Better Late Than Never but Better Never Than Early?

Several weeks ago, we discussed (among the limitations of the DSM) the fact that the DSM symptoms for depression match DSM symptoms of normal bereavement and grief, following the death of a loved one. Because such symptoms are to be expected for some amount of time following a death, bereavement is named an exception to the DSM criteria for depression. A similar instance occurs following a traumatic experience, after which people often display potential symptoms of PTSD; these symptoms do not persist, however, and people most often return to their normal psychological states, excluding them from eligibility for a PTSD diagnosis.

I thought of this idea of when and in what context to make a diagnosis when completing this week’s readings — particularly the Lilienfeld “Psychological Treatments That Cause Harm” paper. Among the category of Potentially Harmful Treatments that qualify as “Level 1: Treatments that Probably Produce Harm in Some Individuals “ are grief counseling for normal bereavement and Critical Incident Stress Disorder (CISD) for PTSD and anxiety disorders. Specifically, CISD may exacerbate symptoms that otherwise would have disappeared with time and adjustment. Not only does research on CISD suggest that people would have otherwise recovered on their own but also that they would have recovered even more without the treatment. Thus, instead of the intended expedition and mitigation of symptom and disorder recovery, such therapies may both create and prolong the disorder. These consequences even appear to be long term.

A similar situation appears to apply to grief counseling for normal bereavement. In a meta-analysis, Neimeyer (2000) found that 38% of clients in the treatment condition would have ended up functioning even better, had they been assigned to the no-treatment control condition. In addition, nearly half of the treatment condition had more severe symptoms following the treatment than they had experienced prior to it. This was especially true among individuals who experienced “normal” — rather than “traumatic” grief reactions.

These examples evidence the risks of intervening too early, before it can fairly be ascertained whether intervention and treatment is both relevant and beneficial. Clearly, there are some circumstances in which a waiting time is essential to determining what, if any, treatment is appropriate. But I also can envision several circumstances in which it is detrimental to wait too long to decide on a course of action for treatment. I wonder how to determine how long should pass between a stressor and the onset of treatment. Should it depend on the potential diagnosis, on the treatment and its potential consequences? Or what about on the person? With different diathesis and different baseline levels of stress and affect, it may be possible that different people would have different time lapses between onset of symptoms and decision about treatment that would maximize their recovery. This is something neither the DSM nor any other generalized manual could address. As seems to have been the case across various weeks’ readings, there appears to be a continuum of psychopathology, ranging from healthy reactions, to unhealthy reactions — with similarities across disorders — that need to be parsed apart in order to treat and understand psychological disorders in the best way possible.