I’m a big believer in holistic health. I appreciate a variety of therapeutic practices, body work, peer support, spiritual work, energy work... I could go on and on. That being said, this “everyone’s a coach” trend raises a lot of red flags for me, especially around missed and misdiagnosis.
My priority as a psychotherapist is and has always been helping people heal. I really don’t care how a person approaches their healing as long as they’re not harming themselves or anyone else and they’re getting their needs met. So where does mental health diagnosis fit in?
Diagnosis in the United States is guided by the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychological Association (APA). In other countries, mental health diagnosis is based on the International Classification of Diseases (ICD) published by the World Health Organization (WHO). There’s a lot of hard science that goes into the development of these publications, and it seems pretty clear that there’s also quite a bit of economic, cultural, and other human bias involved. Mental health diagnosis is every bit as much an art as it is a science and it has limited capacity to be helpful, but it can be profoundly helpful for the right person at the right time.
The purpose of mental health assessment and diagnosis is two-fold: to begin to make sense of a person’s experience, and to guide treatment. I’ll use Posttraumatic Stress Disorder (PTSD) as an example. PTSD is one condition a person may develop as a result of exposure to actual or threatened death, serious injury, or sexual violence. PTSD is characterized by four symptom clusters: avoidance, intrusion, arousal, and constriction. It’s not unusual for a person with PTSD to be unaware that some of their experiences are connected to this condition. I may recognize that the nightmares I have about my car accident are an intrusive symptom of PTSD, but not recognize that my inability to feel connected to my friends is a constrictive symptom, or that my impulse to drive well above the speed limit is an arousal symptom. I can only tell someone about the symptoms I recognize as symptoms. A solid assessment creates an opportunity for someone with a broad understanding of mental health to ask me questions that lead to a more comprehensive understanding of both my strengths and my struggles, and an accurate diagnosis points the way to a wealth of existing information about helpful treatments.
For many people, finding a mental health diagnosis that fits is one of the most validating, illuminating experiences they’ve ever had. Diagnosis is derived from common experience. If there’s a name for your experience, it’s because you’re not alone. You are unique – no one else is exactly like you – but these struggles that you’ve been having? There are so many other people struggling with the same thing. And once you have a name for this part of your experience, you can use that to guide your search for helpful resources. Diagnosis is really only helpful when it provides a pathway to effective treatment. If there’s no effective treatment available, the diagnosis may not be helpful at all.
But isn’t diagnosis pathologizing? The word pathology is derived from the Greek pathos, meaning an experience, misfortune, or condition. I don’t find it inherently pathologizing to be offered a name for an experience that’s difficult for me. It’s pathologizing to label a perfectly normal, healthy human experience as abnormal or bad. It’s pathologizing to blame me for having a condition that I didn’t choose and didn’t cause. I’ll use PTSD again as an example here. The avoidance, arousal, intrusion, and constriction that a person experiences in the immediate aftermath of a traumatic event is perfectly normal, healthy, and adaptive. In an ideal world, my environment will become safe enough quickly enough for my body to process and release the trauma, after which I can naturally return to a state of feeling safe and connected. In the real world, we’re often forced to stay in survival mode too long and the trauma gets trapped within ourselves. Some people would prefer that the word “Disorder” be dropped, recognizing that PTSD is a normal response to abnormal circumstances. I appreciate that perspective and I certainly support people approaching their own lives in whatever way is most helpful for them. For me, the word “Disorder” in PTSD recognizes both the suffering and the capacity to heal. I didn’t cause this condition that I have, but I’m suffering and I have the capacity to heal.
Speaking of an ideal world….. In an ideal world, all mental health providers would actually have a broad understanding of mental health and be able to ask the right questions to help people identify their strengths and needs, and to develop and follow the most helpful treatment plan. All mental health providers would be able to share what they know in a helpful way, maintaining interest, curiosity, and a healthy dose of humility. We don’t live in an ideal world, and mental health providers are just people. There’s only so much any one of us can know about the infinite variations of human experience. Many people go through years of therapy before they discover, with or without the help of a therapist, the diagnosis that best describes their experience. And then there’s the judgement, bias, fear, and ignorance from those therapists who may fail to realize that we’re all just people and we can figure it out together. I've learned tons in my years as a therapist. I strive to continue learning because I want to be the best therapist I can be, yet I will always have a lot more to learn.
I feel inclined to repeat that mental health diagnosis has limited capacity to be helpful. I’ve seen people connect with a diagnosis as an identity, use diagnosis to justify rather than explain harmful behavior, and create community through diagnosis in a way that inhibits healing, growth, and connection. I’ve seen providers use diagnosis to minimize client strengths and struggles, push specific treatments that aren’t helpful, and focus on diagnosis over personhood. In rare cases, people are denied career and other opportunities based not on strengths and needs but on a mental health diagnosis. There are also common human conditions that don’t have a diagnostic label, and diagnostic labels that don’t represent actual pathology at all.
If you’re in therapy and you haven’t discussed diagnosis with your therapist, consider whether or not it would be helpful for you to ask if you’ve been given a diagnosis. If you think a specific diagnosis may describe your experience, I encourage you to find a provider you can trust to explore this possibility with you. Mental health diagnosis isn’t based on whether or not you have an experience, but rather the frequency, intensity, and impact of the experience. Whatever you’re going through, I can assure you that you’re not alone, you deserve support, and you can use the right relationships to find helpful insights and solutions.