The Complexity of Mental Health Diagnosis: Neither a Defense nor an Endorsement from a Progressive Therapist
Cai Fasse, MA, LPC, NCC
Pronouns: they/them/their
Staff Psychotherapist
Inclusivity & Accessibility Lead
Many clients ask me about “what is wrong” with them. Often when they say this, they are looking for something to explain or blame for their struggles. People without deep knowledge or understanding of the diagnostic framework seem to see diagnoses and disorders as a very distinct and objective measure or label that is placed onto them by an “expert.” However, the history of diagnosis is wrought with oppression and bias; it is fundamentally flawed and at the same time can be incredibly useful for clients and clinicians.
The Biomedical Model
The mental health field adopted a biomedical framework for diagnosis for several reasons, primarily for mental health professionals to provide evidence-based treatment protocols which can be covered by commercial health insurance agencies and pharmaceutical interventions and psychiatric drug trials for mental illness1. One of the hopes for this adaptation of the biomedical framework for diagnosis was that it might destigmatize mental illness – that practitioners and the public may develop more empathy and understanding for people who struggle with mental illness and substance abuse, rather than seeing it as a “failure of will” or a “character flaw.”
The problem with this biomedical model is that it doesn’t really work for mental health the way that it does for medical disease, AND it can worsen stigma around mental health. Diagnosis in mental health is oriented around the origin of groups of symptoms that result in reduced functioning in one or more areas of a person’s life. The biomedical model only accounts for neurological origins of symptoms and excludes some of the most important influences on a person’s experiences: social/familial dynamics, societal/cultural systems (particularly involving oppression), and experiences that impact behavior and functioning.
The Ubiquity of White, Cisgender Male Bias
We use the Diagnostic and Statistical Manual of Mental Disorders, or DSM, to diagnose mental disorders in the United States (currently volume 5-TR). While it has undergone many revisions that include multicultural considerations, its origins are steeped in white, heterosexual, cisgender male bias. In other words, the pen holders historically have been white, cisgender men AND the subjects of research often used to inform this manual historically have been white, cisgender men who are natural born citizens of the United States. This means that when a client is assessed for something like Attention Deficit-Hyperactivity Disorder (ADHD) – a diagnosis that is notably neurobiological – the behavioral definitions are often oriented around what it looks like for young, white cisgender kids assigned male at birth (AMAB).
A good example of how this shows up is in the concept of “hyperactivity” which is usually seen as bouncing off the walls or disrupting class. For individuals assigned female at birth (AFAB) who are perceived as girls, hyperactivity may look very different. As an AFAB with ADHD, my hyperactivity manifests internally; primarily showing up as rapid thinking and an internal motor to do something–anything other than what I am doing. Maybe during a meeting where I’m expected to sit for an hour and listen, I feel an intense urge to get up and move or do something else. In short, my hyperactivity is invisible; it went unnoticed by teachers and parents. For almost every single AFAB client I work with, hyperactivity is very similar. Why is this? I suspect that it’s because AFABs are conditioned at very young ages to not be disruptive and to behave in social settings, particularly in school. When young AMABs are hyperactive, a common response from adults might be “boys will be boys.” This symptom presentation therefore has very notable cultural and social origins, which is not captured by a biomedical model.
The white, cisgender male bias in diagnosis shows up often for people of color; research has shown that people of color often don’t return to therapy due to a number of very understandable reasons – most therapists are white and therefore their diagnostic and therapeutic processes are oriented around a white experience2. I remember reading an article in graduate school about how paranoid disorders are diagnosed at significantly higher rates for Black Americans. This can be attributed to the white-oriented diagnostic process as well as a fundamental misunderstanding of how very real the threats are for a Black person in America. If a person is experiencing a real threat to their life on a daily basis, are they actually paranoid? Likely not. They are more than likely experiencing distress related to racial trauma.
The Pathology/Coping Skill Duality
The biomedical model leans so heavily on pathologizing very real and effective ways of coping with toxic or inhumane environments. Let’s say you go to a therapist because you’re dissociating so much that you are unable to focus at work, and it is affecting your performance.
