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Dennis Palumbo

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Who (and What) Defines Normal?

Posted: 12/15/11 04:32 PM ET

In Fever Dream (Poisoned Pen Press) the second in my series of crime thrillers featuring psychologist and trauma expert Daniel Rinaldi, my hero makes use of psychiatric diagnoses when dealing with patients. Yet he also expresses misgivings, as he did in the first novel, about the legitimacy of these clinical terms.

And for good reason. As a licensed psychotherapist myself, I've long been concerned about both the validity and reliability of psychiatric diagnoses. For one thing, the list of these mental conditions is constantly being modified by a group of psychiatrists and psychologists, who meet on a regular basis to argue about what should and shouldn't be in the diagnostic manual used by most clinicians. Which means that the criteria for inclusion or exclusion is primarily determined by social trends, current clinical norms and a fair amount of politics. For example, at one time, homosexuality was considered a mental illness; now it isn't. Conversely, among the more dubious recent additions to the list is Self-Defeating Personality Disorder.

As I see it, there's another danger to an over-reliance on diagnostic categories: namely, the idea that every aspect of the human condition can be quantified, or reduced to an empirical stat. In other words, does the prevalence of assigning practically every single behavior a clinical diagnosis mean that there's no room for eccentricity, personal quirks, individuality? Are we just trying to define what "normal" is? And if so, are therapists really the best people to make such a determination?

Now I'm not suggesting that we do away with clinical diagnoses altogether. If nothing else, these categories provide a common language, enabling mental health professionals to communicate with each other. On the other hand, I believe all clinicians should be wary of seeing their patients only as a set of symptoms. They're not; they're individual human beings, each with a history and a particular (though not always healthy) way of coping with a hard, uncertain world. As are we all.

Moreover, especially in public and private psychiatric institutions, once patients have been tagged with a diagnostic label, it's almost impossible for them to wriggle out of it. It goes in the file. It defines them. It limits their view of themselves, and, all too often, whatever possibility for growth they're capable of.

And inevitably, over time, that file gets bigger and bigger. So that after enough years in the system, their particular diagnosis doesn't merely define them, or limit them. It's what they become.

Unless, like the character Noah Frye in Fever Dream, they happen to be friends with Dr. Daniel Rinaldi. Despite being labeled a paranoid schizophrenic, it's Noah's personality -- foul-mouthed, funny and disconcertingly intuitive -- that defines him, not his diagnosis.

Which is why Rinaldi would agree whole-heartedly with psychiatrist Allen Frances, who warns, "Knowing the diagnosis is not the same as knowing the patient."