The Diagnostic and Statistical Manual of Mental Disorders in it’s fifth edition, spans over 917 pages. The most recent publication, in 2013 by the American Psychiatric Association, was a massive undertaking. The process of updating and refining classifications for mental disorders was lengthy (over 12 years), heavily reviewed, and a collective effort shared by experts. The Diagnostic and Statistical Manual of Mental Disorders (DSM, for short), is used by an array of professionals from therapists and counselors to physicians, psychologists, psychiatrists, nurse practioners, crime courts, insurance providers, etc. The main goal of the DSM is to provide a common language shared by these professionals, a collective understanding of symptoms and how patterns of symptoms create mental disorders.

The traditional way mental disorders are diagnosed goes something like this:

A person is experiencing symptoms that have made their daily life and relationships feel disruptive. Say they seek a consultation with a therapist because they are feeling miserable. The therapist asks them a lot of questions, like when they first noticed the symptoms and if the person has experienced them before. The therapist consults the DSM, they match the criteria of the diagnosis with what the client describes. Then, typically for insurance purposes, the therapist communicates the diagnosis with the insurance company and client so they can get paid and the client can get their services covered. The therapist begins to plan how to address the diagnosis and work together with the client to recover from the symptoms so they are less disruptive to the client’s life.

This all seems pretty simple, reminiscent of a doctor’s visit: patient feels sick, doctor diagnoses their struggles, patient gets the medicine and is on their way to feeling better.

But therapeutically, everything is more nuanced.

For example, the talking part of therapy functions like the medicine someone would take for a cold. And talking to someone, a stranger at first, about the most intimate, painful, and vulnerable parts of our lives, isn’t always easy. Which is why, therapists and clients work to build a relationship that feels safe and comfortable. This relationship is the foundation for the recovery ahead of the client, in fact, the relationship between client and therapist is said to be perhaps the most important factor predicting success or treatment outcomes.

Knowing this, as a therapist, I have come to have mixed feelings related to diagnosis.

I have a deep appreciation and reverence for the DSM and the research, time, and knowledge poured into it’s creation. I’ve worked with people who feel relief after receiving a diagnosis and feel diagnosis validates their experiences. There are some instances, like biological, cognitive, and developmental disorders (autism, for example) that when diagnosed, especially earlier in life, can provide a lifetime of support and relief for a family.

Depending on the diagnosis, medication might be indicated or desired. Medication has the potential to provide important relief from symptoms so people are able to get back to their daily life.

Diagnosis can be empowering as people begin to have words to describe their experience and knowledge they aren’t alone in their experience. It can be a gateway for helping them discover and receive a variety of different resources to get on their way to feeling better.

The struggle for me comes in for me when I revisit the importance of building a relationship with clients in therapy.

When people enter therapy, they begin with sharing something like,

“I’m depressed.”

“I’m anxious.”

“I think I’m bipolar.”

The first way I like to respond to these statements is through attempting to understand who they are as a person, aside from their struggles. I want to know what they like to do for fun, what their family and friends are like, what makes them laugh, and what kind of tv they like to watch. This helps us begin to build a relationship. This part of therapy is really important in the overall process because it helps me learn more about who they are when their “depression” or “anxiety” isn’t so influential in their lives.

The second thing I do when I encounter a client’s description of their struggles is attempt to understand the problem in their own language. I might ask something like, “I know what depression is like for me, but can you help me understand what it’s like for you?”. This allows us to begin to shape a shared meaning of what the client’s unique expression of depression is and perhaps eventually we’re no longer even describing depression but “the blues”, “oppression”, “homophobia”, or “shame”.

I ask these questions to help broaden both my and the client’s knowledge of who they are and what they’ve struggled with in life. The client may initially use the word “depressed” to describe themselves but they are also a spouse, student, or parent. They may be “anxious” but they don’t mention they’re creative, empathetic, and resilient. At times, diagnostic or clinical language becomes the dominant way of describing people and they begin to see themselves through the lens of their struggles.

