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I have had such bad experiences with psychiatrists and psychologists being contrarian and demanding filling in generic tests leading to no working solutions (aka you're depressed here's a prescription for an SSRI. Still depressed? We'll up the dose).

My current psychiatrist figured out my main issues after talking to me for 15 minutes. Sent me off to a psychologist back up his assumptions before prescribing anything. Recommended therapists who specialize in the area I needed support in.

The psychologist I went to was great as well (after seeing one that was a terrible). She did a lot of testing (three sittings lasting around two hours) but said the tests were really just to rule out other things. The important part were the conversations.

My life improved tremendously after that.

My ex was on antidepressants which had a huge impact on her life. If she missed her meds or (god forbid) was late on her prescription, it was terrifyingly bad.

Orthogonally, she also had sensitivities to light and epileptic symptoms. She told the doctor this, and the doctor doubled her dose of antidepressants. Just one of many, many stories. I've come to consider the higher-level of medicine quite scientific, but the on-the-ground doctors as unscientific. They mostly don't have time or enough feedback to make good decisions in most cases I've seen. That's a profession that shouldn't work on faith.

How does one find a good psychiatrist/psychologist? My experiences have ranged from "very bad" to "OK at best" and I think finding someone a bit more invested into figuring things out might help a lot.

It is definitely not easy. Specially because you cannot "see" their past work or results except from someone telling you about it. I practice psychoanalysis (lacanian if you gotta give it a name) and really liked your wording: "finding someone a bit more invested into figuring things out". Feel free to hit me up (gerhn cupipo com) if interested in starting an analysis (or anyone reading this). We can have up to 4 sessions which you won't have to pay for unless you think we are up to something and decide to continue.

And how do you, as a first-time patient, assess the quality of psych* you are seeing?

One thing you can do to become a tiny(!) bit more informed is take some psych classes yourself. PSYC1030 is a popular (free) one and gives you the first glimpses into social, clinical and developmental psychology. It doesn’t give you any particular qualification but it does at least demystify some of the processes. That makes it easier to recognise the hucksters

If you’re focused in particular on getting a diagnosis for something, I’d also recommend reading relevant parts of “Psychopathology and Mental Distress” which is a tomb of a book that aggregates both DSM and ICD diagnostic criteria, but also provides current meta surveys on relevant research, from multiple perspectives. It’s reasonably easy to read but definitely better after getting the basic thinking tools from a proper course on clinical psych.

This. Studying your own psyche from an (as possible) outside perspective can help enlighten you on the who, why and especially -- when. Uncovering latent trauma isn't fun but it is important.

You enter with an open mind, try their process for a bit, and see if you feel better. You can even have conversations with them about the timeline they expect for improvement or what they think can actually be achieved -- "goals of care" isn't just for terminal patients. You can be aware of red-flags, if something feels wrong or misaligned you can discuss it or try someone else, but at the end of the day, you can't know for sure if a modality or a relationship will work for you if you don't try it, and give it some time.

I mean, it's the same question as "How do I assess whether my plumber or mechanic or electrician knows what they're doing." Sure, sometimes there's an easy, obvious difference, but you can't really know for sure whether or not your electrician is grounding your entire house to your hot-water pipes unless you have enough skill and expertise not to need one. After a point, working with any professional requires a weird blend of faith and of assessment you don't have the expertise to actually do.

I found mine by word of mouth. Other than that, the only way I can think of is trying till you find a good one.

The DSM is not designed as a list of questions to use to ask patients, it’s designed to describe disorders.

Asking you “do you have trouble concentrating?” is lazy (at least, on its own. Asking a patient to perform a self-assessment is not bad medicine necessarily). A doctor should also be evaluating your concentration in other ways.

This. Clinical symptoms are latent descriptors of manifest variables, ie it is not expected that a person can verbalize or even introspect the symptom descriptions. If the (prospective) patient could do this themselves, the clinical assessment would not be necessary.

