Central to epidemiology and clinical psychiatry is prediction—identifying factors associated with specific disorders that suggest the subsequent course of symptoms and disabilities. Epidemiology seeks to better understand psychiatric syndromes across populations by identifying biological, developmental, demographic, or psychological constructs that describe expected futures. Clinicians use prognoses to inform colleagues, patients, and family members about prospects related to functions and individual goals. Criteria that define serious mental illnesses include poor prognoses, such as disruption of functioning and achievement of goals related to work, living independently, or intimate relationships.
Despite its widespread use, prognosis has risks, especially at the level of the individual. Individuals who have an illness are often dissuaded from pursuing personal goals that may exceed perceived limitations caused by the illness. Seeking educational, vocational, or independent-living goals beyond one’s expected capabilities may lead to failure and relapse. Of further concern, lay people may exacerbate the troubling effects of prognosis by making judgments that rob others of their rightful opportunities. For example, a graduate student of mine with near-perfect transcripts and a nicely developing list of journal publications—a person who also has schizophrenia—was told by a clinical psychology professor that “someone like you could never get through a Ph.D. program” and that “you should save yourself the bother of what inevitably will be failed educational pursuit.” Some educational researchers call this pursuit of ostensibly unattainable goals “overachievement”; meeting high standards in some situations is “illegitimate” because the person does not meet a priori expectations for success. The problem of prognosis also extends to theories of public violence, which are especially virulent after heinous crimes such as the mass shooting in Newtown, Connecticut. Pundits take to airwaves asserting that violent acts such as these are to be expected and require planned interdiction of people with mental illness. Prognosis in these various forms deprives people of hope, which is one of the more pernicious legacies of recent psychiatry: the demoralization that comes with diagnoses and implicit messages that derail aspirations.
Prognosis in this light leads to institution-bound treatments “to keep the person safe” rather than to community-based strategies that promote the individual’s goals. Such prognoses yield discriminatory actions by employers who avoid hiring people with mental illness because these new hires will do bad work. Prognoses are incorporated into public policy to identify and intervene against potentially homicidal individuals in ways that will lead to huge false-positive rates and egregious violations of civil liberties. We must be wary of the pernicious effects of prognosis, both in our practice and in the public’s use of seemingly science-based ideas to promulgate stigmatizing and discriminatory statements.
