How I really feel about diagnosing

An unpleasant part of my job as a psychologist is diagnosing people. I know, I'm very familiar with

which would seem to imply that we psychologists love diagnosing people and that we do it all the time unconsciously or consciously.

I'm here to tell you, though, at least for myself, diagnosing is one of the things I dislike about my job, and I'm NOT diagnosing you when you're talking unless you really are my client--and the reason why may surprise you.

When a client comes in for therapy, and they're using insurance to pay for this therapy, the insurance company requires a diagnosis for the client--after just one session. Any good psychologist knows that making a diagnosis after a 50 minute session is going to be challenging. Most people don't present in the first 50 minutes as a clear, text-book case of one of the hundreds of possible diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). More likely than not, I'm able to figure out that they're "somewhere in the anxiety disorders" or "somewhere in the mood disorders" category fairly easily but fine-tuning the diagnosis down to specifiers (like mild, moderate, or severe) and feeling really sure about that diagnosis is something that is less certain, even with lots of experience. I have to diagnose an insurance client after that first session, though, or the insurance company says "I guess they don't have any problems and therefore don't need to see you so we're not going to pay for it."

It is illegal for me to give a diagnosis just to get reimbursement from an insurance company--as it should be! So I do my very best to make a diagnosis for each client that is a pretty good match to at least one of the specified diagnoses in the DSM-5. My job is to diagnose my client using my experience, training, and clinical judgment. Whatever I have determined to be their diagnosis is what I report to their insurance company. 

The way in which the DSM-5 is, (and all previous editions have been) laid out, each diagnosis has a number of (usually 3 or 4) major categories that must be met to qualify for a diagnosis. The first one is usually a given number of symptoms (sleeplessness, racing thoughts, etc.). The second category is usually that "the symptoms cause clinically significant distress" to the client. The third is usually making sure that the symptoms are not "better accounted for" by some other problem (usually a different disorder, substance, or medical condition).  Then, for many of the diagnoses, a professional needs to determine "specifiers" which may be like those listed above or things like "with atypical features" or other such language.

Don't get me wrong, diagnosing a client certainly gives us lots of information and many clients ask me to tell them what diagnosis I have given them, because there is comfort, sometimes, in knowing that you're not the only one to have these problems and that there's a name for it. It is a time consuming process to do for each client and usually, as mentioned above, a client has some of the symptoms of a particular diagnosis but sometimes they don't have enough to qualify for the diagnosis or, most commonly, clients have a few symptoms that go under one diagnosis, a few under a second, and possibly even a couple that fit a third diagnosis--so then the work becomes trying to figure out if any of them are affecting the level of functioning more than others, or if the symptoms are really, in total, pointing to a completely different diagnosis altogether.

So, you may be thinking that the reason I don't like diagnosing is really because its a lot of work. That's not it, though. Here's why. I like to focus on what my client's strengths are, not that with which they are struggling. Could the DSM-5 be re-written to focus on the positive instead of the negative? Probably, but it wouldn't be much help. We DO need to understand what is going wrong in addition to what's working and where the client wants to go (understanding the difference between where they are and what they actually want to accomplish). 


The other problem, as noted in the above graphic, is that when people hear that a person has a particular diagnosis, assumptions about them may be made which may be very unhelpful and inaccurate. It would be naive to think that there is no stigma attached to mental disorders. So, at the very least, when we label a person as having a particular disorder, we open the door to facing the stigma of that disorder. Some disorders carry more stigma than others, but all still carry some stigma despite our best efforts to view mental disorders like health disorders.

 When someone comes in and gives me a laundry list of all of the diagnoses they've been given over the years, I recognize that they have probably gone to multiple professionals and at various times qualified, at least minimally, for these diagnoses. A person may have been given a bunch of diagnoses over the years because of the difficulty in actually diagnosing. We only have what the client is telling us (or family member if that person is unable to communicate their symptoms to us) so we are already getting a biased view. I could have just had a very bad night of sleep and focus on all the terrible sleep and insomnia that I feel I have, giving more weight to this symptom than perhaps it deserves. That is why a good clinician will ask many questions about each symptom, trying to determine a better overall picture of what is happening for a person. In just a 50 minute session, however, when collecting diagnostic information, sometimes there is insufficient time to ask probing questions so we run with what the client is focused on, sometimes leading to an erroneous diagnosis. I think this happens all too frequently. I personally would feel much better about diagnosing if I knew I had two or three sessions to determine what is really going on before reporting that to an insurance company, but that's not how the current system works.

The danger in giving multiple diagnoses to clients, even if it is different professionals looking at different symptom categories, is that it can feel very overwhelming to a client. Something like "I have so many things wrong with me that there's no way I'll ever be okay!" I think this really increases a tendency to anxiety and depression, so I try to help clients understand all of this--that sometimes inaccurate diagnoses can be given due to many different factors. I prefer to put all those other diagnoses behind and look at what is currently going on.

Back to the reason I don't care for diagnosing. Once I have "diagnosed" a person, I rarely look back at that information. Rarely. Usually only when an insurance company is asking me something about the case which then requires that I list their diagnosis again--I usually have to go back into my notes to see how I diagnosed them the first time! I don't sit during each session trying to fine-tune my diagnosis (sometimes fine-tuning does come into play but usually not). I am focused on listening to how that person is functioning. What things are working and what things are getting in the way of success? That is how I view symptoms--things that are getting in the way of a person being the person that they want to be or have the capacity to be. THAT is what I work on. How do we overcome these symptoms? How do we work with our strengths so that our symptoms are minimized? How do we strengthen our resources with skills? Those are the questions that run through my mind as I sit with a client.

Diagnoses tell me what's wrong but they don't necessarily tell me what to do about it. I want to focus on what we can do about it. To me, that's where the therapy begins.