> I'm happy to see such results be "properly" recognized. The DSM is imo helpful only as a baseline, especially in contexts where without it, doctors might have (significant) personal bias. And... this might ruffle some feathers with the "live and die by the book" crowd, but a good, perceptive doctor doesn't need the DSM to diagnose anything.

My own personal experience with psychologists and psychiatrists, is most of them don’t go by the text of the DSM, they go by the understanding of various disorders they’ve received from their teachers, mentors, supervisors, colleagues-which at times has a rather loose relationship with what the text of the DSM actually says-and once they’ve made their minds up as to what is the correct diagnosis, then-when required for a formal report-they look at the DSM text and work out how to justify their diagnostic decision by relating what the text says to the evidence at hand

The point is to make a differential diagnosis which isn't possible in 5 minutes. So if someone concludes after 5 minutes your psychiatric diagnosis, you can be almost sure they aren't following good practice for their profession. Or to use another word - malpractice.

> I've also had a 45 minute "by the book" DSM-based session where boxes were being ticked... and the questions were f---ing terrible

The DSM isn’t the source of those question inventories. There are different question sets for different conditions that each have their own source, often a set of researchers or an institution that has put in some work to study and test them. Some of the more obscure question inventories are even paid material that clinicians (or their offices, more accurately) are supposed to license.

I caution against the clinicians who do rapid-fire diagnostics and slap a label on the patient within minutes of talking to them. Some patients like this when the diagnosis matches what they already self-diagnosed or they want to hear, but in these cases some clinicians are just picking up on the hints the patient gave and mirroring it back to them.

This rapid diagnostic method is an easy way to improve your patient satisfaction scores (important for performance measures at some clinics, especially when PE or corporate gets involved) and it’s an obvious way to free up some time in a clinician’s busy day.

There is a growing problem of lazy providers who try to speedrun the diagnosis and send patients on their way with a prescription for something and a request for a follow up appointment. During COVID when controlled substance prescribing rules were loosened for remote appointments there were even pill mills that would advertise for specific diagnoses on TikTok and then incentivize the providers to see as many patients per day and prescribe them all Adderall because it turned them into repeat customers for the recurring prescriptions. There was a whistleblower who revealed that they were measured on their rates of prescribing controlled substances and discouraged from prescribing alternatives with lower abuse/addiction potential even when patients admitted to having drug abuse problems. This is an extreme example but don’t discount the incentive for your provider to shorten your appointment for selfish reasons, not because the patient’s condition is obvious and easy to diagnose accurately within minutes.

Sounds like the field needs to acknowledge the weakness of prescriptivism similar to software engineering with design patterns. The need for diagnostic criteria is understandable - but it definitely should be up to the discretion of the doc.

> "Do you have trouble concentrating" is terribly vague and can always be justified either way

To be fair, for the practitioner this shouldn't be a question about objective capital-letter Truth, it's one throw of darts representing a self-reported aspect of self-experience and self-perception.

As someone who has designed questionnaires for a public health agency, reading the article made me feel we should've fully randomized the order of appearance of individual questions, including the 'front-matter' stuff like self-reported gender, age, education, marital status.

As someone who got quite upset about a particular questionnaire's formulations at the tender age of 10, I'd now say let's not get too wrought up about this, a questionnaire can be a valid tool but it will also always be a somewhat blunt tool, so let's use it bluntly: don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out. If it's about me then it's about how I feel about it, now, and I can choose to feel extremely good or bad or fairly somewhat well-nigh indifferent about sh*t, just here and now. As the one being questionnaired, I also have the right to lean into the questions and bend the outcome as I see fit. Been there, done that.

> don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out

That is not always seen as an option for some patients. Having observed a family member take a specific autism questionnaire, I can tell you that as for some people - often exactly the people who should be dianosed - it does not always feel possible to pick an option that to them is wrong.

In said case, they ended up getting diagnosed with autism elsewhere, because that one question on the first questionnaire was one they felt impossible to move past, and so it was never submitted.

Thankfully they had another option that wasn't being gatekept with a broken quesionnaire.

This might not be directly relevant to the article, but I think it's worth mentioning it in the general context of questionnaire design.