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The Emptiness of Diagnostic Labels


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Every once in a while someone will come into my office and announce that they’re a Narcissist, an Addict, a Depressive, or they have Borderline Personality Disorder or that they have some other nasty label that accounts for their difficulties in life.

Sometimes at professional events, I’ll hear other therapists diagnose their clients with similar labels: Histrionic, Schizoid, Sociopathic, and so on. And in graduate school, as my classmates and I learned the hundreds of “official” disorders listed by the American Psychiatric Association, students would condemn their friends and relatives — and sometimes themselves — as suffering from Major Depression, or Generalized Anxiety Disorder, or Bulimia or Panic Disorder. And as we worked our way through the Diagnostic and Statistics Manual (DSM) which contains all those official disorders, the range of diagnoses would expand.

It seems a common need to label ourselves and others, to put people neatly into boxes. Perhaps it serves a built-in need for order in our lives, a desire for things to Make Sense. We’ve been doing this at least since the ancient Greeks, who thought that psychological trouble and physical illness were both caused by an imbalance between or corruption of the four ‘humors’: black bile, yellow bile, blood and phlegm. That idea, by the way, held sway for about two thousand years.

We may laugh now at the backwardness of the Greeks and the lack of scientific understanding through until the 1600’s or even later. But people who live in glass houses shouldn’t throw stones, and I’d suggest that our attraction to psychiatric diagnoses is not that different from telling someone they’ve got a bile or phlegm imbalance problem.

The truth is that the diagnoses that professionals (and sometimes lay people) hand out are almost entirely nonsense. Now, that’s a pretty dramatic statement and it requires some evidence, so here goes: For a diagnosis to be useful, it has to be accurate. Unfortunately, when professionals try to diagnose people, they simply can’t agree. Two therapists can and do look at the same person and come up with entirely different diagnoses. Imagine if you went to three doctors for a back ache and one said you had a slipped disc, another said your core muscles were too weak and the third said you had a tumor — how useful would that be? Most people who see multiple psychology professionals come away with the same bewildering array of diagnoses. And the research supports this: the ability for any two professionals to agree on a diagnosis is a little more than chance.

Even if the diagnoses were accurate, there would be one other requirement before they could be considered useful: They would have to lead to different treatments. This therapy would be used to treat one disorder, while another therapy would be used to treat a different disorder. But the research shows that all therapies work about equally well on virtually all disorders. (There’s some indication that behavioral therapy is better than others for phobias, but that’s about it.)

So that’s the dismal situation with psychological diagnoses: mental health professionals will happily give you a diagnosis, but can’t even agree among themselves what diagnosis you should have. And even if they do agree on the disorder you’ve got, it doesn’t mean you’re going to get a treatment that’s any more effective than if you went undiagnosed.

At this point you might well ask “Then why do mental health professionals bother diagnosing at all?” There are many answers: Partly it has to do with the need for insurance companies in the USA to manage their reimbursements. Another part is the desire of the psychiatry profession to be seen as equals with their colleagues who treat physical illnesses. And part of it is the innate desire of human beings to categorize things.

But the part of the diagnosis craze that is the most dangerous for those suffering from psychological pain is this: It smooths the path for a therapist to give up on their client. Therapists are human, and we all find ourselves frustrated at times that we’re unable to help someone, or irritated by the way they treat us. What a relief to be able to say “No wonder my client is angry at me — she’s a Borderline.” Or “He’s not getting better but what can I do? He’s a complete Narcissist.” Or “His Generalized Anxiety Disorder is really out of control, there’s not much I can do.”

The diagnostic label frees a therapist of the most important responsibility: to truly understand their client. No matter how irrational a behavior or emotion appears, no matter how mean, cruel or self defeating a client’s actions may seem, there is always a reason for it that will make the behavior or emotion understandable and rational. A therapist must dig for that reason, dig until they can say to themselves “If I had my client’s experiences, I could see myself feeling and acting the way they do.”

Harry Stack Sullivan, a famous psychologist, once said “We are all much more simply human than otherwise, be we happy and successful, contented and detached, miserable and mentally disordered, or whatever.” When we put a diagnostic label on a client, the therapist, in effect, says “You are less human than I”, and puts distance between them. And everything we know about therapy tells us that this kind of distance makes it harder for clients to feel better.

One author wrote that diagnostic labels are the tombstones that mark a therapist’s frustration with their failed therapeutic efforts. And indeed, when I listen to therapists diagnosing their clients, it’s rarely in an effort to figure out how to help them: it’s almost always to bury the case and relieve themselves of the responsibility of helping.

Tim Hoffman 

M.A. Mental Health Counselling

Psychotherapy in Hong Kong

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