Let me start this by saying I am not innocent of this. I have done this too. I don't morally judge any therapist who does this out of principle. I'm not even particularly feeling all that judgy about therapists who do it out of the basic self-interest of trying to keep a roof over their head in a society that has been driving down therapist compensation for decades, to the point that therapists were making, in equivalent dollars, half of their incomes a couple decades previously.

But here's the thing.

There's actually problems – real, serious ethical problems, both for the individual and for society – with diagnosis fraud.

So if you are a therapist who decides to get sanctimonious and supercilious about how committing diagnosis fraud is some kind of ethical imperative to resist capitalism, the scam that is health insurance, and the injustice that is the deprivation of the general public of the mental health resources that should be theirs by committing insurance fraud, I'm coming for you.

And by "coming for you", I mean "I am going to write out at length how it's actually a complicated and nuanced topic to which that kind of belligerence and disrespect does no justice" and also "but not on Reddit, where I am not paid to diplomatically flame my colleagues, but on Mastodon, where I am."

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So what happened over on Reddit to provoke this was that a American student therapist on one of the therapist subs asked, quite reasonably, how, given that it's highly recommended for therapists to get their own therapy, they might access therapy for themselves, observing that they didn't actually have medical need for it, so it wouldn't be covered by their health insurance, and being a student they definitely couldn't afford to pay out of pocket.

(As a side note, their actual question has been answered, and they have been pointed in the direction of resources.)

One of the responses was, reasonably enough, and I paraphrase, "What are you talking about, insurance not paying because you don't have a diagnosable mental illness? I see people who don't have diagnosable mental illnesses all the time, and it's totally not a problem getting insurance to pay. I just put down Adjustment Disorder or something similar."

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Well, in reply to *that*, someone else said, just as reasonably, but maybe a hair intemperately, and this is an exact quote, "Let’s be realistic. Not everybody has a diagnosable mental illness, and not everybody is going to meet criteria for even adjustment disorder. And insurance is only going to pay for medically necessary treatment. We have to be ethical and honest with this. So someone who is in good mental health and who doesn’t feel they are dealing with any particular symptoms or issues that are affecting their quality of life or daily functioning is not going to be getting mental health treatment covered by insurance. It may be that you have never experienced this, but I absolutely have.

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(quote continued)

> I’ve had some clients in the past who were private pay specifically because they had no mental health diagnosis that is considered billable by insurance as a primary diagnosis, but who wanted to come to therapy anyway “because I just feel like it’s a good thing for people to have a therapist, y’know?”.

And then things started escalating.

It's kind of unusual for anyone in a therapist forum to take a stance in any way against diagnosis fraud, even the pragmatic observation that it might just not work, much less to suggest diagnosis is a matter about which it is incumbent upon us to be "ethical and honest". So I'm not surprised that there was some pushback.

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And as one might expect, that pushback came in three forms: it's not fraud; maybe it is fraud, but it's justified, and; therapists who are unwilling to commit fraud against insurance companies to get their clients access to care that they need are complicit with an unjust and oppressive system, and have a positive moral duty to commit such fraud. (Okay, maybe you didn't expect that last one.)

To summarize the first two positions, they are respectively, "If you can't find a legitimate diagnosable mental illness in the symptoms a patient reports, you're not trying hard enough. Do you even DSM bro?" and "The diagnosis requirements of insurance companies to get paid in the so-called US healthcare system are clinically absurd, what with their requiring diagnosis from first appointment, so we're already having to fudge it. What's the big deal?"

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There's merit to both of those positions, by the way. They're both quite legitimate.

The definition of Adjustment Disorder is such a low bar, it's *extremely* easy to justify. The adjustment disorders are basically, "patient is going through some stuff right now, or went through some stuff in the last 6 months, and they're having some psychological challenges with adjusting to that."

Now, that said, it does still *have criteria*. The patient has to have *symptoms*. Mental health symptoms. If you're just kind of stressed but mostly otherwise okay, you just want to talk to a therapist about it, teeeeeeeeeechnically you don't qualify as having an adjustment disorder.

