We tend to talk about diagnosis as if it is something that happens in a single moment of time. The documentary about the DSM presents a psychiatrist claiming that doctors make decisions about diagnosis within two minutes of meeting someone. But can that possibly be true? In two minutes, can you get the full sense of a person and how and what they are experiencing fits into the larger picture of their life? In my experience, the answer is no. I've never seen a psychiatrist or anyone else, make a diagnostic decision in two minutes. It actually takes a lot of time and the collaboration of many people, including people who know that person best, to make a decision about a diagnosis. That's why I think diagnosis is more appropriately understood as the outcome of a series of social events. And that's what we'll be discussing in this section. I assigned the Kelm paper for today's lecture, because it gives a great example of how a series of social events, and negotiations are necessary before a decision can be made about how to describe and deal with disruptive or disturbed individuals. Kelm's paper is historical and focuses on the comittal of woman to asylums in the early 20th century. But her observations transfer easily to a discussion of diagnosis in the 21st century. In the same way that she suggest psychiatrists did not work in isolation to designate someone is appropriate for commital, in the contemporary context, psychiatrists did not work in isolation to designate someone as appropriate for diagnosis and treatment. The definition of diagnosis obscures its social context. The idea of an examination reinforces our image of diagnosis as a moment in time. A specific act executed by an individual in a specific moment. But truthfully, diagnosis is not an isolated event, it is the outcome of a series of events that we often discuss using the term pathways to care. We have an idea of a straightforward path or path, sorry, we have an idea of a straightforward pathway from problem identification to problem-solving. It seems that somewhere here, we identify our problem and then we found, we travel a path that's going to get us to a diagnosis and some kind of medical solution. But the more common reality, reality is that there are many events that happen before a problem is identified. And many events that happen before a medical solution to that problem is activated. And, in fact, the course, in the course of all those social events, the pathway between problem identification and problem-solving can be anything but straightforward. People can be send off in other directions, some of which may lead them to gain some kind of help that make sense for them and some of which may send them in a direction that is not helpful, helpful at all. An example of a helpful pathway could be a series of social events that take someone to spiritual help and through that spiritual help, they find relief in a solution to their distress. An example of an unhelpful pathway could be a series of social events that take someone to the criminal justice system. They don't find relief. They gain a criminal record. And they do not get appropriate, get an appropriate solution to the problem that set them on that pathway. Bearing in mind that a psychiatrist in mental health care is only one possible way of dealing with mental distress, it is clear that there are many social events and interactions that have to happen before someone comes to the attention of a psychiatrist and the potential for receiving a psychiatric diagnosis. And people like the ones you see listed here are the people who have those interactions and participate in those social events. And they make the decisions that will influence whether the pathway ends with psychiatric diagnosis or ends somewhere else. Psychiatrists can operate in the ways that we as a society allow them to operate. Therefore, diagnosis depends on a series of social agreements between us and them. There are some agreements that must be in place about the scope of psychiatric diagnosis. Psychiatric diagnosis can only be imposed in the areas where we allow them to be imposed. So, so there is a process of determining where psychiatric knowledge matters. For example, we have decided that psychiatric knowledge matters when we are trying to understand what happens to soldiers when they come back from war. But have we decided that psychiatric knowledge matters when we try to understand what people go through after the death of a loved one? This kind of deliberation by family members, family doctors, school officials, neighbors, and all kinds of other people determines what type of problems get taken to psychiatric, psychiatrists for the definition of a diagnosis. Part of what goes into those deliberations is some kind of evaluation of whether psychiatrist or diagnosis has anything to offer in the situation. Is this something that they actually know? Are they experts in this area? Is there something that they can do to help? Although we often think of psychiatrists as an incredibly empowered group, and there is something to that, it's also true that psychiatrists work within the boundaries of public acceptability. If we don't think that they have something to offer in dealing with a particular problem, then we simply will not involve them in our search to find solutions. There are a set of agreements about who comes under the scrutiny of psychiatrists and psychiatric diagnosis. There are certain groups that are more likely to come under psychiatric surveillance and judgment than others. The Kelm paper reminds us that women have always being considered as suitable subjects of psychiatric diagnosis. When we consider that this so-called proclivity to insanity, we're so often tied to a belief that the foundation of mental disorder was in their reproductive functions, we have to ask ourselves, why was this a psychiatric problem? If the problem is in the reproductive system, then why isn't it a gynecological problem? Why aren't they being sent to people with ex, with expertise in the reproductive system? And if we think about the women who were picked up for prostitution or sexually inappropriate behavior, did they have mental problems or did they maybe have economic problems? Or maybe spiritual problems? Why was this dealt with psychiatrists and not family services? Now if we move into contemporary times, women are still treated as though they have a proclivity to insanity. There is a wide-spread belief that because of our hormones, we become mentally unstable at various times in the month or various times in our life cycles. But who says this is a mental disorder? If hormones are causing instability, then why isn't it the territory of endocrinology? How did psychiatrists get involved? Well, there's been a social agreement that says, psychiatrists can, can involve themselves in this situation. And in fact, that agrement has been in place for a very long time. Just so you know, there has been recent research that suggests that there is no connection between women's hormonal cycles and mental instability. There's a link to an article talking about this work, by Dr. Gillian Einstein at the University of Toronto in the Resources Section. When I read about it, I sent her a congratulatory email. Now, they have to find some other reason to keep us away from the important jobs. Good work, Dr. Einstein. There are a set of social agreements about the social function of diagnosis. Kelm's paper references references the application of commital