The pressure for a clinician to accept insurance is strong in mental health, the primary impetus being client access to care. The presumption of compassion in mental health and the benefit of a steady referral source are additional factors. So when I began working in private practice as a resident in marriage and family therapy I assumed I would accept insurance payments. Why would I want to restrict client access to care? The reality I have discovered since that naive thought answers that question for me and raises many concerns about the implicit agreements both client and clinician enter in to by utilizing third party payments. One primary concern relates to the requirement for diagnosis.
Requirement for diagnosis
In order for me as a therapist to receive insurance payment for services rendered to a client, I must document with the insurance company the mental disorder for which the client is seeking treatment. If you struggle with lethargy, sadness, worry, anger, a troubling past, frustrating habits, sleep disturbance, or marital distress, I need to diagnose you as mentally disordered in order for insurance to pay for your therapy. If I work with a child in distress due to a divorce, a move, or troubles at school, I must diagnose a mental disorder. If a couple comes for help because they are fighting, having trouble connecting, or disagreeing about how to parent their kids, I must designate one or the other of them as the identified patient and document that person’s mental disorder.
As a systemic therapist who looks at symptoms in the context of relational dynamics and environmental factors, the concept of diagnosis is fundamentally problematic; diagnostic criteria is designed to pinpoint individual pathology. Yet my clinical approach assumes that the each person cannot be viewed in isolation, and my clinical focus requires I account for external influences on a client’s situation. To assign a diagnosis—even a diagnosis that can be justified based on documented criteria—in and of itself undermines the relational and contextual nature of systemic work.
Subjective nature of diagnosis
Mental health diagnosis is almost entirely subjective. Though there are standardized qualifying criteria for diagnosis, determining whether a client meets that criteria requires clinical judgement. Furthermore, very often the data informing that clinical judgement is the subjective experience of the client him- or herself. Decisions hinge on whether symptoms are present “nearly every day,” if they impair “important areas of functioning,” and if the client’s distress is “out of proportion the severity or intensity of the stressor.” Such criteria cannot be confirmed or denied with a throat swab or a blood test; they require case by case analysis based on subjective experience and individual interpretation, none of which can be fully verified by a clinician engaging a client in session, especially early on it the therapeutic relationship.
Limited scope of diagnosis
The diagnostic criteria for many mental health disorders requires a very specific timeline of symptoms. Adjustment disorders require symptom onset within three months of an identifiable stressor, but symptoms do not last beyond six months from the termination of the stressor “or its consequences.” Or its consequences? How does one determine the termination of the consequences of a stressor? If the stressor was a cross country move, one could argue that the consequences never terminate because such an event changes the course of a person’s life. What about a stressor such as a marriage, having a child, discovering a spouse’s affair, or losing a job? When, exactly, do the consequences of such major life events go away? Major Depressive Disorder requires that someone display a particular set of symptoms over the course of at least a two week period. Are we then to assume that if a client sees a therapist on day 17 of their symptoms that they’ve kept an accurate log of the symptoms since they first appeared? Perhaps the client is feeling better by day 19 or 20, but by then they have already been diagnosed. Do they still have MDD? It is ethical or wise to tell them that they do?
Impact of diagnosis on client perception and progress
When a client learns that they have been diagnosed with a mental health disorder, it impacts the way they think about themselves. It impacts the way they conceptualize their difficulties, their circumstances, their relationships. It may impact their motivation to engage fully in the therapeutic process. It may affect their level of hope or despair. Is it ethical, proper, and wise for a clinician to diagnose a client, not knowing if doing so will hinder or help?
These questions are particularly salient in the realm of mental health because mental disorders relate, by definition, to the state of the mind. The realm of thoughts, feelings, inclinations, assumptions, and perceptions is integral to therapeutic work. Clinicians need to seriously consider the implications of potential diagnosis on each client and be conservative in applying diagnostic labels. The requirement for an ethical approach to client care demands no less. The fact that diagnosis does have an impact—and that the specifics of the impact are unknown prior to its application—must not be dismissed. To put a name to the thing that’s wrong with you, whether that act brings comfort or distress, becomes a factor in client care.
The AAMFT Code of Ethics promotes the ethical concept of beneficence, which means that the clinician is to work on behalf of the best interests of the client. Is it in a client’s best interests to apply a diagnosis of a mental disorder when to do so may exacerbate their symptoms of distress? How many clients diagnosed with Generalized Anxiety Disorder come to see themselves as an anxious person rather than as a person who has experienced anxiety? Is the number high enough to make us consider whether it is useful to tell someone they have a diagnosable condition when the fact that they suffer is already apparent? The answer to such questions is complex, but is one that is wholly overruled when clinicians feel compelled to proceed with diagnosis because to neglect to do so means insurance won’t pay and clients may not receive care.
