On Diagnosis

Occasionally I’ll run across a colleague in the mental health world with one of those coffee cups or t-shirts that say, “Keep talking… I’m diagnosing you.” It’s supposed to be lighthearted and funny… I get it. But it makes me cringe to my absolute core. What’s implicit by that stupid cup is the idea that my licensure and education authorize me or my colleagues to park you in a semantic container without your consent or input, that you belong in that container simply because I say so, and that my power and authority to do so increases the more you speak. I struggle to imagine a notion more antithetical to the soul and spirit of counseling and psychotherapy. You’ll note in my allegory on psychotherapy that the mentor never bothers diagnosing — he simply sees the hunter and shows up to help him.

Naming a thing isn’t inherently bad, but diagnoses in mental health seem to come with significant risks that are often understated relative to the benefits. If I had my way, I wouldn’t use diagnosis for anything other than my own internal map of your experience and suffering to inform how I try to help you. It would avoid the pitfalls of stigma and over-identification with a “disorder.” If you pay out of pocket, I may keep my diagnostic thinking and considerations to myself as an internal map that informs my approach rather than something we need to formalize or discuss — unless you want to. However, I am required to provide a diagnosis if you are going to use insurance. We will talk about what an appropriate diagnosis is for you as well as the implications. In addition, I am — and believe I should be — required to justify my diagnosis to both you and your insurance carrier, so I will expect you to complete periodic assessments through my portal. My hope is to be as transparent as possible with you about what diagnosis I use while working to mitigate some of the pitfalls of utilizing a diagnosis.

In the absolute best-case scenario, the purpose and intent of creating a diagnosis is simply to create a semantic container around a collection of observations. It’s meant, hopefully, to inform the “proper” treatment for whatever is causing your distress. Psychology and Psychiatry set out to establish the same set of criteria for psychological distress and dysfunction. We have a manual for these diagnoses called the Diagnostic and Statistical Manual. It has been rewritten and reorganized several times since inception. It is the culmination and collective work of lots of really smart people who want to identify kind, clear, and compassionate ways of understanding human experience, and to help people suffer less and / or live well. It ought to suggest and inform a course of treatment which might help or improve the condition. It might also identify individuals who simply cannot and should not be expected to live up to the same set of “standards” we might apply to those we identify as “normal.” Unfortunately, this often goes poorly in psychology and psychiatry.

As an example, you might consider that at one time there was a diagnosis in the DSM-IV-TR called Mental Retardation. It was meant to describe individuals in childhood who, for various reasons, struggled with intellectual delay and difficulty — thus the term “retardation.” Psychologists got together after years of IQ testing and realized that a subset of children fell well below what we would statistically define as the “normal” population in terms of academic and intellectual ability relative to peers of the same age. From that you would ostensibly provide additional academic and social support as well as specific skills building within reasonable expectations. The term “retardation” was NEVER meant to hold the pejorative and insulting connotation that it carries today. Alas, here we are. Within the collective consciousness, a strange but somewhat predictable alchemy transmutes the kindness and clarity of a psychiatric diagnosis into the insufferable cruelty of the word “retard.” This doesn’t happen nearly as often or as powerfully in other medical disciplines with other more “medical” diagnoses.

In what can only be described as a giant “whoops” moment, psychiatry backpedaled hard. After some semantic grappling and reorganizing, we now have things like “intellectual disability,” “dyslexia,” “ADHD,” and “autism” — and yet again, the alchemy is hard at work transmuting all of the above into an unintended but stigmatized, belittling, and insulting form. Ever heard anyone say: “He’s got a touch of the ‘tism…”? Here we go again…

From my perspective, the application of a diagnosis to psychological development or experience suffers the most as soon as it arrives in the collective and common consciousness of those it’s meant to help. My hope, if we are to use a diagnosis in our work, is to be really careful with how we decide to name your struggle.