as a way of dealing with women who were socially redundant. Women who were abandoned, who weren't or [LAUGH] sorry, women who were abandoned or who weren't somehow making themselves socially useful, were more vulnerable to committal at that time. It is still true to some extent that you are more vulnerable to diagnosis and treatment, especially involuntary diagnosis and treatment, if you are not performing what is considered a useful social role. If you're not in a useful social role, it may mean that there is no one there to advocate on your behalf and assert that you are needed where you are. And if you're not in a useful social role or if you are in a disruptive social role, psychiatrists can be called in to pronounce a diagnosis that removes you from wherever you are causing inconvenience and disruption. But unless, we, as family members and community members decide that this is something we want them to do, then they never have the opportunity. Another consideration is that there must be set of social agreement about whether diagnosis or treatment is an appropriate option. The agreements between institutions about whose responsibility is to care for a person who is dealing with a potential mental disorder. In Kelm's paper, we often saw that family resources would become overwhelmed, and that is why women would be committed. But there was clear class differences there. People with more resources could avoid committal because they could afford other options. They could take their loved ones on a voyage or pay for increased care at home or surveillance at home. They could offer private care instead of using the public system. It was only people with no other options that ended up in the asylums. And even for these richer families, the asylum was a place that they used when they could no longer make use of other options. The, the decision to present someone for psychiatric diagnosis can represent the determination that they no longer, that they can no longer be supported or contained within another institutional system. When a soldier's distress cannot be contained within the military support system, the psychiatric system and diagnosis steps in. When a child's behavior can no longer be contained or managed within the school system, sometimes the psychiatric system and a diagnosis steps in. One notable exception to the practice of the mental healthcare system picking up where other systems get overwhelmed is the criminal justice system. In this context, it works the other way around. An overwhelmed mental healthcare system is often blamed for the presence of people with mental illnesses in the criminal justice system. Specifically, in the jails and prisons of our nations. Although there are many jurisdictions where they're developing programs so that people with mental disorders that are not managed adequately in the criminal justice system can make use of more appropriate options in the mental healthcare system, there's much debate about which options need to be available and how they can be used most effectively. We spent time on the social determinants of health last lecture and I want to suggest to you that social determinants also play a role in diagnosis. Social determinants have an affect on health and therefore, they play a role in vulnerability to illness. I would suggest that social determinants also play a role in the likelihood of receiving a psychiatric diagnosis. This can cut two ways. People who are privileged have more access to healthcare and more access to specialist healthcare, so they can seek out psychiatric expertise more easily and on their own terms. They can receive psychiatric and diagnosis, sorry, psychiatric diagnosis and treatment, if desired. At the other end of the socioeconomic and social status continuum, people who are in situations of poverty, people who are socially excluded, and people who don't have personal or social resources to seek options aside from mental healthcare, are more likely to receive a psychiatric diagnosis. In addition, our most socially marginalized population are under more scrutiny by police, child welfare, and other official systems that can put them in position of receiving a psychiatric diagnosis involuntarily. I've done some writing about how diagnosis can become a prescribed social role, specifically in the context of a diagnosis of schizophrenia. Schizophrenia has a unique status in mental health, I believe, and that receiving it as a diagnosis can lead to people seeing their other social roles eclipsed. This is indicated by the unfortunate tendency that some people have had to refer to people as schizophrenics rather than people who have a diagnosis of schizophrenia. When somebody has a diagnosis of another disease like cancer or heart disease, you don't see the same process happening in which their identity is then taken over by the diagnosis. When someone receives a diagnosis, whether it's a diagnosis of a mental illness or a physical illness, they must find a way to integrate it into their personal biography. It becomes part of a story that explains their past, their present, and the potential for the future. For some diagnosis, the effects are minimal. A diagnosis of, let's say, eczema, is not going to shift someone's biography very much. For mental health diagnosis, it's different. And it's different because of the social context in which people must negotiate their post-diagnosis identities. The persistance of stigma against mental illness is a major determinant and a major impediment in the negotiation of identity after the diagnosis of a mental illness. I've already alluded to the fact that diagnosis can be an important part of social recognition for experiences of distress and suffering. In the example of post-traumatic stress disorder, establishing a diagnosis legitimizes the need for support of soldiers attempting to recover from traumatizing war experiences. The integration of diagnosis into a personal biography can provide information that was not previously available about the past, the present, and the future. And for many people, that is a tremendous relief. So, diagnosis can be the answer to a very distressing set of questions that people carry around with them for a very long time. So, you can see that there's a lot more to diagnosis than just checking off symptoms or putting people into diagnostic boxes. Diagnosis is something that happens in a social context. And, on the one hand, you can see it as a potential mechanism of social exclusion, oppression and social control. On the other hand, you can also see it as a mechanism for determining when help is needed and what kind of help people should get. I would also want to leave you with the idea that this is a social process with multiple participants including the person with a potential illness. There are opportunities for that person to participate in the determination of what's going on with them and to also exercise their self-determination in the process of diagnosis. As people who care about somebody who may have a potential mental disorder, you may also be a participant in the diagnostic process and you also have the opportunity to advocate for your loved one who may be receiving a diagnosis of a mental disorder. So, we'll leave it at that for now. And in our next section, what we're going to talk about is a situation in which we see how the social context has had a profound influence on the establishment of a diagnosis and also on the options that people have for treatment.