Dissociation is defined by the American Psychology Association (APA) as "a defense mechanism in which conflicting impulses are kept apart or threatening ideas and feelings are separated from the rest of the psyche."3 The act of dissociation itself is not a “bad” thing to do. It is not inherently problematic. It only becomes problematic when the intensity, frequency, or nature of it is affecting important aspects of your life. In therapy with you, I might ask you when you dissociate, what triggers it? Do those situations remind you of anything that has happened in your life? Maybe you tell me that when you emigrated to the United States in elementary school, kids in your class would make fun of your accent, so you would space-out/daydream (i.e. dissociate) to avoid feeling the pain or hurt from the bullying. And maybe, as a result, your grades suffered a little bit – maybe you got some C’s as well as B’s, where you otherwise would have gotten A’s.
When considering dissociation in this context, my thought process as a therapist might be: if you hadn't dissociated, it’s possible the pain would have been so overwhelming that you wouldn’t have gone to school in the first place. In that toxic environment, dissociation helped you survive and function. However, in a different, healthier environment, it is no longer serving you. Part of what can make therapy so powerful – when it is done by a therapist who is thoughtful, curious, and humble about an individual’s intersecting identities and experiences – is the acknowledgment and validation of a behavior (i.e. dissociation) as a skill that helped you survive oppression and aggression. Pathologizing the dissociation runs the risk of undercutting the value it has for you in your growth as an individual. When we see these behaviors as skills, we can learn how to utilize them when they are necessary and let them go when they are no longer serving us.
Utility of Diagnosis
Despite the problematic nature of pathologizing the internal byproduct of oppression and the cultural bias built into diagnostic frameworks, diagnosis can be beneficial in some situations. Some clients find it validating to have a thing to point to as an explanation for their internal experience, particularly for those whose concerns about their own mental health have been minimized or dismissed by important figures in their life.
As a therapist, it can be really useful short-hand to convey a cluster of symptoms and presentation of a client’s internal experience to another clinician. Furthermore, our health care system, such as it is constructed and maintained, requires diagnosis for insurance providers to cover clinical mental health counseling or psychotherapy. Building a true diagnostic picture of mental health can take months. We must provide a diagnosis after the first session. The diagnosis can and likely will change. But the system itself forces us to use its operational standards and put our clients in boxes that may not truly fit; otherwise, a client would need to pay full fees out of pocket for mental health.
Most therapists take great care in considering the risks and benefits of a particular diagnosis for a client, noting how it may impact them in the future. Some of the questions I might ask myself when going through the diagnostic process are: How might this impact their current or future profession? What might they be required to disclose on documentation for insurance or licensing? Can another diagnosis explain their symptom presentation that does not stigmatize their experience internally? I do my best to explain this to my clients so they understand the purpose of diagnosis, and we process their feelings about what they have been diagnosed with.
The DSM has a long history of contributing to the pathologizing of queerness and transgender. The American Psychological Association (APA) removed homosexuality from the DSM in 1973, formally recognizing that it is not a mental health issue4. The DSM 5-TR includes Gender Dysphoria as a diagnosis, which describes the internal distress experienced by, for example, transgender individuals. This diagnosis is used especially when mental health professionals must write letters for clients seeking gender affirming surgeries. As a trans, nonbinary therapist, I discuss this diagnosis with all of my clients it applies to, and ensure they understand its purpose and have a lot of time to process any frustrations they may have with the diagnosis..For now, at least, the diagnosis is useful for individuals seeking gender affirming medical interventions, which often can be and are life-saving interventions. Oftentimes, the best thing I can do is help the client with the wolf on their doorstep, while gently resting my attention on the potential wolf in the woods.
But this isn’t a defense or a suggestion that we excuse the problems and oppressive features of diagnosis. A thing is not necessarily only oppressive or only encouraging. It can be both at the same time. What we do in clinical work with clients is developing an understanding and honoring these complexities so that clients can obtain the care they need and deserve while also ensuring that therapists are paid for their work, and that we are not carelessly perpetuating oppressive systems.
At Sage Stone Counseling, we hold that everyone should have the right to mental health care. We focus on providing affirming and safe therapeutic space to marginalized groups of all kinds, and are here to help. If you or a loved one is seeking support from a therapist, consider contacting us today.
References
Deacon, B.J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33(7). 846-861. https://doi.org/10.1016/j.cpr.2012.09.007
Day-Vines, N.L., Wood, S.M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M.J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85(4), 401-409. https://doi.org/10.1002/j.1556-6678.2007.tb00608.x
American Psychology Association. Dissociation [https://dictionary.apa.org/dissociation].
American Psychological Association. Banning sexual orientation and gender identity change efforts: Suggested discussion points with resources to oppose transgender exclusion bills. https://www.apa.org/topics/lgbtq/sexual-orientation-change
