If you have used insurance for therapy or another mental health provider, you likely have a diagnosis on file. But where did diagnosis in mental health come from, what’s the point, and what should you do about it?

In this week’s post, I would like to talk about diagnosis in mental health care. I’d like to start by saying there is no right/wrong way to look at this topic. These are some ideas speaking from my experience in the field and collaboration with other clinicians. If you have other thoughts, I would love to hear more! We learn and grow by being challenged or presented with new information to consider.

Where did it come from?

Although diagnosis has become much more prevalent, diagnosis has been around for as long as recorded history. Dating back to 6500 BC, discovery of prehistoric skulls show evidence of a practice called trephination, which was a practice of surgically drilling holes into the skull to alleviate injury or free evils spirits (Restock,2000). Diagnoses were more formerly depicted and documented in the age of the Greeks, but the first formal system of diagnosis was published by a German psychiatrist named Emil Kräpelin (1856-1926). This system centered around patterns of symptoms and paved the way for the diagnostic system we use today, The American Psychiatric Association’ Diagnostic and Statistical Manual (DSM). First published in 1952, the DSM provided a shared language for clinicians to identify and research “disordered behavior” (APA, 2022).

One of the largest criticisms of the DSM are that the “disordered behavior” is based on finding from western culture and might label cultural norms outside of western influence as being disordered when they are not. Another concern with the DSM is that the number of diagnosable disorders have tripled since the first edition, this has led almost half of Americans to have a diagnosable disorder in their lifetime. This is true even of the most recent edition of the DSM-5 which came out in 2013 (Farreras, 2023). Whether or not a behavior is considered normal or abnormal has a lot to do with the context and cultural norms surrounding the behavior. There may be rituals or practices of a given culture that are a spiritual awakening, but in a different culture could be identified as an episode of psychotic behavior. This has led to a shift from normal or abnormal behavior being the measure and instead having threat of harm to oneself or others be the factor determining if the actions are maladaptive.

There have been multiple theories behind diagnosis over the years. Some of the earliest theories, such as supernatural theories, focused on evil or possession to be the cause of mental illness while others like somatogenic theories focused on physical disturbances or imbalances. At a point in time, humoralism was a dominant belief held by ancient Greeks and Romans. This belief held that an excess amount or deficiency of blood, black bile, yellow bile, and phlegm dictated health and temperament. This belief was held until the late 19th century. The newer age theories are psychogenic which focus on traumatic or stressful experiences that led to learned associations or developed distorted perceptions and possibly maladaptive behaviors (Farreras, 2023). We’ve come a long way since phlegm, but there is still a way to go.

What’s the point?

• Pros

  • Having a Shared Understanding

    • The primary intention of diagnosis was to create a shared understanding so that clinicians would more easily be able to collaborate with treatment and find effective modalities. It was also the intention to make studying specific disorders and passing along information streamlined.

  • Treatment Approaches

    • A shared understanding of disorders has helped the development of “evidence based practices” which are the go-to for agencies because they are easier to get reimbursed when paired with the diagnosis code. These theories are heavily vetted and are shown to have significant impact. For instance, Cognitive Behavioral Therapy is known as a great approach for depression and anxiety, Eye Movement Desensitization and Reprocessing is a leading treatment for trauma, and Dialectical Behavioral Therapy is consider the most effective treatment for Borderline Personality Disorder.

      • Despite a belief that there are “best” “evidence based practices”, continued studies and research have brought this idea into question. Although there are therapeutic models preferred by insurance (and therefore agencies), there is no statistically significant difference in treatment outcomes based on the theory used by the clinician. What has been shown, is that the development of a therapeutic alliance is the primary factor in effecting change (Luborsky et al., 2002; Messer & Wampold, 2002).

  • Medication Management

    • One of the dominant pros for diagnosis is having an idea of where to begin with medications as well as having a reference for medications to avoid. For instance, there are some medications that would be effective to treat depression that could actually induce a psychotic episode in someone who was misdiagnosed with depression when a Bipolar Disorder was the accurate diagnosis. There are continuing advances in medications to help reduce symptoms and help people get the most out of their life.

  • Access to Resources

    • There may be cases where funding to programs or access to certain resources are dependent on your diagnosis. When I worked in community treatment, the team I served was a dual-diagnosis team meaning that to work with me, the client had to both be experiencing a Severe Persistent Mental Illness (treatment resistant illness lasting more than two year) as well as begin diagnosed with a Substance Use Disorder. This program did have clinicians with additional training and we did have access to resources to help support our clients that other teams might not.

