Diagnosis Demystified

Labels have the power to enlighten and enslave us. Hopefully more of the former. An individual officially labeled with a physical, mental, or developmental disorder may be entitled to certain supports and protections. In optimal circumstances, a diagnosis helps people understand themselves better and find direction toward living their best life possible.

The process of diagnosis tends to be veiled in mystery and deemed the territory of very expensive specialists. Capitalism loves a pedestal. However, diagnosis of disorders (I prefer "conditions") actually entails one basic element: matching up an individual's behavior with criteria identified through ostensibly scientific procedures and listed in the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD). The DSM is generally used by mental health practitioners and the ICD is used by medical professionals. The numbers after their name refer to the current revision of the work. Most of the conditions which are listed in both volumes entail the same or mostly similar criteria for diagnosis.

Let me diverge from the main topic for a second. At this point in time, diagnosis tends to be based on observable behavior rather than internal experience. Which means that diagnostic pronouncements are made by an outside authority often based on commentary given by others known to the patient, especially in the case of children. There has been a recent shift in the healthcare field toward replacing the term "mental health" with "behavioral health", as if a person is what they do. This mindset has the power to create more barriers to truly understanding and serving people who are looking for help. I place value on the internal experience of the individual and I like to imagine a world where people's own experience of themselves is honored more than an outsider's judgment of their visible symptoms.

Many paths can lead toward determining whether a person meets criteria for diagnosis, and specifying exactly which diagnosis fits best. I imagine everyone reading this article has had an experience of seeking understanding of a physical or personal concern, only to be told several different things by several different professionals while receiving little useful help. This is because diagnosis, at its core, is not technically scientific. It is based on the clinician's knowledge base, clinical experience, personal and professional biases, competence with measurement tools, energy level and brain power at the time of diagnosis, insurance company influence, and sometimes convenience.

People qualified to deliver diagnoses are those licensed (not certified, credentialed, or trained) by the medical and behavioral health boards of each state. LCSW (licensed clinical social worker), LMFT (licensed marriage and family therapist), and LPCC (licensed professional clinical counselor) licensees are all governed by the Board of Behavioral Sciences (https://www.bbs.ca.gov/) in California and are all technically qualified to make diagnoses of conditions listed in the DSM. However, each field's initial training has a slightly different psycho-social-emotional focus so it's up to the clinician to enhance their knowledge base with further learning and clinical experience throughout their career in order to be competent  in their delivery of services. We have an ethical commitment to work within our scope of competence and to define our field of practice based on our specialty focus and expertise. Just because my license qualifies me to diagnose Hebephrenic Schizophrenia doesn't mean it's the right thing for me to do.

Many clinicians are unclear on the capabilities and limitations afforded them by their professional license. Lacking confidence, information, and scruples leads many clinicians to fall back on common, trendy, or generic diagnoses. Rather than truly understanding the person through a variety of perspectives, they grab at a couple obvious straws and slap a quick label on it. Every decade sees a handful of over-utilized diagnoses which often tend to be the ones most highly reimbursed by insurance companies. Mental healthcare is absolutely part of the capitalist game.

I sound cynical, don't I? I like to think I hold a healthy amount of skepticism toward the whole system. Enough to stay grounded and keep my focus on the welfare of the individual over the corporate bottom line.

So when seeking answers as to why you feel, act, or react a certain way, it's important to have some guesses as to what might be your concern. Trust me, your guess is as good as your healthcare professional's. It will give them a place to start as they consider your symptoms, explore your experience, and weigh that information against their knowledge base of various conditions which may share characteristics or overlap in certain dimensions. The best diagnostician is one who can skillfully discern between varying presentations of conditions and individualize their conceptualization of your particular case. A good practitioner will also be able to explain their thinking and conclusions in a way that makes sense to you, the patient.

I value self-recognition as a useful step toward appropriate diagnosis. Although WebMD has caused many unwarranted panic attacks and sleepless nights, it has also helped millions learn about conditions to which they previously had no exposure. Approaching your healthcare provider with questions and suspicions is extremely valuable in helping them attend to the important details of your concerns. In the best scenarios, they will consider your suggestions and use them as jumping-off points to explore your concerns and arrive at a determination as to the source of your trouble.

I've somehow saved some of the most important points for the end of the article. Most mental health conditions in the DSM do not require expensive testing and long procedures to diagnose! Of course the general public typically has no idea of the correct way to arrive at a diagnosis, so they trust the professionals they hire. And as we all know as seasoned capitalists, the more expensive something is, the better it is. So a $5,000 diagnosis must be more correct than a $500 one, right? I am here to say that is entirely false. Most conditions can be identified through careful interviewing and observation, and perhaps the completion of a written survey or two. If your clinician has expertise in their field, they will know what fits and doesn't fit with all the conditions similar to and affiliated with the predominant symptoms reported and observed.

Clinicians do their best to gather copious information from multiple sources to make the most accurate assessment possible.  Some patients are better able to perceive and articulate their experiences. Some concerns are actually more internal than external and may be difficult to convey. Sometimes observation and psychometric testing is inconclusive. Truly, diagnosis is not typically a linear, objective process. Mistakes are made and details are overlooked, even by the most expensive of diagnosticians.

This is not to say that extensive psychological testing is all hooey. There are many conditions such as developmental and learning disorders which truly reside in the deepest parts of the brain and defy clear outward expression that need expert attention and review through complex processes. The processes are usually not the first step in a diagnostic process, though. Practicing therapists in clinics and private practices ought to be adept in their offered services and worthy of the trust their clients put in them.