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The second position is even stronger. The way insurance companies use diagnosis looks perfectly sensible at first glance, and then completely falls apart into bureaucratic absurdity when you try to implement it, making the system downright kafkaesque.

First of all it's predicated on our being able to diagnose a patient after an intake appointment. And here's where things get very, very touchy. There are many psychotherapists out there, and particularly many psychologists (both among those practicing as therapist and those practicing as assessors) who will absolutely insist that this is not a problem, *they* certainly can diagnose after a single 90 minute intake, and if *you* can't, it must be that you're just not a very good therapist – or maybe it's because your entire profession should never have been granted diagnosis authority.

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Understandably, this makes a lot of therapists chary of expressing their reservations about being expected to diagnose their patients on basically first contact, as a condition of being paid. Maybe, after all, it *is* just that they're, personally, not good enough at diagnosis; and if they don't believe that themselves, well, there'll be someone along shortly to say something that insinuates as much in a publicly humiliating way.

I, being pretty confident about the quality of therapist I am, and very confident in my ability to sling the DSM across the room and hit somebody on the head with it, clearly do not share this inhibition. It is really fucking stupid and no little bit outrageous that psychotherapist compensation is predicated on being able to diagnose at first meeting given that, pretty much definitionally, some of our patients are, to use the technical term, "unreliable historians".

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Like, right now, over on r/medicine, there is a discussion about "a while". You know:

"So how long have you had this symptom?"

"A while."

So here's the thing about the DSM: an awful lot of the things in it come with various sorts of *time limits*. Usually duration minimums. If the patient can't tell me how long they've been feeling depressed, I can't tell them whether or not it's a major depressive episode (two weeks minimum). The difference between mania and hypomania – which is also then definitionally the difference between Bipolar I and Bipolar II? Either 3 days or psychosis.

And that's even assuming the patient is willing to play ball. Not everybody in this profession is always seeing patients who either are seeking care willingly, or are willing to divulge their symptoms.

One of the weirdest intakes of my career was an ostensibly voluntary patient – not court ordered or anything – whose response to almost every question I asked was to snap, "That's private!"

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And to be clear I'm not even talking about the problem of *accurate* diagnosis – of trying to get the diagnosis right. I'm talking about the problem of getting enough information to make a diagnosis *at all*.

Because here's the thing: we're allowed to be wrong. It's okay for us to submit a diagnosis that is *mistaken*. It has to be: we're human. And so are our patients, on whom we are relying for all of the information we are getting about their conditions. And patients are mistaken, or forget, or just up and lie.

Which raises the question: if it's okay for us to submit, as a condition of getting paid, diagnoses that are wrong because we are mistaken, why would it be a big deal for us to submit diagnoses that are wrong, deliberately? What is the real difference between saying, "Eh, whatever, I guess maybe it's MDF? Can't really tell at this juncture, patient is being guarded, gotta code 'em with something" and "I think it's MDD, but maybe I'm wrong."

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And then there's the problem of what do you do with a patient that clearly has something very wrong with them, but it doesn't really meet DSM criteria? By which I mean, how do you deliver treatment to them and still get paid by an insurance company that has been given the privilege by our society of declining to pay for the treatment of anything that's not in the DSM?

The classic example of this, by the way, is a patient who *had* PTSD, but whose treatment thus far has been successful enough that *half* of their symptoms have remitted – and half have not. The patient is still symptomatic, and still has symptoms of PTSD, just not enough to meet the criteria of a PTSD diagnosis.

(This, I will point out, is a much more fundamental nosological idiocy of psychiatric diagnosis, the unpacking of which is beyond the scope of this present rant.)

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To be clear, approximately 100% of therapists, presented with a new patient on intake who previously did really good work with some other therapist on their PTSD and now no longer qualifies as having PTSD in a de novo diagnosis but is still symptomatic, will just diagnose the patient with PTSD and get on with their lives.

Even though it is technically incorrect – because of some fundamental faults in the underlying philosophy of psychiatric nosology embedded in the DSM – no therapist loses sleep over this.

And that's sort of the point of this position: everybody's lying all the damn time about diagnosis, because our diagnostic tools are stupid and broken and not even *ours*, but the insurance industry requires that we use them to get paid.

