Let’s talk diagnosis. But first, let me backup a bit.
I receive the most wonderful questions from JOY listeners and readers of this newsletter. Y’all are really paying attention and few things make me happier than answering your questions about psychology. What I didn’t know was going to happen when I started JOY, was that I would get asked quite frequently for my take on things that are floating around the psychological ether. Kind of like a myth buster.
Here’s what that looks like. A DM of a post on social media that just doesn’t sit right with you. What do you think about this Lisa? Is there any truth to this? I call bullshit. Thoughts?
And I LOVE this! If I have created space where we can think critically and ask questions, especially about psychological information that is being presented on social media, no joke I can die happy. Keep up the good work psych enthusiasts. And keep sending me your questions.
I was asked by a JOY listener quite recently about codependency, and yes I will unleash a whole episode just on that, but for now I want to focus on my response. Which actually surprised me. Instead of immediately launching into what codependency is and is not, I thought about whether I had actually said the words codependency to any of my patients before. And What I found was that in all my time seeing patients at schools, hospitals, colleges and in private practice, I don’t think I ever used those words. And I certainly never diagnosed anyone with codependency, because it’s actually not a diagnosis. Dependent Personality Disorder code 301.6 (F60.7) comes close, but it is presents differently. And this presentation as an Axis II disorder is really, really important in terms of treatment. Even still, I did not hear this diagnosis often. Nor did I ever hear codependency presented at a professional conference, or during a case study, or clinician consultation group. Interesting, right?
To offer a little perspective, the modality of psychotherapy I closely adhere to, psychoanalysis, does not really consider codependency. Is it A thing? Sure, but it is not THE thing. And there are other words and phenomena used in psychoanalysis to discuss attachment and relationships.
So it could very well be that I wasn't using it or hearing it because of my focus. Additionally in all my years of clinical work I haven’t known too many seasoned clinicians to lead with diagnosis or labels. Believe it or not, I’ve heard diagnosis thrown around a lot more on social media and in the general public than I ever have with licensed clinicians. But I’m a scientist, so I decided to go a little deeper than my initial thought. And further investigate this lack of my consideration of the term codependency with patients and consider the number of times I could have used it or heard it in a case presentation.
Licensed clinicians in the state of California must complete a minimum of 3,000 face to face patient hours. That’s on top of a minimum two year specified graduate degree. These hours must be met with adults, children, couples and groups and all earned under the close supervision of a licensed clinical supervisor. That might not sound like a lot at first glance, but here’s how it breaks down. The fastest one could complete these hours would be at the pace of about 5 patients or clinical hours per day, 5 days a week. That’s 25 hours a week. Four weeks a month. Every single week for a year. No breaks for holidays or vacation and the assumption that no one was ever sick or had to cancel, would equal 1,200 hours in a single year. Give yourself another full year of that with no breaks, holidays or canceled sessions, then add another 6 months of that. So 2.5 years non stop is the quickest you could move through that requirement. In fact, the state gives people seeking licensure up to 6 years to finish those hours. I think it used to be 8. So that’s a lot of opportunity for codependency to come up. And I cannot remember a single time it ever did. But it certainly comes up a lot now. Along with many other terms and diagnoses.
What I find so interesting is that blame is often put on the profession for the use of diagnosis and diagnostic criteria. And yes, the DSM along with many white men of the past have named mental health struggles as a disorder in the DSM and they have been wrong. But when it comes to the current usage of diagnosis this is one of the few times I feel like the profession of psychology isn’t singularly to blame for this truly skewed perspective of diagnosis. Let’s dig in.
First, let’s take a look at the DSM. The DSM is the Diagnostic and Statistical Manual of Mental Disorders. It is a publication by the American Psychiatric Association for the classification of mental disorders using a common language and standard criteria for clinicians. The purpose of the DSM is so that teams of clinicians from different disciplines working with patients can easily and quickly communicate a diagnosis. Imagine a social worker, a psychotherapist, psychiatrist, psychiatric nurse and physician attending to a single patient on a hospital unit. It’s super helpful to have a diagnosis to go on when making decisions about medication and care. A diagnosis in the clinical community is a foundation, but never a single defining presentation of someone’s mental health struggles. I have never met anyone in the professional realm who believes that a patient is nothing more than their diagnosis.
