful breaks down the more closely we look at them. It may be very hard to shake the belief that we need labels like “clinical depression,” “alcoholism,” “anorexia,” and so on and yet shaking that belief is a necessary step if we are to effectively answer the question, “What should replace diagnosis?” The uncomfortable answer is to not diagnose and to not create taxonomies of convenience.
Each person is his own story. No theory about him is true; no category into which you put him is a legitimate definition of him. This is the high ideal at the center of humanistic, existential and person-centered therapy, that each person be considered a person, acknowledged as a person, and accepted as a person. What action plan for the profession flows from this way of thinking? I think a very simple one. The new slogan of the profession might be, “We try to offer people the help they want and the help they need without labeling them.”
It would be easy to create talking points that paint a picture of this new way of helping. A simple brochure could capture everything we wanted to say about what we believe and what we are doing to help. The problem is that the profession wants something fancier than this. It can’t reconcile itself to the reality of what its work amounts to. It is listening to sighs, making guesses from smiles, hearing about hurts, and trying to understand human beings. We aren’t doing science; we shouldn’t be “diagnosing” and “treating mental disorders”; we shouldn’t be labeling and categorizing. We should just try to help.
That isn’t to say that we wouldn’t need tactics. We would indubitably need tactics to deal with all the tricky ways that human being behave. We would need tactics to deal with the person who refuses to eat, who starts drinking at dawn, who can’t get on a plane, who feels sad every day. We would need lots of tactics! To say that we listen and respond is not to say that we are sitting in some easy chair. After all we are dealing with human beings! But to say that we need tactics is not to say that we need taxonomies. It adds nothing but an easy-to-use label to call the girl who refuses to eat “anorexic” or the man who starts drinking at dawn “alcoholic.”
Of course you would need to know these labels, since the world uses them and it would be silly not to be able to find useful information because you didn’t know the lingo. But that is a different matter from believing in the labels or countenancing them. The human experience specialist that I am picturing as the mental health helper of the future would know the lingo but she wouldn’t call the girl sitting across from her “an anorexic.” She would call her by her name.
Helpers need tactics and not taxonomies. A human experience specialist is a tactician and not a diagnostician. When you sit across from a person and you want to help him, you don’t need to know what to call him. You need to know what to do to help him. The place for diagnosing and treating is medicine—or auto repair, for that matter. When it comes to the emotional and mental health of human beings, we must refrain from pinning labels on them just because we can. As far as that goes, we could label everyone. And that would help no one except those who profit from labeling.