The term mental illness is misleading. Although the so-called mental illnesses involve thought most center around emotions so mental is not quite the right word.

The causes and consequences are mostly social and interpersonal rather than physiological. So they are are not all illness in the usual meaning of the word

Diagnostic systems have drifted in and out of fashion over the centuries. They have limited usefulness for treatment and prognosis as they tend to fit in with political and commercial interests and cultural trends without sufficient independent research.

Anxiety and depression are diagnoses for persistent emotional states but persistent anger has not found a place. Aggression is not a diagnosis in most systems but depression is.

A diagnostic system is adopted once its diagnostic categories are officially recognized as billing items for government subsidies and health insurance. Professionals are then compelled to use it to be paid and to communicate. Its use is taught, examined and is required for professional registration. It does not have to be accurate or reliable and at the time of writing the DSM 5 is neither.

People are more complex than a diagnosis. There is less evidence for the effectiveness of treatments designed for diagnoses than treatments designed for individuals.

Diagnosis of a mental illness by symptoms looks at parts rather than at the whole person and creates expert tunnel vision while diverting attention from the overall picture and causes and complicating factors.

Many symptoms of mental illness are similar to those of infection, poisoning, nutritional deficiencies, traumatic experiences, metabolic disorders, hormonal dysfunction and prescribed and recreational psycho-active drugs so misdiagnosis is not uncommon.

People with sensory or other impairments are vulnerable to a misdiagnosis of mental illness. When my after hours crisis team went on strike our director stood in and on her first night certified and committed as schizophrenic a man who was deaf and dumb but otherwise healthy. This was quickly spotted the next day.

Not so fortunate was a lady who spent 20 years confined as a catatonic schizophrenic in a mental hospital. The longer she stayed the more she fitted in, confirmed the diagnosis and became a part of the scenery. She was discharged after a visitor started a conversation with her in her native tongue - the only language she knew. She came from a culture where it would not have been easy for her to look strangers in the eye.

These kind of errors are not made by beginners. They require training and experience.

A practical working understanding of people is necessary to interpret a diagnosis or any other sort of words that someone. And to understand others we need to understand ourselves. Grammar, vocabulary and instruction are not enough. They are just words. They can straight-jacket our thinking and cover our eyes.

Many Psychiatric diagnoses merely restate symptoms in the words of the assumptions and values of professionals that only they understand.

Being told who you are or you should be can be bewildering especially in an unfamiliar medical environment. An expert offering judgments is a first step towards someone making decisions for you. The diagnosis might not be correct or complete and its meaning or where the treatment that follows might lead is not often clear.

On the other hand a diagnosis can be reassuring for anyone who respects treating authorities particularly if it helps make sense of a distressing situation and hope for a remedy are offered.

A diagnosis can be self-fulfilling if it lowers a person's expectations of them self. Vague and poorly understood labels like depression, dementia, schizophrenia, cerebral palsy are used to interpret behaviour and unnecessarily lower or extinguish the expectations of others. Conversation is often restricted and opportunities are withheld even when there is no significant impairment or the person is capable of functioning above average in some areas of their life.

When I worked as a Social Worker on acute psychiatric admission wards I followed the principle as far as possible of helping patients work through how to do things rather than doing things for them. I found that dealing with everyday challenges helps people re-orientate and get on their way. Staff estimation of the capacity of patients was mostly lower than their potential.

I was assigned a patient with complex problems with their sickness benefits payments who was said to be a delusional, hallucinating and aggressive schizophrenic. We were able to talk together but I did not grasp what exactly the problem was or whether he could resolve it I did feet comfortable enough to try and walk him through dealing with the benefit agency and provide support if he ran into difficulty. The ward refused to let me take him to the agency offices to sort out his benefit payments. The director of the unit over-turned this decision provided I accepted full personal responsibility for the consequences if anything went wrong.

I drove the patient to the agency. He got out of the car, strode ahead of me through the entrance, went to the front of the queue, explained to the counter clerk that he didn’t want to hold me up. He detailed what he wanted and asked her firmly, clearly and politely to fix it. She was fully engaged and obviously happy to help and we left in a few minutes.

He managed this much better than I would have with all my years of experience. I was chastened and wiser. The instant we returned to the ward he resumed “hostile” and “delusional” interactions with staff.

stress disorders
Some stress disorders like PTSD are diagnosed in the DSM 5 according to causes rather than symptoms and so are more clearly defined and grounded in reality than most of the others.

Routine and standard tick-box diagnostic or risk assessments on admission or first encounter provide comprehensive information that everyone in a team can understand and rely on. However they are also dangerous when applied without careful consideration.

If an assessment takes a long time a client’s preoccupations and urgent needs are put on hold. Many of the questions that have to be answered are going to be irrelevant in any particular situation and some may be experienced as intrusive or offensive.

In crisis or emergency situations an assessment interrupts or denies emergency care and emotional first aid.

Formal assessment protocols introduce judgments, concepts and values that influence the logic, language and direction of therapy if they havn’t already derailed therapy by alienating a client by sidelining or overriding them.

Practitioners are forced to fall back on protocols at the expense of exercising clinical judgment. Clinical skill, judgment and engagement may diminish.

Many agencies mostly assess and refer. Some only assess and refer. Waiting lists compound their problems.

Most assessments could be part of treatment rather than postponing it. The most useful assessments are the moment to moment clinical judgments arising out of observation and intuition.

Staff satisfaction and productivity increases when they are actively involved instead of being at the bottom of a micromanaged hierarchy of protocols.

Once someone attracts a diagnosis of a mental illness it usually follows them around whether or not it still applies, particularly after a senior practitioner endorses it. Behaviour that would pass unnoticed in anyone else becomes a symptom.

Psychiatric diagnoses encourage professionals to ignore the person and treat their diagnosis instead. Dangerous medications can be prescribed without thinking beyond a diagnosis. Often prescribing and then not following up for weeks or months at a time.

So far diagnostic systems are not sound enough to rely on as a central focus of mental health which is mostly neither mental or medical in the first place.