The Strengths and Limitations of Diagnoses
Numerous people have asked me about their diagnosis during the course of therapy. Sometimes it’s very direct: “So, what’s wrong with me?” Other times, less so: “Well, a lot of my friends and family say that I’m a narcissist; that I’m selfish – I mean, I don’t think I am, but what do you think?”
Whether it is to confirm a diagnosis that they have already given themselves (“I have these high highs and low lows, so I’m bipolar, right?”) or to refute a diagnoses that they are afraid of having (“I just can’t shake this sadness – am I clinically depressed? Should I be on meds? I don’t like medication!”) or simply curiosity about how we as therapists conceptualize the clients we work with: there is a paradoxical nature to diagnoses. I listen respectfully when patients do self diagnose, but then try to explore their reasoning for doing so. It is important not to trivialize or magnify any of the conditions that are classified as mental disorders.
They can be both useful and have their limitations.
Why diagnose? Well, a diagnosis is useful in helping a patient understand why they are experiencing certain symptoms. It can also help the clinicians who are treating them to find and implement an effective solution based on scientific evidence that has been consistently replicated in other similar cases.
How do we do it? The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard tool that we use when assessing a case. At 991 pages and weighing in at just over three pounds, this massive publication essentially provides a checklist for beginning treatment: What are the symptoms, how long have they lasted, and so forth. This is fine for insurance companies who want to know what they may be reimbursing, but it really doesn’t do anything in attempt to understand the patient as a person. Systems exist to facilitate control. The DSM has been devised and maintained by a select group of clinicians who are in a very powerful and privileged position of being able to prescribe labels for the conditions which we as therapists work with in our practices. But sometimes people just need to be heard without being pathologized.
A very rewarding part of my job is not “fixing” clients, but rather helping them to see themselves for who they truly are and how they developed that way. Many come into treatment in a very vulnerable state. They may view therapy as a last resort; as evidence that they have failed to manage their own life’s problems.
And so, I will often ask my clients: “Why do you want to know?” – because I tend not to disclose my diagnoses. This is because they often change as the therapy progresses and new information becomes available. Over time the obsessive thoughts and compulsive behaviors which accompanied a particular person’s anxious symptoms can come to be understood and respected as protective defenses against memories from a childhood of deprivation and neglect. Does that need a diagnostic label or the opportunity to express itself to an empathic ear?
Perhaps both. To be fair, there are some people who aren’t in high risk situations who do benefit from having a label for their condition. It can be a relief to know that years of nightmares after having grown up in an abusive household may allow a person to say: “Yes, I have PTSD. That is this ‘thing’ that I experience.” It can provide some grounding and clarity to an otherwise disorienting state of being. Still, in other instances, it can be rather stigmatizing. I work with some transgender and non- binary patients who are able to use their therapy to help them receive medical procedures to help them affirm their identities, yet in order to do that they must first be labeled with a “disorder” (Gender Dysphoria), as if they hadn’t already experienced enough labeling in their lives.
To summarize: a diagnosis may help to explain, but it doesn’t define.
by Vernon Bauer, LMSW