Stigma of diagnosis
The joke is that older clients don’t seek help because they perceive it as a sign of weakness, while younger clients brag to their friends about how often they see their therapist. Societal attitudes about mental and emotional health have changed, but individuals still must contend with what it means for them to attend to their personal needs. Requiring that a client agree to be diagnosed as mentally ill in order to seek professional help inherently exploits the person seeking help. It dangles the possibility of relief behind the acceptance of pathology. It has led to a societal trend toward identification with mental health problems. There are several ramifications of this, one of which is the medicalization of mental health and the overemphasis on pharmaceutical interventions. The more we label reasonable emotional responses to unreasonable societal norms as “mental illness,” the more we encourage people to think that mental health can be accomplished through simple fixes like pills and and mindfulness, as though the core human needs for connection, purpose, and identity are too laborious to attend to.
The truth is that many people experiencing depressive or anxious symptoms in today’s stressful society have good reason to feel the way they do. They are not disordered; they are sensitive to the disordered state of the world around them, and need help in finding solid ground upon which to stand. It is a fundamental disservice to suggest the person within the chaos is the one with the problem, rather than the one responding reasonably to problems all around them.
Individual nature of diagnosis
As I mentioned briefly above, diagnostic criteria, as currently outlined and standardized in the DSM, are created to explain individual pathology. As a relational therapist, the focus of my work is not individual psychology, but intrapsychic dynamics—relationships. When I work with a husband and wife, my client is the marriage itself—the unique one that results when two individuals engage with, around, and in relation to the other. DSM diagnostic criteria are not designed to attend to this distinction. This means that even when the presenting problem is a relational issue, one partner needs to be designated as the identified patient (IP) so a diagnostic code can be applied for insurance coverage. This issue is an ethical tightrope for relational therapists who are trained to take into account context and relational dynamics in therapeutic assessment and treatment. One partner may display symptoms of depression or anxiety. But if these symptoms are on display in the context of a distressed relationship, is it reasonable to diagnose someone with a depressive disorder?
There is the added responsibility for a clinician not to commit insurance fraud—i.e. to make sure that they don’t apply a diagnosis that is not entirely applicable simply to garner third party payment. That’s a tricky spot for a clinician facing a potential client in deep distress due to an emotionally abusive partner. Does it makes sense for a victim of domestic abuse to show depressive symptoms? It sure does. Do depressive symptoms mean a person is mentally disordered? No. But if insurance only pays when a person has a diagnosis, clinicians bear the pressure to diagnose to facilitate the flow of funds.
This situation raises hairy questions about who deserves professional help. Not everyone who feels sad suffers from depression; not everyone who feels anxious has generalized anxiety; not everyone who needs a listening ear is mentally ill. Is it ethical to withhold treatment from a client because they are not disturbed enough to fit the diagnostic criteria? Plenty of people need help getting their lives in order but don’t meet the clinical criteria for mental disorders—does it follow that they ought not to receive treatment?
Beyond diagnosis: issues of training, expertise, and authority
A diagnosis is only as reliable as the judgement of the clinician who documents it, which brings to the fore issues of training and authority. The question of who gets to decide what is “disordered” may seem a philosophical undertaking, but is one with practical implications within the clinical mental health system. Also at issue is the training required for a clinician to qualify as a diagnostician. Are masters level clinicians—which is a great many clinicians offering mental health services at this time—sufficiently trained to diagnose serious mental disorders? In recent years this issue has shown its relevance with the rise in diagnosis of gender dysphoria and the use of clinical diagnosis as a basis for justifying medical interventions such as hormone treatment or even surgery. Masters level mental health professionals are not medical practitioners and should not be in the position of endorsing or recommending medical interventions on behalf of clients reporting emotional distress. The blurring of these lines endangers clients and conflates emotional well being with healthy biological functioning, putting clients in grave danger and clinicians in an ethically untenable position.
I am aware that insurance enables many to seek important therapeutic services, and I sympathize with those who otherwise do not have the means to pursue professional support. There is much room for faith-based and community services to seek creative ways to address this dilemma, and many already are. Society plays a role as well, in creating a culture that promotes mental health not only as a political talking point but in the practical ways that we live and relate. However, a scarcity of perfect solutions does not justify the proliferation of harmful ones. In our attempts to care for the needs of hurting individuals and families, we must be diligent to safeguard against creating new hurts with the solutions we devise. Assuming disorder in every person who walks through the therapist’s door is a grave misuse of clinical discretion.
