Diagnosis: finding a balance.
Subject: Mental illness (Diagnosis)
Author: Rosenberg-Javors, Irene
Pub Date: 03/22/2010
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Spring, 2010 Source Volume: 13 Source Issue: 1
Topic: NamedWork: Diagnostic and Statistical Manual of Mental Disorders (Reference work)
Accession Number: 222558225

Several of my graduate students came to class wanting to talk about diagnosis and the all-pervasive use of the DSM-IV. They expressed their discomfort with using the manual, and they felt that their work settings put too much emphasis on diagnostics. As fledgling counselors, they feared that by relying too heavily on the manual they would be "missing the forest for the trees." Their concerns became the focus of discussion for our weekly meeting.

The Diagnostic and Statistical Manual of Mental Disorders is a virtual bible of the mental health professions, as well as the primary reference work used for insurance reimbursement. Like it or not, the manual's contents are ingrained in the minds of clinicians. The DSM-IV defines disorders, and in so doing, defines our norms. The next edition, DSM-V, is scheduled to appear sometime in 2012-2013. A panel of psychologists and psychiatrists have been appointed to add to, delete, or maintain current diagnostic categories.

The fact that diagnoses can be removed or added reminds us that these categories are constantly reconstructed. For example, the second edition of the DSM listed homosexuality as a mental disorder. In 1973, the American Psychiatric Association voted to no longer list homosexuality as a disorder. Fourteen years later, in 1987, the American Psychological Association removed all references to homosexuality as a diagnostic issue. Each new generation of clinicians who are charged with the task of revising the manual are products of a discrete historical context and bring with them the values and biases of the age in which they live.

Our assumption that the manual is a scientific classification system needs to be challenged. In truth, the diagnostic manual describes symptoms and not underlying causes. Symptoms can be ordered and organized in various ways depending on the perceptions of the clinician. There is some truth in the old cliche that no two clinicians will offer the same diagnosis without some variations on a theme.

In this age of evidence-based practice, diagnostics has taken an important place in the counseling profession. My students question whether or not putting a diagnostic label on a client helps. A student reported that one of her clients uses her diagnosis as an excuse for not taking responsibility for her behavior. The client said, 'Tm bipolar; there's nothing I can do." Another student reported that his client has reduced himself to the diagnosis and now derives his identity from being "manic." Yet another student reported that the moment that she reads the intake and scans down to the diagnosis, she finds herself influenced by what she reads and she fears that she comes into the sessions with bias.

As a counselor educator, my goal is to help students learn to balance the heavy emphasis placed upon diagnostics with a wellness model that focuses on the strength and resiliency of the client. I encourage students to remember that they are working with a person and not a diagnosis. I challenge them to stay mindful of their biases and assumptions and not to fall into the trap of self-fulfilling prophesies.

As new theories, practices, and research studies proliferate, we sometimes forget what is at the heart of the counseling endeavor: the client, warts and all. Diagnostics is useful only if it helps us to work more effectively with our clients. Otherwise, we need to be vigilant against letting ourselves get carried away with a lot of confected, professional jargon to explain away very real problems in living.

By Irene Rosenberg-Javors, MEd, LMHC, DAPA

Irene Rosenberg-Javors, MEd, is a Diplomate of the American Psychotherapy Association, a licensed mental health counselor, and a psychotherapist in New York City. She is also adjunct associate professor of mental health counseling in the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology at Yeshiva University. She can be reached at ijavors@gmail.com.
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