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Key points
- Therapists who are too eager to diagnose tend to use labels to explain most of their patients' problems.
- Therapists who under-diagnose often fail to help the patient make meaningful changes.
- Certain patients may deliberately seek out therapists who will help them externalize blame onto others.
There's a widespread and far-reaching controversy in psychology and psychiatry: to diagnose or not to diagnose. Proponents of diagnosing cite the validity and reliability of personality patterns that contribute to chronic distress; opponents, meanwhile, note the stigma often attached to the labels.
But there's a deeper question: Beyond diagnosing, how honest should we be with people?
Fearing criticism of any sort, some prospective patients seek out therapists who don't diagnose because the aversion to it signals the potential for loyalty and sympathy; some are looking for yes-men who will, by definition, find all the fault in anyone but the patient. It isn't just diagnosing these individuals are opposed to; it's any type of full-scale character assessment.
In this case, the therapist, for his own reasons, colludes with the patient while both parties consider the therapist to be of superior moral standing. The result: The patient's relationships continue to suffer as he abandons one after the other, wondering why everyone is so terrible to him.
Yet the therapist who too eagerly diagnoses often carries biases similar to the public at large while tucked under the didactic blanket of intellectualism. Patients tend to complain about this therapist's moralizing tone and tendency to explain away any complaints as resulting from the personality problems being treated. When this therapist's patient balks at their feedback, a responding scowl may hide their own inability to withstand the tide of labeling.
Complaints about unconscious biases due to the diagnoses should be taken seriously, even if we try our best to be fair. It's been argued that changing the labels—say, from borderline personality disorder to complex trauma—would help mitigate primal responses, but these arguments fail to account for the biased individuals themselves.
While a label may be replaced, the tendency to externalize and find fault elsewhere is the underlying issue (which all of us, at any point, may struggle with), both individually and culturally. It isn't as though there's no stigma attached to PTSD, despite the fact that it isn't considered a personality disorder.
The problem, in reality, is us, regardless of the labels, which can be used in many ways. I’m of the opinion that stigma inevitably becomes attached to any difference that causes interpersonal problems, regardless of what we call it.
Additionally, our perfectionist patients tend to hate the labels because they indicate their flaws. Helping them accept their diagnoses can be part of a broader treatment plan which aids them in learning how to live with the more challenging parts of their personalities.
On the other end, patients deserve better care than that received from individuals who deny their ailments. An all-too-common misunderstanding in the field is the split between a diagnosis and the patient's circumstances.
So, a therapist might remark: "It isn't bipolar; it's just an extreme circumstance." Without a follow-up assessment, he'll decide what constitutes an extreme circumstance and that, based on his intuitive understanding of his patient (along with his unacknowledged lean toward anti-psychiatry), a bipolar diagnosis completely misses the mark.
I've made this mistake too, wanting to protect my patients from that kind of label, realizing what I've done only long after the fact. When patients inquire about the validity of a label, more often than not, they aren't hoping for their therapist to talk them out of applying it to themselves. (A really informative article by Psychology Today editor Devon Frye recounts the experiences of those who received a mental health diagnosis later in life, which changed their trajectories for the better.)
So, if you're searching for a therapist or psychiatrist, ask yourself why you're seeking help. Has a life led avoiding criticism been a happy one? Can it really be the case that you can't maintain any semblance of stability in your relationships and yet you bear no responsibility? How many "extreme circumstances" finally warrant a diagnosis or at least a consultation?
Therapists who are fixated on using your personality label to define all of your problems should, I argue, be as shunned as those who coddle you. To make your life better, you need to develop an understanding of your patterns within the bio-psycho-social model in order to address them.
Understanding your family history of mental illness, the effects of trauma, current triggers, the common effects of your social and financial standing, the likely temptations based on familial personality patterns and your own anxieties, your internal toolkit, how your decisions influence the world around you, what evidence sustains your general beliefs, and your ability to trust and hope provides a map far grander than the ones used by those preoccupied with blame or denial.
I end on this note: There’s a difference between being polite and kind. Politeness is about self-protection and managing your anxiety by making others feel comfortable. Kindness is about pushing through your own discomfort to provide them with necessary insight. Many are polite; few are kind. Genuine kindness, or compassion, involves a high degree of honesty. Remember that when you're searching for a therapist.
