At the community mental health center where I work every single person I see gets a diagnosis. There’s a preliminary diagnosis after the first session, which I may write without even seeing the client. (When we do an intake on a child we see the parents without the child for that first diagnostic assessment so the preliminary diagnosis is based on the parents’ report.) The preliminary diagnosis isn’t set in stone; it’s considered a starting point. Clients at the clinic use insurance or Medicaid to get services and they require a diagnosis to open the case so we give one based on the information that we have.
Then a few more sessions in we write the actual diagnosis. By then we’ve seen the client, we have a fairly full history and we can make a full five axes diagnosis. We base that diagnosis on the client’s symptoms and history and when we write the treatment plan we refer back to it and it all works very nicely.
The reasons behind diagnosis are pretty clear — when we make a diagnosis we are creating a picture of the client for ourselves, for other clinicians who might work with her, and for the client herself. As we design treatment plans and measure progress we can refer to the diagnosis to get a better understanding of the work we’re doing together. When we case consult at our clinical meetings we can use diagnosis to better communicate the issues for our client in order to get appropriate feedback to improve her care.
That’s all good, right? Usually it is good. But sometimes it’s frustrating.
Diagnosis is an imperfect art. You know that old joke about rabbis? Here, I’ll tell it to you: What do you get when you have three rabbis? Four opinions. Same goes for therapists. Sometimes a person is experiencing such clear symptoms that it’s very easy to say, “Ahh, yes! Recurrent, persistent and intrusive thoughts? Behaviors meant to neutralize these thoughts? Repetitive hand washing, counting and rules about light switches meant to stave off distress? That’s 300.3 Obsessive-Compulsive Disorder!” Easy-peasy. Everyone gets it.
But other times you can have a client and it’s not nearly as clear for lots of reasons. Like clients may not really know their own history. They may exaggerate or understate the length of time they’ve had symptoms or the severity of those symptoms. Sometimes I get a client’s records and find out she’s had several different diagnoses (this is especially true for children). This speaks to the fact that it is all open to interpretation.
A diagnosis doesn’t just exist in the clinical setting; our clients live with it. I’m not talking about the symptoms or history that lead to the diagnosis; I’m talking about the label. The diagnosis doesn’t just live in her file, all nice and neat and detached from real life. The diagnosis lives in her experience of herself.
Part of working with a client around her diagnosis is helping understand that she isn’t her label. She is not “a depressive” or even a “depressed woman;” she is a “woman with depression.” Even if her illness dictates some of her choices (medication, counseling, etc.) it is not HER. But it can be hard, particularly when I have a client who has been living under the shadow of a diagnosis for some time.
This is especially important when it comes to teenagers. Teens are already trying to figure out who the heck they are and getting a diagnosis in the middle of that can be heady stuff. A diagnosis can be used like a shield to protect her from expectations, to excuse herself when she hangs back, and to rationalize her failures. She may become her diagnosis, reading information on the internet and shaping herself to fit the criteria.
I have a lot of clients who come in with a self-diagnosis based on reading magazines, talking to friends or just a general understanding of what a label actually means. (Lots of clients use words like “anxious” and “panic attack” and “bipolar” without understanding their clinical definition.) They sometimes feel very defensive when I tell them that they don’t actually meet criteria. Feeling sad about a pet dying is not clinical depression; it’s appropriate grief. Feeling nervous about going on a first date is not social anxiety disorder; most of us are nervous before a first date. Feeling happy one day and sad the next is not bipolar disorder; it’s part of the human condition. Our sadness and our fears and our struggles do not need labels to be real.
When I give a client her diagnosis I first give her a rundown about how we got to it. I explain that a diagnosis is a label for a cluster of symptoms and that our focus will be on addressing symptoms. I tell them that a diagnosis is just a way for us all to communicate with each other and it’s not more real than what they’re actually experiencing. It’s a tool, I say, OUR tool, THEIR tool and we own our tools; our tools do not own us.
I don’t take insurance in my private practice and one reason is that it allows me the freedom to give or not give a diagnosis. A diagnosis should serve the client and sometimes I think a client is best served by not being given one.