Words have power.

Until 1973, “homosexuality” was a mental illness, according to the DSM. This means the year the manual removed homosexuality, that overnight, thousands of people were no longer considered “diseased”. The impacts of the “homosexuality-as-disease” mentality didn’t end with the diagnosis’ erasure in the 1970’s. LGBTQ+ folks everywhere struggle with their own experiences of internalized homophobia and transphobia. The path to progress is slow. For example, only in 2019 did the state of Colorado finally ban the harmful practice of conversion therapy (a type of “therapy” that attempts to make gay people straight or trans people cisgender).

People who write words have power.

The above examples certify this. One can imagine the identities of a majority of the authors and decision makers of the DSM throughout time: most likely white, mostly likely cisgender, most likely straight, most likely male, most likely European or of European descent. Think, Freud. In other words, a certain world view and perspective is the foundation on which the DSM was established.

The rates of depression and anxiety in the United States are well known due to their reportedly high rates. As of this very difficult year, a third of Americans report feeling depressed and anxious. That’s about 34% of the population. With numbers in a range like this, it’s hard not to consider anxiety as symptom of broader issues occurring within society.

How else are people to respond when they’ve been confronted with a global pandemic, violent white supremacy, and unemployment under confusing and incongruent national leadership?

I’m wondering about how our views of mental health might shift if we had a DSM to describe our social and cultural systems. Imagine if there were a Diagnostic and Statistic Manual for Disordered Societies. Some of the disordered illnesses might include: misogyny, white supremacy, transphobia, racism.

Or, what if the Gold Standard for clinical treatment was an Encyclopedia of Courageous and Resilient Practices? A compendium of ways people have overcome or coped with their struggles in authentic, courageous ways. Therefore, when a person meets with a therapist with help overcoming their difficulties, they could consult the encyclopedia to see examples of how others have overcome similar struggles, or perhaps even provide their own unique knowledges to the book.

How do you think society might come to view those with mental health struggles differently if we filtered people through their strengths and ability to go on living through their most challenging struggles?

I want to be clear I don’t think diagnosis is bad or wrong. I think the diagnosis itself can become problematic when a person and the person’s relationships become impacted by a limited view of all a person is and can be. I think the experience of struggles can become worse when people start to feel disempowered by a diagnosis and they’ve grown out of touch with the many resilient qualities that have allowed them to confront their challenges. I consider it in part my role as a therapist to help explore more preferred ways people would like to see themselves and live their lives.

Words matter because they impact our relationships.

I keep imagining what it might have been like for queer people in the days following the dismantling of Homosexuality from the DSM. Had they been excommunicated from their parents or families of origin because of their “illness”? And then what of it after? Did their family relationships shift in the coming years? Were they renewed with a sense of power and self-acceptance that allowed for more genuine and loving relationships?

What about when I sit with clients and try to understand what it’s like to be them? How might our relationship shift if I got to know their depression instead of their humanity?

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I’m wondering about you. Have you had an experience with mental health diagnosis that was useful? What about not-so-helpful? Share your thoughts in the comments below or feel free to email me at hello@inbloomfamilytherapy.com.

REFERENCES

https://www.psychologytoday.com/us/blog/compassion-matters/201612/the-importance-the-relationship-in-therapy

https://societyforpsychotherapy.org/evidence-based-therapy-relationships/

https://www.psychologytoday.com/intl/blog/freud-fluoxetine/201906/setting-the-record-straight-homosexuality-and-dsm

https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-7-2

ABOUT

Lauren Lottino MA, MFTC, absolutely loves her work as a Marriage and Family Therapist. Lauren loves provides compassionate family therapy, couples therapy, and individual therapy for womxn in Denver, Colorado. In Bloom Therapy is a private therapy practice which is an LGBTQ+ safe space and inclusive to those with non-conforming gender identities, race, ethnicity, abilities, and spiritualities or lack thereof.

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