Hence the position, "Maybe it is fraud, but what's the big deal?"

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After all, it's not like the patients aren't presenting with legitimate conditions that need legitimate treatment, even if they don't neatly slot into DSM pigeonholes.

The fact that the DSM is a Procrustean epistemology* is a fact near and dear to many psychotherapists' hearts, not just as a conclusion independently come to, but one lovingly passed on from one generation to the next in our graduate training, wherein we are exhorted things like, "Treat the patient, not the condition!" My psychopathology professor liked to quip about the messiness and diversity of actual real life clinical presentations, "The problem with the patients is they haven't read the DSM." (He also liked to say, "We diagnose on Axis I, but we treat on Axis IV", but I'm not explaining that today.)

* Q.v. ibid "Procrustean Epistemologies" (2019 Sep 30) https://siderea.dreamwidth.org/1540620.html

It is a commonplace among psychotherapists that the DSM does not contain a lot of the things we deal with on the regular. Like, there's actually efforts afoot to introduce new diagnostic categories to the DSM. And there's other stuff, that's not even really on the official radar, that really really should be.

For instance, I once had a client who was a middle-aged gay man. He was from a Catholic family and grew up in a Catholic community. He was a kid in junior high when the AIDS crisis hit the newspaper headlines; he went through adolescence wondering if he was going to hell rather sooner than later, and whether his nearest and dearest would cheer him on his way, if they knew. Not an uncommon story. That shit leaves scars.

But he was never the victim of violence, or a witness to violence, and he never had imminent cause to fear for his life. He simply didn't meet the trauma requirement for a PTSD diagnosis.

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And more fundamentally, the way it affected him didn't map to PTSD either. The symptoms were different.

I don't think any of us have any question in our hearts that somebody who's suffering psychologically, both subjectively and in their ability to function in the world, because of going through something like that, needs therapy, and that that is a valid *medical* need.

And therefore his insurance *should* pay for it.

Frankly, most therapists would slap a PTSD diagnosis on the paperwork and call it a job well done, and not lose a moment's sleep over it.

It's only us tedious pedants who are ever like, "Well, *aKsHuLlY*...." and even we haven't got it in us to really object in practice.

So you see what we mean when one of us says we're all lying all the time.

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The argument that such a patient really does have a legitimate medical need, and if the DSM does not provide us with a diagnosis that describes that medical condition, and we have to use something in the DSM to get paid to treat the patient, without which the patient will not be treated (by us or anyone else), then we should *just lie about the diagnosis on the paperwork* to make treatment happen and for us to get paid is a pretty damn compelling one.

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You can even see, now, where someone might go from "sure maybe it's fraud, but what's the big deal?" right to "it's an ethical imperative to do so".

Which gets us back to the third position.

Someone replied to the above proposal that maybe we have an ethical responsibility not to lie about diagnosis to get paid:

> I’m not sure I agree with this take. It very much buys into the system that currently exists where insurance companies, who know next to nothing about mental health and psychological growth and change, have an inherent right to decide who and who does not receive treatment. [...]

To which the therapist they were responding replied:

> It buys into the system because that is the system we currently have. As with all other healthcare, people outside of the patient and their care team make decisions about what is covered. It sucks, and there’s constant work being done to try to shift it, but that is where we currently are.

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(quote continued)

> I refuse to falsify a diagnosis. If a client does not meet criteria for a diagnosis, it doesn’t mean that they don’t deserve therapy, but it does mean that their insurance won’t pay for it. It’s a shitty system, but I’m not going to fabricate diagnoses where there aren’t any and commit fraud in order to subvert it. I’m much more help to current and future clients while my license is intact.

Now, this therapist is being a bit intemperate in how their position is hardening with a kind of absolutism, and by implication is casting aspersion on pretty much the whole profession, so it's not really surprising it drew some heat.

Someone else entered the conversation:

> you refuse to 'falsify' a diagnosis? You recognize this is an illegitimate system, yet you refuse to resist it? It is a complete cop out to say "but this is the one we have" - I could draw historical analogies to that logic, but I'll leave it to your imagination.

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