The Allure of Diagnosis

‘How quickly do you think you’ll be able to diagnose patients?’

Diagnose. The process of diagnosis is not as straightforward as one might think. Because of its subjective nature⁸, many clinicians disagree on how diagnosis should be carried out⁹. But for me, I sometimes wonder how helpful diagnosis is altogether.

In the United States, we generally use The Diagnostic and Statistical Manual of Mental Disorders (DSM) as a guide for diagnosis¹⁰. It is the widely accepted standard, but it is not without its flaws. The DSM has been largely criticized as an ever-expanding diagnostic system¹¹, that pathologizes¹² and medicalizes¹³, lacks validity¹⁴ and scientific rigor¹⁵, is not reliable¹⁶, and presents cultural biases¹⁷. In fact, the National Institute of Mental Health (NIHM) no longer supports the DSM¹⁸. And this is to say nothing of how diagnoses fuel the insatiable appetite of the pharmaceutical industry. Allen Frances, M.D, who worked on several versions of the DSM has criticized the industrial mental health complex:

'if I've learned anything during these 40 years I've worked on DSM’s, it's that if anything can be misused, it will be misused, especially if there's a financial incentive…And pharma, the big drug companies, have a tremendous financial incentive in making sure that every DSM decision is misused by expansion, so that people who are basically checked well are treated as if they're sick. They become the best customers for pills'.

-Allen Frances, M.D¹⁹

Apart from the predatory nature of the system, perhaps my biggest gripe is that diagnoses can harm those who need help the most. A diagnosis can be given in a few thoughtless minutes. But the ramifications can impact someone for a lifetime. Easy to judge someone and give them a label. Much harder to actually try and fix it. (I don’t accept insurance in part because insurance companies require a diagnosis—even if one is not warranted).

A diagnosis can convey a sense of permanence²⁰—something that does not instill hope for those looking to change. And a focus on diagnosis is a focus on symptoms and pathology, not on overall health²¹. If we go looking for illness, that’s what we’re going to find²². In my view, such preoccupation misses the big picture. Diagnosis is a means, not the end.

I prefer the term, condition. It carries much less weight and much more hope.

To be fair, diagnosis is born out of necessity and convenience. It can be useful, for example, in quickly understanding a broad clinical presentation of someone’s issues. But in my opinion, it shouldn’t be more than that. Yet unfortunately, it seems to have become much more.

Diagnoses have moved beyond an institutional requirement to a strange form of social capital. Today it’s commonplace to discuss mental health matters publicly²³. Diagnoses have become sensationalized²⁴, broadcast²⁵, and even desired. I can hardly go online without running into someone talking about trauma. Perhaps what began as a well-intentioned approach to reduce stigma has backfired²⁶; now, an overemphasis on diagnosis might actually be increasing mental health-related stigma²⁷. 

As a clinical mental health counselor I also want to call attention to this trend; over-identifying with diagnoses, labels and medications, especially on social media, can hamper your own sense of self-efficacy, distort your identity, and ultimately get in the way of healing and growth.