With a new diagnostic manual out (the DSM-5 replacing the DSM-4TR), I’ve been thinking more about the dangers of diagnosis. It’s just human nature that if you’re holding a hammer, everything looks like a nail.
So the way a therapist sees a client is shaped by the diagnostic criteria available, and that can influence how clients see themselves (“I’m a depressive borderline,” one new client informed me.)
Given this, therapists have to diagnose with care. And clients have to take their diagnoses with a grain of salt: The diagnosis you’re given is not the sum total of who you are.As therapists, sometimes we forget how much power we have. I find this is especially true in couples therapy, where I’ve been asked point-blank whether a couple should split up or stay together.
Therapists today are often more transparent than in the past. That means we might explain a diagnosis to our clients as part of deciding on a treatment plan (for example, if I feel a client has Borderline Personality Disorder and I want him/her to start doing exercises from a workbook on Dialectical Behavior Therapy.)
On the one hand, I think this shows respect for my client: I’m not trying to trick them into working on something; I’m partnering with them in what I believe to be the best treatment. On the other hand, it puts me in the position of an authority who is placing a label on my client, and that label itself can have significant repercussions.
Ideally, it has a positive repercussion: The client feels hopeful that they finally have a name for what’s been causing problems in their life, and a set of skills they can acquire that can help. In this scenario, the client is empowered, and motivated.
But as therapists, we have to be aware that it can go the other way. A client can feel hopeless in the face of such a diagnosis, and maybe they don’t believe it fits but they don’t feel they have the right to resist it. So maybe they terminate therapy prematurely, or they withdraw from therapy without actually leaving (showing up each week but with no true conviction or commitment.)
It’s the job of all therapists to recognize when our clients are discouraged and/or disengaged from the process. But sometimes we might not know why. We might not think about how it connects to the diagnosis.
We also might not be thinking about how the diagnosis is blinding us to individual differences between clients. Even if we believe the diagnosis to be accurate, we still have to see beyond it.
This is especially crucial when treating personality disorders. If we stop seeing the client as a unique individual and instead only as a set of problematic characteristics and tendencies, that will affect how we interact. It can mean we’re less imaginative in our approach, or we’re too ready to give up and blame it on the client’s disorder.
Diagnosis is a useful tool for guiding treatment. But it’s not absolute (if it were, how could the new DSM have so many changes?). It’s also not the only tool. We also have to be guided by the relationship we’re having with the client in front of us. Recognizing the limits of diagnosis and the fallibility of categorizing systems puts us in a position to better treat our clients.