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Tuesday 31 July 2012




by Paula J. Caplan, Ph.D.

Many people have presented me with the following challenge: ‘People suffer. Often, good therapists can help relieve suffering, and suffering people deserve to have insurance pay for their therapy. But insurance companies won’t pay unless the person gets a psychiatric diagnosis. However, psychiatric diagnosis is unscientific and has often caused both direct and indirect, devastating effects in people’s lives. So what is the solution?”

Of course, I totally agree with all of the above statements. What do I think is the solution?
For years, my answer was: “I don’t know what the solution is, but I do know that we must not keep silent when we know that people are being harmed. So first we have to expose the harm, and then we have to brainstorm about a solution.”

However, the work of a student, Meadow Linder, in her brilliant undergraduate thesis at Brown University, combined with what countless therapists have told me over the years, suddenly revealed a solution to me. I will describe it here, but be aware that it may seem overly simplistic, and you may immediately think, “But that will never happen!” I do not believe it is overly simplistic, and as for whether or not it will ever happen, well, if we don’t aim for honesty and the repair of the world (what in Hebrew is called Tikkun Olam), then we can be sure we won’t get there.

In her thesis, Meadow Linder (see her chapter in Bias in Psychiatric Diagnosis, Caplan & Cosgrove, Editors) found through interviews with some really fine, ethical psychotherapists that when a traumatized, suffering person comes to them for help, they do not worry about whether or not the person meets the number of criteria for Post-traumatic Stress Disorder that it says they must meet in the psychiatric diagnosis manual. Because the person is traumatized, and they think they can be of help, they assign the PTSD label, and then the insurance company will pay for the therapy. They do this on the most humane grounds, and many of them are even more comfortable doing this because they are aware that the psychiatric diagnostic manual is not grounded in good science, so it does not make sense to stick to unscientific rules when it means sacrificing the welfare of the patient. As a member of two of the committees that wrote the current version of the diagnostic manual, the DSM-IV (until I resigned after seeing how unscientific and how politically motivated the writing of this manual is), I saw firsthand that good scientific research is ignored, distorted, or lied about when it suits their purposes, and poorly done research is used to support whatever they want to put in or keep out of their manual.

I have been working with therapists since 1969 and cannot count the number of times that excellent, compassionate, ethical therapists have told me that they don’t worry about what psychiatric diagnosis to give patients, because they know that that rarely, if ever, is of any help. Instead, they consider what the insurance company will and will not pay for and how the companies often agree to pay for more or fewer therapy sessions, depending on the diagnostic label given to the patient. Then they, to a greater or lesser extent, base their choice of labels on what will enable them to provide the best and most appropriate kind of help. So many therapists do this, and know that others do it, and even the insurance companies are surely aware that this goes on. So what is happening in fact is that, once a person has been licensed as a psychologist or psychiatrist (in some states, people from other disciplines can be licensed therapists), right now, the therapist's judgment of the patient's needs is what is really the basis of insurance coverage. In spite of this, insurors and some therapists throw up their hands and ask, "Without diagnosis, how would we know whose therapy to pay for?!"

My Proposed Solution:
In light of what I have just described, my solution is simply that everyone involved -- therapists, insurance companies, the DSM authors — start being completely candid about what is happening, and we all skip the step of assigning a diagnostic label. In addition to the importance of an increase in honesty and ethical conduct all around that this would entail, there is an added, important clinical advantage that would accrue; the advantage is that, as the brilliant psychologist Jeffrey Poland has described in one of his chapters in the book Bias in Psychiatric Diagnosis, therapists would be encouraged and even liberated to try to learn about the whole patient, including their strengths and resources, instead of focusing too much (as many do today) on figuring out which set of DSM symptoms the patient most closely fits.

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