Diagnosis and non-diagnostic therapy

Diagnosis is a hot topic among psychotherapists. For those new to the debate, this might seem like a surprise. After all, diagnosis isn't particularly controversial in medicine--when you're sick and visit your doctor, you expect him or her to tell you what's wrong, i.e. diagnose the problem as an essential part of treating it. And while the word diagnosis might not be used, it's a quite ordinary part of our day-to-day experiences with plumbers, computer technicians, and auto-mechanics. If our doctor or plumber can't tell us what's wrong, we feel we haven't been helped (and often we'll be referred to an expensive specialist with the expectation that he or she will be able to get the right diagnosis).

Many people assume the same goes for psychotherapy. For one thing, of all the professions mentioned above, it is psychiatric diagnoses that are by far the most prevalent in everyday discourse. Even if you're not familiar with the DSM-V, you're almost surely familiar with some of its contents. Concepts like anxiety, mania, depression, PTSD, and addiction are all terms that reference diagnoses outlined in this manual used by psychiatrists, psychologists, and psychotherapists. Diagnostic concepts from plumbing or ophthalmology haven't exactly worked their way into everyday conversation in the way these terms from the DSM-V have.

And so it may come as a surprise to learn that there are a growing number of psychotherapists who don't diagnose, and who advocate a movement away from (or at least to dramatically reorganize our relationship with) mental health diagnosis.

How come?

If diagnosis is a helpful part of the process of curing a mysterious rash or getting my garbage disposal to stop making that awful groaning sound, why can't it help me with my emotional problems?

For one thing, you're not a garbage disposal. Nor are your skin cells. Yes, you have skin cells, but your emotional life can't be separated from the totality of you in the same way that most medical ailments can. (Although many quite sensibly argue that we separate parts of our body that aren't functioning well far too much from our bodies as a whole.)

Secondly, you (and your emotional life) aren't broken in the ways that garbage disposals and body parts can be. Being depressed, for example, isn't the same thing as being broken or sick.

Thirdly, your emotional difficulties aren't just located within you. You are a part of countless relationships and environments that help to shape your emotional life (and which are shaped by your emotional life). To relate to emotional difficulties diagnostically is to relate to them individualistically and therefore deny the ways the world impacts our emotional well-being. In other words, diagnosis assumes that you are the problem. While it is critical not to ignore very real emotional struggles many people have, diagnosis leaves out the social context of these struggles.

Where do we stand?

Obviously, given our comments above, we take a highly critical stance with regard to diagnosis. But it would only be mostly true to say that we're "anti-diagnosis." There a few, rare instances where diagnosis may become a part of the therapeutic dialogue:

Many patients come to us desperate for a diagnosis. Perhaps they've struggled for years with inexplicable emotional pain and always assumed there was something terrible wrong with them--and perhaps assumed they were lazy or morally deficient. A diagnosis can help give hope: My experience is shared by others. It is acknowledged by professionals and by an establishment charged with intervening with this kind of suffering.

On the other hand, there are many with emotional difficulties who struggle to come to terms with the challenges therein.  Serious depression, bipolar disorder, and difficulties involving psychosis can be hard to accept, yet have serious repercussions if not addressed. While a decision to take psychiatric medications is not a straightforward question, many people with serious emotional challenges would be in dangerous shape, and for some failure to take a difficulty like this seriously can be life-threatening. Often talking seriously about a diagnosis is an essential part of being honest about what's going on and what kinds of decisions need to be made in order to maintain safety and health.

In both of these cases where we may choose to include diagnosis in the therapeutic conversation, this is done creatively and with caution and respect. Whether the diagnosis is a welcome addition or dreaded, we never allow it to determine the course of our work together. We take pains not to relate to patients as problems, or to relate to the challenges they're having as simply a function of a category in which they've been placed.

Nor do we limit the scope of our work to those matters that fit neatly into that box. For example, in the case of depression, we do not assume that the sole focus of our therapy will be on matters related to mood; depression (and anything else one's challenged by) is a complicated matter, and growth, in my opinion, demands making broad changes in how we're living our lives.

Making up our own diagnoses

Another failing of working with diagnosis is that it assumes that all emotional challenges have been identified and put neatly into the DSM-V by its authors. But why should these authors have such a privilege? Couldn't we all have the authority to make and assign diagnoses ourselves? While such an activity still comes with caveats, the notion of inventing our own vocabulary brings exciting possibilities to the table.

How about diagnoses of health?

The practice of diagnosis falls short in another way: Only deficits are included. This leaves us wanting in creating conversations about mental health. We have much work to do towards the end of creating a lexicon of strengths. What are we doing well? What's producing health and wellness in our lives in spite of the forces working against us? What activities/ choices/ factors add resilience to the lives of those who have survived and thrived through difficulties?

We need to find more ways of talking about our emotional lives, and more ways of helping one another live happy, decent, successful lives. Diagnosis, at least as commonly practiced in psychotherapy, limits the conversation, eliminates language that might otherwise help us create these new ways of talking and, by extension, of living our lives.