Diagnosing mental health issues is a complex area full of contradictions. The reduction of services for those in poverty has led to a growing acceptance of mental health diagnosis of all ages among the poor. In the previous chapter, we saw that those receiving the labels are aware of the negative outcomes that arise from labeling. Viewed from the perspective that this is a
fundamental example of institutional and structural factors increasing the prevalence of stigma, a situation has been created whereby the necessity of a disability benefit-related diagnosis is a means to counter the harsh welfare reform policies which have been described by Hansen et al. as the “pathologization of poverty” (2014:2).
A diagnosis (label) can mean many things for those involved in the criminal justice system, including the difference between remaining in jail and being granted bond. A diagnosis may help an inmate qualify for a re-entry plan that includes housing, court-ordered substance abuse programs, and mental health treatment and support. It can mean access to federal educational resources for children, the kind of medication that is being credited with giving
privileged kids an edge. Thus, underprivileged kids gain the ability to concentrate and not get into trouble resulting in expulsion or worse, juvenile detention.
The ongoing criminalization of poverty mirrors the intense pathologizing of African Americans. The increase in mental health diagnosis generally has meant an increase in the number of people taking prescribed psychotropic medications. The removal of alcoholism and substance abuse from qualifying criteria meant a rise in a dependency diagnosis coupled with psychiatric diagnosis. This dual diagnosis is subject to harsher political policies regarding any type of assistance. A mental illness or chronic pain diagnosis remain the only options left to qualify for social security benefits that can be relied upon for relative stability (Hansen et al. 2014).
This qualification has become a matter of survival for some, according to Marcia Angell the former editor of the New England Journal of Medicine, “as low-income families experience growing economic hardship, many are finding that applying for Supplemental Security Income (SSI) payments on the basis of mental disability is the only way to survive” (Angell 2011; Hansen et al. 2014:77). Furthermore, Angell questions, how have “structural stressors and bureaucratic pressures” to obtain a psychiatric diagnosis shaped and defined their personal identities? (Angell 2011; Hansen et al. 2014:77).
Like psychiatry generally, the diagnostic protocols for childhood mental health issues have been racialized and weaponized in ways that reinforce the process of pathologizing people, mainly poor minorities, who increasingly support a diagnosis of ADHD for their school age children. The benefits are considerable, as one attorney points out:
Well, there's the federal stuff, like there's IDEA (Individuals with Disabilities Education Act) and IEPs (Individual Education Plans). So it's kind of like a—it's one of those things. Because sometimes, if I were a parent of one of these
could get some extra services through the 504 plan (1973 or IEP or
something…But yeah, it's kind of messed up because it's really—you know, like, if they'd be doing those jobs and providing those services in the first place, you wouldn't need to have an ADHD diagnosis to get a break every two hours, you know?
The 504 was intended for children with a wide range of disabilities who are able to participate and succeed in a general education classroom. An IEP, on the other hand, was offered for children with a specific diagnosis who require special education services.
Labeling, of course, can lead to malingering accusations. Another attorney Max describes the phenomena of diagnosis acceptance, even when the label has the potential to be far more crippling. An example is a conduct and oppositional disorder diagnosis. When asked who was diagnosing these kids, Max, a juvenile defender, explained, “well, sometimes. Sometimes a state doctor. But a lot of times, it's the children's own—Yes. Their psychiatrists. And you know it's hard, because I think sometimes parents and teachers see those as a way to get help.”
Research supports that more resources will be directed to the child when a diagnosis/label has greater potential for danger (Atkins-Loria et al. 2015). So essentially, application of a
severely stigmatizing label becomes necessary for adequate access to educational resources, but outside of the child’s immediate environment, the diagnosis basically ensure his/her exclusion from mainstream opportunities of the greater society. When faced with the absolute lack of alternatives, this strategy becomes the practical choice.
The diagnosis of younger children with mental illnesses is often seen as a way to circumvent the Personal Responsibility and Work Opportunity Act (PRWORA) and access services for families exposed to unmitigated poverty. Add the defunding of public education in Georgia and elsewhere, disaster is faced by those who are struggling, most notably single mothers, but two- parent working families as well. Well-intentioned clinicians may exacerbate
the situation by connecting diagnostic labeling and the signification of urgency, using more severe diagnostic labels in the attempt to access scarce resources for treatment (Atkins-Loria et al. 2015).
They are desperate. They are desperate. And if you put somebody in a situation where they have to make some decisions on what needs to be done in order for X, Y, Z to be taken care of, they're going to do that. They're going to figure out a way to do it. And if me getting my child a diagnosis, getting my child an IEP, can get my child disability, can get some money in this house, so that we can eat, that's what I've got to do. And they'll do it. And what pisses me off about—I don't know if I'm supposed to say "pisses me off" (LaToya).
SSI supplemental income thus begins as a mechanism to secure services for a child or to provide at least a modicum of stability for the most disadvantaged. Another intention may be to gain educational attention and facilitate a more conducive learning environment. But while these programs may initially meet needs and improve situations, they also provide the justification for harsher societal treatment and greater negative impacts.
This process is the same that impacts adults, the hope of services with a diagnostic label to qualify specifically for Social Security Benefits or (SSI). Without SSI, little chance exists for securing housing or any type of medical services, mental health or otherwise.
The over-diagnosis of African Americans in childhood, adolescence, and adulthood contributes greatly to the multidimensional stigmatization of this population, further
compromising life chances and outcomes. Therefore, as noted previously, to study individual stigma neglects the identification of the ways in which multiple stigmas, and their social categories mutually construct and reinforce each other (Cole 2009; Collins 1990; Collins and Bilge 2016).
In the forensic context, the requirement of a label, i.e. diagnosis is mandated to access treatment:
When someone comes into jail and they're psychotic and they're trying to get them some help, they'll give them medication, and they'll put a diagnosis of, like, "psych, NOS," not otherwise specified. That'll give the doctor enough to be able to start treating the person without having to call around and confirm the
medication before they give them treatment…When I want to put them in a mental health program, "psych, NOS," won't get you in. (Tequila)
Individuals must have a diagnosis to qualify for the option of outpatient psychiatric services as an alternative to incarceration (West et al. 2015).
Having a diagnostic label also means accessing benefits in and out of the criminal justice system. Outside of the criminal justice system, labeling can lead to education benefits and medical coverage, and within the criminal justice system, to housing and re-entry assistance. As noted earlier, much of this access is Judge-dependent, and attorneys may investigate mental health status to provide the best legal representation possible. Unfortunately, many labels have the opposite effect of producing more, rather than less punitive outcomes (Mizock and Harkins 2011; Washburn et al. 2008).
Differences in perception with respect to different mental illness labels are not limited to judges in criminal legal systems. Studies have found that other professionals, including clinicians and probation service workers, also have strong biases related to specific mental illness
diagnoses and consider future “dangerousness” on this basis and not necessarily on actual behaviors (Rockett, Murrie, and Boccaccini 2007).