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Diagnostiske virkeligheter – Speilvendt
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Diagnostiske virkeligheter


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Diagnoser kan være nyttige verktøy, så lenge man er klar over hva en diagnose sier noe om og hvilke begrensninger den har.

 

Illustrasjon: Sara Risvaag
Illustrasjon: Sara Risvaag

Diagnoser og diagnostiske vurderinger hører til hverdagen for alle psykologer innenfor psykisk helsevern. Vi er i dag pålagt av helsemyndighetene å stille diagnose på alle dem som skal behandles. Kravet er delvis innført av pasientadministrative hensyn, delvis på bakgrunn av trygdeadministrative forhold.

Imidlertid har diagnostisering vært en omstridt praksis i vårt felt, der det i ytterpunktene er blitt hevdet henholdsvis at diagnosene i seg selv er skadelige og ødeleggende for den enkelte pasient, eller at de i motsatt ytterlighet blir sett på som helt nødvendige for å sikre rett behandling.

I de fleste polariserte debatter av denne typen ligger sannheten et sted midt i mellom. Imidlertid er det en del aspekter ved diagnostikk og diagnoser i psykisk helsevern som ofte overses både av pasienter og behandlere, aspekter det er viktig å være klar over for den enkelte praktiker.

Særlig vesentlig er grunnleggende misforståelser omkring hva psykiatriske diagnoser er og hva de sier noe om, slike misforståelser kan ha betydelige negative konsekvenser for den enkelte pasient.

 

Øyeblikksbilde

Innen helsefagene er diagnostikk definert som identifikasjon og klassifisering av sykdommer, lidelser og forstyrrelser ut fra deres observerbare symptomer. I en del disipliner innebærer dette også ofte identifikasjon av årsakene til lidelsen, slik vi kan se det for eksempel i kreftdiagnostikk.

I andre disipliner, slik som klinisk psykologi og psykiatri, har ikke diagnosen etiologisk innhold eller verdi. Den identifiserer ikke årsakene til en forstyrrelse, men begrenser seg til klassifisering av prototypiske mønster av samvarierende symptomer. Det vil med andre ord si at diagnosen kun utgjør en beskrivelse av pasientens observerbare symptomer, og ikke har noen forklaringsverdi i seg selv.

Nettopp dette elementet utgjør en risiko for feiltolkning av diagnoser i psykisk helsevern, både for pasientene som får dem og behandlerne som stiller dem.

Siden diagnosen ikke har noen forklaringsverdi i seg selv, forblir den i realiteten et øyeblikksbilde av den enkelte pasients tilstand. Likevel kan det faktum at diagnosen har en presis operasjonell definisjon, at den er listet opp i et offisielt, vitenskapelig basert nomenklatur, og at den i andre disipliner som regel befatter seg med årsakene bak et gitt tilstandsbilde, invitere til at den oppfattes som en kausal faktor, en forklaring på tilstanden pasienten er i.

 

«I disipliner som klinisk psykologi og psykiatri utgjør diagnosen kun en beskrivelse av pasientens observerbare symptomer, og har ikke noen forklaringsverdi i seg selv.»

 

Forklaringsfiksjoner

Med andre ord vil da både pasient og terapeut kunne begynne å behandle diagnosen som en årsak til at pasienten handler, tenker og føler som hun gjør. Terapeut og pasient har da etablert det vi kunne kalle en forklaringsfiksjon, de har funnet opp en årsak til pasientens problemer som faktisk ikke eksisterer.

Falske forklaringer er selvfølgelig ikke i seg selv farlige, etableringen av forklaringsfiksjoner finner vi på utallige områder uten at de skader så mye. Imidlertid kan slike forklaringsfiksjoner knyttet til psykiske helse gi grobunn for uheldige måter å se og forstå seg selv og andre på og gi negative ringvirkninger for den enkelte.

Et eksempel på dette, er når en pasient begynner å forklare sin egen ustabile oppførsel som forårsaket av en emosjonelt ustabil personlighetsforstyrrelse. En annen vil kunne hevde at hans rastløshet og uro er forårsaket av ADHD. Sannheten er selvfølgelig den motsatte, at diagnosene er stilt på bakgrunn av og dermed forklares av den ustabile eller urolige oppførselen.

I seg selv forklarer imidlertid ikke diagnosene eller tilstandene noe som helst. Ved å lage en forklaringsfiksjon der diagnosen forstås som årsaken forvitrer altfor ofte ideen om det personlige ansvaret for og bidraget til oppførselen.

Diagnosen kan da ta form av en unnskyldning for at en gitt problematferd utøves: ”Det er tilstanden som lager problemet, ikke mine reaksjoner og valg.” Denne posisjonen tillater også den enkelte å forholde seg maktesløs overfor problemet: ”Jeg må bli frisk før jeg kan endre meg.”

Andre konsekvenser kan være at mer reelle forklaringer og dermed også mulige løsninger på problemene ikke blir lett etter og undersøkt, eller at problemene blir akseptert som uunngåelige. I blant kan også andre problemer enn dem som spesifikt inngår i diagnosekriteriene bli fiktivt forklart ved hjelp av diagnosen. Dermed kan en med ADHD- diagnose forklare eget rusmisbruk eller kriminell atferd med henvisning til diagnosen.

Når andre benytter slike forklaringsfiksjoner overfor den diagnostiserte, kan det også være uheldig. Hvis vi holder oss til ADHD som eksempel, vil en lærer eller forelders bruk av en slik forklaringsfiksjon kunne sementere en holdning til et barn med konsentrasjonsvansker som identifiserer diagnosen, og dermed barnet, som det primære problemet. Man velger dermed også implisitt å definere de omgivelser barnet samhandler med som i denne sammenhengen ikke-problematiske. Dermed stilles det eksempelvis ikke spørsmål ved om skolens krav til at små barn må sitte stille i, for noen, for lange perioder av gangen, utgjør en lite hensiktsmessig tilrettelagt opplæringsordning for enkelte, eller ved om foreldrenes krangling og uforutsigbare måter å sanksjonere på kan bidra til barnets vansker.

 

«Det er viktig for den som stiller diagnosen, og den som får den, å ha et klart forhold til hva diagnosen er og hva den ikke er.»

 

Diagnoser på godt og vondt

Nå er selvfølgelig ikke diagnosen alltid et onde. For noen pasienter i psykisk helsevern kan en diagnose utgjøre en lenge etterlengtet bekreftelse på at de har en reell plage. En ytre stadfesting på at det er rimelig grunn til at en ikke takler livets utfordringer så godt som ønskelig.

I en del tilfeller kan en diagnose utløse trygdeytelser som for enkelte kan være nødvendig for et anstendig liv. I blant vil også diagnosen kunne gi en nyttig pekepinn om hvilken type behandling som vil være egnet. I tillegg letter diagnostikken kommunikasjonen mellom helsepersonell og legger til rette for systematisk forskning som ikke er mulig uten slik klassifisering.

Imidlertid er det viktig for den som stiller diagnosen, og den som får den, å ha et klart forhold til hva diagnosen er og hva den ikke er.

Når diagnosen feilaktig trekkes inn som kausalfaktor for de problemene den egentlig bare er en beskrivelse av, kan den ofte lede til devaluerende stigmatisering av den diagnostiserte, tap av ansvarsfølelse for egne handlinger, avmakt overfor egen situasjon og blindhet for mulige løsninger på det faktiske problemet.


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