A Therapist Grapples with Diagnosis Culture
When seemingly everyone has a DSM disorder, how do we find out what's actually going on?
by Elizabeth Polly
Elizabeth Polly is an associate MFT. Though she has abstracted the details of her client's lives, she is writing under an alias to further distance herself and protect their privacy.
At a big public high school where I worked as a therapist-in-training, a student used to drop into the wellness office saying she was scared, she had a pit in her stomach, and asking if it was a panic attack. Knowing from first hand experience how suggestible the nervous system is, I found myself reluctant even to assess possible symptoms for fear of feeding her imagination, like say: short of breath, say: dizzy, say: pain in chest. But I did and the next time she came to me in a panic she asked if this meant she had panic disorder. The worry that she was developing a chronic disorder was indistinguishable from the disorder itself. She’d learned that mental health problems can lead to suicide so she became terrified that she had a life-threatening disease on her hands. By then she was coming into the office almost every day.
In the midst of this, it’s easy to wish this student had never learned about diagnosis. It’s understandable to worry that over-identification with psych disorders has become too casual, creating something like a self-fulfilling prophecy. Because it’s true that a person’s suffering will express itself using their culture’s vocabulary of suffering, meaning the actual words and even the symptoms they describe. But, I’ve found that when diagnosis plays an outsized role in a young person’s life it’s not because of something as incidental and easily preventable as watching a few TikToks. There’s always a deeper need being managed, but the vocabulary is the entry point on offer. Dismissing that entry point is just as risky as taking it at face-value.
The most obvious and sound reason clinicians are wary of diagnosis in adolescents is that we are worried about entrenching a fatalistic story. We think: what if this 14-year-old adopts major depression as a feature of her essential self for the rest of her life instead of listening to what her mood is trying to tell her is so wrong in order to change it. Of course diagnosis can be vital for treatment and recovery in many cases. It can also give one the sense that they are powerless to change their condition. That liability is greater in adolescence.
Another reason I’ve been frustrated with young clients’ focus on diagnosis is that it seems at odds with the kind of deep work I was excited about doing. Therapy seems to be, at least in part, about making our own meaning—seizing the terrifying responsibility of authorship. Defaulting to a predetermined diagnostic framework can verge on giving that responsibility away. We can come to see our own suffering as an already-known thing, known better by experts than ourselves.
For adolescents, I think there is a wish to return to a time when adults knew what ailed us better than we did. In fact, it can feel like a desire to not know. Yet, at the very same time, using authoritative diagnostic language can be a way for young people to sound adult and hold their needy problems at arm’s length. It can feel like the young person is trying to join me on the other side of the room and prod parts of themselves with a long probe. Or like they’re ceding territory in their intimacy with themselves. This part is not-me, it’s where dissociation and compulsion take over. This part is the object we can tackle with a toolbox and a manual, or maybe a doctor can just do it for me. I worry because I want the young people I work with to feel alive with every inch of their subjectivity, which is all they have.
But talking about diagnosis is a route to talking about these very underlying dynamics, if you’re open to listening. Young people want to know if they are free to self-invent or if their destiny is sealed. They want to know if they are different from everyone around them or if there is somewhere they belong. They want to know if they can be loved despite their flaws. Diagnosis is a compelling and open-ended way to ask about these questions. But they are rarely asked directly. Instead, the questions are acted out. When we are dismissive, we are answering their implicit questions in the most disappointing way. We are acting out back.
I worked with a student who initially told me she was neurodivergent and probably had ADHD. From the beginning, I was skeptical, so I challenged the meaning of these labels for her. I also disclosed a bit about my personal critique of diagnosis and the manualized treatments that often go hand in hand with it. She perceived me as undermining her self-definition, and I was. That was particularly threatening because this student had no one but herself. She was used to being responsible for everything. She never looked to me or gave me an in when we spoke. She spent her sessions complaining that her parents wouldn’t give her a diagnostic assessment and meds. She did not believe talk therapy could solve her problems but often assigned me logistical, case management tasks. In various ways, I invited her to imagine needing or hoping for something from her relationship with me, beyond practicalities. She resisted. She was angry at me for undermining her self-reliance and I was angry at her for dismissing me as a therapist.
