David, I must commend you on your choice of topic for today. I appreciate that your conversation reflects the complexity the issue.
You mention the cultural aspect. The stigma attached to seeing a “shrink” is real. Personally, I’d prefer they be called “mind expanders”.
Gone are the days where you would lie for hours on the psychoanalyst’s couch to unload your neuroses à la Woody Allen. Now the model is medical and empirical, hence the necessity for a diagnosis which is required for reimbursements by health insurance. The flip side is that mental health treatment, precisely because it is covered by health insurance, is now accessible to a larger population than before.
The caveat of course, as you rightly point out, is that in order to be reimbursed, you need a bona fide diagnostic code contained in the current edition of the Diagnostic and Statistical Manual of Mental Disorders which is now in its fifth edition (DSM-5).
If the diagnostic criteria are helpful in pointing the healthcare professional in the direction of an appropriate treatment plan, and if putting a name to an individual's experience is often instrumental in helping them make sense of their experience (if you can name it, you can tame it), there is also a large amount of stigmatization involved with a diagnosis. Certain diagnoses are more stigmatizing that others, such as Bipolar Disorder and Borderline Personality Disorder, and the very fear of stigmatization does keep many individuals from seeking help. From “mental health diagnosis” to “mentally ill” to “crazy” it doesn’t take much in people’s minds.
In addition, the way the mental health system is run in the US is confusing for a lot of people, and complicated further by differences among the states.
I’ll take this opportunity to clarify a few terms for your public. Generally speaking psychiatrists prescribe medications. They don’t normally do therapy anymore. Psychologists, psychotherapists, social workers, counselors are the ones who do the “talk therapy”. Psychologists have doctorates and the others have at a minimum a Master’s degree. In my experience, their level of education impacts minimally, if at all, the quality of the therapy. In most states, the former (psychologists with a PhD or PsyD) are qualified to administer and interpret psychological tests forensically and the others are not.
By the way, you are correct about the least stigmatizing diagnosis. It is indeed Adjustment Disorder and it has several sub-categories.
The one thing I would have to add, is that mental health practitioners must make a correct and applicable diagnosis. On one hand they do not want to commit insurance fraud, and on the other hand they need to practice within the guidelines of their respective professional boards. They are kept on a tight leash and their licenses and livelihood are on the line. The declared purpose of these boards is to regulate the profession in order to protect the public from malpractice and harm, so here again we have two sides of a coin.
You mention the negative fallout of medical personnel in mental health treatment. The percentage of truly “crazy”, “off their rocker”, “insane”, potentially dangerous/homicidal people in mental health treatment is minute. Someone with a Major Depressive Disorder or Generalized Anxiety Disorder is not “crazy”, however these fairly benign diagnoses can and often are used against an individual, especially when it comes to government employment or, more painfully, in nasty divorce and custody cases.
Finally, it is a sad reality that a medical record is actually a legal document…