• Cons

  • Becoming a Tool for Insurance Companies

    • The DSM-5 was never intended to be a tool utilized for insurance reimbursement and it has become predominantly that. Anytime you access mental health care with your insurance, you receive a diagnosis code which is then submitted to your insurer along with a service or “CPT” code. Some insurers will deny coverage if the primary diagnosis is not eligible for reimbursement.

  • Medical Model

    • Mental health does not fit the same model as other types of healthcare. The way to heal a broken bone might work the same way in every client with the same break. The way to heal a person is entirely dependent on the person being treated. We are a culmination of not only what the presenting problem is, but also all of our unique strengths and experiences in life.

  • Unexpected Impacts for Your Future

    • One thing that has always made me angry has been the impacts of diagnosis that are unforeseen and often not explained to the client. I have had cases where clients had no idea they carried a diagnosis and then were penalized by an increase in premiums for insurance when they switched providers or in one case I worked with, denied for an extension in life insurance due to their depression. There are also impact for individuals trying to have a fitness for duty evaluation or in obtaining security clearances.

  • Labeling - Identity

    • I lose my mind when someone says, “Oh.. well you know how __________’s are.” This is such a sordid way of thinking, no matter what fills in the blank. I unfortunately have worked with a handful of providers who make that statement about categories of clients or diagnosis types. I have intentionally supported and participated in research that take feedback from clinicians who have worked with individuals that are often lumped into harmful categories and worked to support shining the light on how incredible those individuals are no matter the diagnosis or presenting concerns.

What should you do about it?

• Clients

  • Ask Questions and Give Feedback

    • Even though you are coming in to see a licensed professional for a psychological evaluation, you are still the expert in the room on you. Do not be afraid to ask questions, give feedback, say no when you are misunderstood, and allow yourself to share your experience. Even if what you express parallels cases that your clinician has seen, there is only one you, and the treatment approach should be tailored to what works for you so that your clinician can see you where you are at.

  • Check Possessive or Identifying Language

    • You are not your diagnosis. I have heard countless clients share, “I’m Bipolar” - I’m an addict” - etc. and although I try to match the language of the client, this is one of the areas where I will speak with clients about not identifying with their “disorder/dysfunction” and that they are far better served identifying with their strengths, “I’m resilient” - “I have found ways to cope with ____”. Even this little shift keeps us from feeling like the “problem” is us and that we need to change ourselves. You are the solution. How can you use your language to promote light?

• Clinicians

  • Be Collaborative!

    • Collaborative diagnosis in mental health is an essential approach that allows for the integration of diverse perspectives, leading to more accurate and personalized treatment plans that truly address the individual's needs. The collaborative process fosters trust, empowers the client, and creates a supportive environment that promotes healing.

  • Consider Impacts on Your Clients

    • Before giving someone a diagnosis, communicate with them about it. One of the first things I do when I complete an intake is inform the client that if they are using their insurance they will need to have some type of diagnosis on file to bill under. You would be shocked at how many people I have met with that have been in therapy off and on for years without any idea that they had a diagnosis in their record. We need to be mindful when making assessments and give the client all of the information possible.

  • Avoid Labeling Language

    • We may have experience treating a diverse spectrum of individuals, along with training and education that supports us in identifying patterns, symptom clusters, etc., but there is only one person in the room with you. They are unique and have a depth of experience that makes them the expert on their life. Do not use labeling language or lump clients together by a diagnosis or witnessed behavior. This is harmful and luckily, much less common than it used to be in the field.

What do you think?

Although there are some recognized benefits to diagnosis, it is important to remember that a diagnosis does not define who you are as a person. You are a complex and unique individual, with strengths, passions, and dreams that extend beyond any label. Embrace the idea that your mental health diagnosis is only one part of your story, and that you have the power to shape your own narrative and journey towards self-discovery and well-being.

What are your thoughts around diagnosis? Are there any pros or cons of diagnosis that surprised you? Let me know what you think in the comments below and I would be happy to continue the conversation!

Take care, be well, and Companion Your Journey!

Resources:

1. Farreras, I. G. (2023). History of mental illness. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. Retrieved from http://noba.to/65w3s7ex

2. Restak, R. (2000). Mysteries of the mind. Washington, DC: National Geographic Society.

3. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

4. Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T., . . . Krause, E. D. (2002). The dodo bird verdict is alive and well—mostly. Clinical Psychology: Science and Practice, 9, 2–12.