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Wednesday, May 30, 2012


What we should be wary of is not the act of diagnosis itself, but diagnosis that is crude, simplistic, and unthinkingly applied. There is nothing epistemologically special about medical diagnosis; diagnosis is merely the act of appraising the nature of a situation, and we presumably accord it respect when it is based on real expertise. An attorney "diagnoses" a client's legal plight, a real estate agent "diagnoses" the market potential of a property, and a lawn care guy "diagnoses" the botanical properties of grass. A therapist who refrains from diagnosis thus broadly considered offers...nothing. Yes, mute witness is something, but the sea and sky offer as much.

Psychiatry's problem is that its expertise is being disputed from so many quarters (ironically, mainstream/biological psychiatry is suffering a fate similar to psychoanalytic thought a generation ago); there is no longer a critical mass of consensus. Yet there are still suffering patients, and no end of them. In the absence of clearer signposts, the practitioner can only resort to intelligence and humility.

I would add Ronald Pies's observation (in a Psychiatric Times article I recall) that DSM diagnoses are uniquely thin and widely unpopular because they manage to be neither phenomenologically nor medically compelling. They offer neither the narrative richness of psychoanalytic understanding nor the physiological rigor or medical or surgical phenomena.

The psychiatrist is most analogous to the pain specialist, specializing in varieties of cognitive and emotional suffering irrespective of (generally unknown) origin. Pain is a real scourge, but suffering may be culturally enhanced by widespread expectations of painless living.

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