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Complex Patients Not Defined by Rigid Categories

April 29, 2019

As a clinical psychology student, I enjoyed learning about ways to categorize personalities and psychopathology, but my discomfort with classification systems has grown through the years. In fact, I don’t think our field has produced a useful classification system. I love to make sense out of chaos, and after many years of clinical work, I think this effort, in itself, may be most important – more so than any particular model we have found for organizing the chaos of life.

Let me approach this from another angle. While categorization seems to be an irresistible impulse, we should never reduce people to a category. I am hardly the first person in our field to recognize this. We commonly hear today that it is wrong to say that a person is bipolar, and even in the medical world, the admonition can be heard to stop calling people diabetic. We are missing the complexities of that person when we reduce them to a category or a diagnosis or a label.

I think this is a good orientation in general, but it is particularly good in behavioral healthcare. We can monitor fasting glucose levels and hemoglobin A1c levels for a person with diabetes, but we only have the fantasy (or marketing hype) of a chemical imbalance for depression. There is no measurement for such an imbalance.

Yet the main point I want to make is not how empirically strong the case may be to place you in a category, but rather how damaging it may be to place you in a category based on any level of validation. While glucose levels are real and a “chemical imbalance” is not, we should avoid reducing people to a category or a construct or a measurement.

My best friend in high school

My arguments to this point are based on decades of work as a psychologist, and yet the real motivation for this article goes back to high school. My best friend was very smart and funny, and I never had a sense that there was anything wrong with him in our high school years. He was kind and understanding, and always a good friend. I sensed a change during our college days, when we attended different universities, but maintained contact. We lost contact for the next 10 years.

My best friend in high school visited me for an evening when I was in my early years as a practicing psychologist. He recalled the events of his young adult life which I had missed. He spoke both with a sense of bewilderment and humor, since he was always one of the funniest people I ever knew. Yet the story he told me spelled out a classic tale of someone struggling with a bipolar disorder that was ineffectively treated.

In the prior decade, he had experienced dramatic mood swings, alcoholism, diabetes, homelessness, and complete denunciation by his family. They fundamentally rejected him based on perceived moral failures. During his college years, I remember him reading me a letter from his father that essentially disowned him due to his transgressions. I vaguely remember the transgressions as poor grades, and while my friend pretended to be bemused, he was certainly devastated by the letter.

My friend was searching for answers on his own as best he could. He decided to go into the Navy because he knew that he needed routine and structure. He accepted a military ROTC scholarship midway through college so that his father would no longer have to pay for his education.

He navigated his young adult years poorly, both during and after the military, and he described many misadventures to me. I told him that he sounded like a person with bipolar disorder, who had deteriorated with antidepressants, then struggled with addiction and homelessness. It seems likely from later communication that he had also added diabetes to his list of disorders.

He sent me a letter a few years later thanking me for my assessment. He was stable and working as a bank teller. He was trying to live a healthy life, as best he could. Those stable years were short-lived. He died a few years later from causes that I don’t know for sure, but his obituary made reference to diabetes. We know that people with serious mental illnesses die, on average, 25 years earlier than the general population, and this is largely due to poorly treated chronic medical conditions like diabetes.

Diagnose, treat, and know your patients

My friend may have fit into a lot of terrible categories, but he was an amazing, complex person. I would never reduce him to the sum of his diagnoses. This is a natural reaction when reflecting on a person you care about, and yet a clinical mindset can push you to search for the right pigeonholes, followed by the right treatments.

This may be a bit more straightforward in physical medicine – you have an infection and so I am giving you this medication – but even then, you are prescribing poorly if you don’t know anything about the person you are handing that prescription. For example, If I know you are too poor to buy the medication or too mistrustful of doctors and medicine, then the job is not done once the prescription is provided.

This may sound like an argument for physicians to heed, while the empathic therapist has nothing to worry about. However, I have heard many caring therapists persistently push their CBT logic, their 12-step solution, their favored clinical technique as the all-important solution for their properly categorized client to follow.

I believe that the best clinicians among us accept the importance of diagnosis and treatment, with full knowledge that both may be quite inadequate currently, and yet always strive to know the complexity of the person they are trying to help. Clinical work in every area of specialty is messy. We rely on training and on our best judgment.

Rigid practices for complex people

I have already argued that personality and diagnostic categories fail to capture the complexity of real people, and yet our clinical models and practices also cannot encompass that complexity. We hear all too often today that a particular clinician or treatment program uses evidence-based practices. There are three significant problems with that assertion:

  1. We have no idea what really happens in a therapy session despite someone describing it as fitting a certain model.
  2. No standardized treatment model can handle the complexity of what real people present.
  3. Clinical improvement is actually more important than adherence to a set of clinical practices.

Let’s address how the evidence-based argument can fail us. A new medication is approved by the FDA when it has two studies showing statistically significant improvement over a placebo. Furthermore, the FDA will approve a medication even if, in addition to the two positive studies, there are multiple studies that fail to show superiority of the treatment over placebo.

This low bar has resulted in many anti-depressant medications being approved that appear, upon further analysis, no better than placebo. The focus of the additional analysis that reveals the error focuses on clinical results by prescriber. The healing impact of the prescriber seems to account for much of the variance in results. In other words, the evidence-based argument sounds very strong, but can crumble like a statistical house of cards.1

We should then move to the essence of the evidence-based argument concerning psychotherapy models. We frequently hear enthusiasm about the evidence for treatments ranging from cognitive-behavioral therapy (CBT) to eye movement desensitization and reprogramming (EMDR). Bruce Wampold has been analyzing the data for the superiority of different treatment models for decades, and his two editions of The Great Psychotherapy Debate (2001 and 2015) summarize those analyses. His findings are sobering. No treatment model is superior to any other. However, the good news is that psychotherapy is remarkably efficacious overall.

We should never stop searching for meaningful categories of human experience and effective models for treating human suffering. However, we should also never lose sight of the complexity of people nor the inherent simplicity of any categorical structure for theory or practice. We must try to get beyond complexity to find a path forward to greater clarity, but we should never forget that we are more than the summation of the categories we create.

Ed Jones, PhD

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

References

1 The Emperor’s New Drugs, Irving Kirsch, Basic Books, 2010.

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