Additionally, the DSM is used to treat patients who have access to medical insurance. Patients are given a code and a diagnosis by a licensed clinician in order to have access to psychotherapy, psychiatric medication, and inpatient and outpatient treatment. And that is a whole different conversation about there is not equitable access to healthcare. I’ll return to that cluster fuck another time.
For now, just know that the DSM is for professionals. There is a reason that this book is not given as a wedding gift, although maybe it should. Ha! It is kind of rendered useless without all those face to face clinical hours and a lot of experience understanding the full spectrum of how mental health concerns present. To pick up the DSM without this experience gives a terribly incomplete picture.
When I come across clinicians who take the stance that they do not believe in diagnosis at all, I have to believe it is because they do not have experience with acute populations in hospital settings. There is a very good reason for the DSM in these treatment team settings. There is no faster way to get everyone on the same page in a crisis than a quick standardized code that allows clinicians to communicate across disciplines and make life saving decisions. And like I said, I never came into contact with a clinician in any of these settings who thought that a patient was no more than a diagnosis. There can be a hospital floor full of patients, some with replicating diagnoses and each and every one of them presents differently. And each of these humans is also warm and wonderful and loving. What I’m saying is, a diagnosis does not make you not a human being.
What I want to address here more than anything is the act of self-diagnosis. And this is a real problem. And it is happening all over social media. And the act of self- diagnosis is being led by people with no business doing so. Ouch.
You may be surprised to find out that given all those clinical hours and education, psychotherapists are not in the habit of self-diagnosis. Nor are we in the habit of diagnosing our partners, kids, family members or friends. One reason being, it’s hard work and we are not paid for that shit. The other more serious, being that even professional clinicians lack the perspective necessary to self-diagnose. Or diagnose someone who is close to them. It is unethical for a therapist or a psychiatrist to treat a family member or close friend for precisely this reason. Not to mention that it is considered a professional standard for psychotherapists with an active case load to be in their own psychotherapy. In fact, you should ask your therapist if they are in therapy. They should say YES. And most of the time psychotherapists are not only in their own therapy, but also part of consultation groups and case conferences with other licensed professionals. The work of maintaining uncompromised perspective is no joke and something that clinicians take very, very seriously. It’s a critically important part of the work. And it is WORK. All caps.
So if licensed professionals are not self-diagnosing or encouraging people to self-diagnose everything from ADHD and depression to codependency to HSP, why the fuck would anyone be encouraging this? Honestly, I’m asking you because I cannot figure it the fuck out.
This self-diagnosis leads to way many more “diagnoses” and labels than actual diagnoses from professionals. Why is this bad? Because it perpetuates the idea that we are our diagnosis. And a diagnosis no less that is probably totally inaccurate. So while I truly appreciate social media expanding the conversation about mental health, I urge you to only consider a diagnosis or formally accept a set of symptoms coming from someone with letters after their name. And only if you are actively their patient. Licensed professionals do not offer diagnoses to anyone who is not actively their patient. It is unethical for the reason that we simply do not know the whole story. And the whole story is important. So important that learning about how to understand the whole story requires an advanced degree and a minimum of 3,000 hours.
At the same time, yes to having access to information about mental health. Read the blog posts, watch the influencer reels. Save the lists on how to navigate stress, anxiety, depression, and ADHD. Lean about things. And if something sounds familiar, seek the opinion of an actual professional. Diagnoses and professional confirmation of symptoms when they are accurate can be incredibly freeing! I felt truly understood when I discussed being HSP with my therapist. It was like someone gave me a roadmap for how I had been feeling my whole life. It made a huge difference for me. An inaccurate diagnosis or alignment with a set of symptoms that are inaccurate can be limiting. And not only limiting but alignment with a set of symptoms that are not confirmed by a licensed professional can actually cover up something deeper. Meaning you could spend a lot of time spinning your wheels in conflict and pain because what really needs to be addressed is not being illuminated.
So when it comes to self-diagnosis remember that the pros don’t do it so maybe you shouldn’t either. Seek a professional opinion because anything else is just a rumor. And you deserve better than that.