What I learned with this client and the one with panic disorder is that the subject of diagnosis is not an issue to be sidestepped in order to begin work. The work is happening. Or really, it’s struggling to happen but important difficulties are arising. One tenet of the kind of relational work I do is that only from within the stuckness that a therapist and patient create can the two of them notice the patient’s signature self-defeating pattern and improvise a way of breaking it. For the student with panic disorder, we discovered how panic was, counterintuitively, a way to avoid fear itself, and how being sick and cared for by adults had long been a way to avoid scary points of connection with other kids. As for the second student, she became curious about her way of relating to diagnosis as an appeal to a credible authority that outranked her father, and her tendency more generally to use her father’s invalidating voice against herself and others. Diagnosis was not a distraction, it was the door we took to get somewhere.
Clinicians and people in general have valid reasons for being critical of the culture around diagnosis. But in my case, and I suspect in others, the good reasons can give cover to bad ones. Such as, it’s annoying. It’s annoying not to be deferred to when I’m supposed to know better because I am insecure about my authority. It’s annoying to hold the totality of a person’s experience while they abandon that work in favor of a single explanation because it makes my job feel harder and lonelier. It’s annoying when people seem to desire exaggerated victimhood probably because it reminds me of how tired I am of being strong. And it’s annoying to feel obligated to validate something I don’t believe as a condition of beginning the work because I don’t want to share power. In other words, I have my own problems. We can be concerned about the liabilities and misconstruals in diagnostic language but when that concern veers into collective derision it’s likely because our own internalized stinginess about care is being threatened.
For some critics, the face of the social media-based self-diagnostician is a privileged white woman who wants status and attention for what might better be thought of as personality quirks. But much more often, at least in the population I work with, a biology-based explanation is a way of side-stepping facing what they’ve actually lived through. I think of the young man who thought he might have Oppositional Personality Disorder or Autophobia (“fear of loneliness”). This came after we’d worked together long enough for him to reveal his mother’s long battle with cancer during his elementary school years, his father’s betrayal of them during this time, and all the anger and mistrust he feels in relationships now. “The past is in the past, it doesn’t affect me,” he’d say. I think of a young woman whose family was for years violently targeted for political persecution, then moved to the U.S. to get her life-saving medical treatment, only to encounter a fresh new batch of emergencies. She reported feeling on edge, vigilant, and distracted, and wondered if she had ADHD.
I find in most of the young people I work with, a powerful desire to minimize what has happened to them and how they’ve been hurt. Their past is a haunted, lonely, senseless cave. Diagnosis is a shareable infographic. Of course, these dynamics collude with the society-wide political incentives toward medicalization, which, as Danielle Carr writes, put “the focus on the individual as a biological body, at the expense of factoring in systemic and infrastructural conditions.”
Though diagnosis is approachable for young people and seems to offer something tangible, I think there is something crucially ambiguous about what exactly it confirms. That ambiguity seems perfectly suited to this age group. Does it confirm that there is a problem, or that I am a problem? Is diagnosis an exoneration, or is it an indictment? It’s a loop they get caught in, which is maybe the same loop all adolescents are in as they struggle to differentiate from their caregivers. Who is right and who is wrong? Does diagnosis mean they’re right and I’m defective? Or does it mean that they are wrong for blaming me so the blame is on them? Diagnosis can’t answer this question, it can only ask it.
Recently, a student who is haunted by memories of her father’s violence with her mother, and who has been punished for refusing to forget it, talked in circles about diagnosis. Since she was 11 she’s been occasionally gripped by the urge/fear of jumping out her window. She has the sensation that her father is with her everywhere she goes and the window presents itself as the only escape. The way I feel—am I complaining about nothing? She asked. Because if it’s nothing then it shouldn’t be anything to worry about. Which would be good. But feels bad because then I made this all up. Isn’t that a problem? As long as the only proof of her suffering came from her self-report, she couldn’t shake the feeling that it was her fault for speaking it into existence.
I see the craving for diagnosis against the larger backdrop of our time. The adolescents I work with seem to want an explanation that feels real in a stable way. The news, politics, religion, family, gender, the future of the planet, what bodies look like; there’s no unquestionable legitimacy in any of it. With this comes greater possibilities for freedom and authenticity. But it also makes us desperate for something more credible than our own disorganized thoughts and feelings.
It’s not surprising that so many young people seem to be true believers in what they think is the doctrine of the DSM. It feels like a toe hold. Diagnosis often doesn’t live up to its face-value. But the more I think through it the more I can see it’s as good a starting point as any. Patients come with the language of the discourse they know and the inheritance of every social construction that came before them. In the context of a treatment relationship, we don’t make meaning out of thin air, we make it out of the world around us.