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by Joni E. Johnston, Psy.D.

Mental health diagnosis began with the United States Census of 1840 when millions of Americans were faced with the question, "What is the incidence of lunacy or idiocy in your family?" Fortunately for all of us, diagnosis has grown up.

If used appropriately, diagnosis can be a useful tool for both the clinician and the client, one that can save time, money (and, perhaps, additional pain) by pointing the therapeutic relationship in a direction that is backed by solid empirical research. For the new client, it can also provide that first ray of hope.

Finally having a name to put around so much pain can be the first glimmer of hope. I've seen clients who suffered for years with nameless agony, only to read an article about agoraphobia or panic disorder in a popular magazine. Suddenly, they see themselves. If there's a name for it, surely there must be help as well. The relief and hope they felt in learning that they were not alone and that others had gotten better was equal to any therapuetic assistance I could provide thereafter.

As clinicians, diagnosis can help us to efficiently guide our clients into the best possible treatment. Our client comes in complaining of depression. Helpful information, but there are many kinds of depression. So, we begin the diagnostic process by asking questions. Have long have you been depressed? Did something happen recently or did it come out of the blue? Do you have highs that go along with the lows? Have you lost or gained weight in the last six months?

The answers to these questions help us to formulate answers to more the most important one -- how we can help our client get better. As we sort through all of the shapes depression can take, we begin to sort through treatment options. Will this person benefit from medication? If so, what kind? About how long should treatment take? Is this problem likely to go away once the situation gets better or has depression become in part a coping mechanism?

While diagnosis can be a useful tool, let us also keep it in perspective. Like all tools, diagnoses are only as good as the craftspersons using them. Diagnoses inevitably reflect the expertise and, to a greater or lesser degree, the mindset of the diagnostician. Noted psychiatrist, Dr. Thomas Szasz, was quick to poke fun when he observed his colleagues' diagnoses carrying less-than-objective criterion, as evidenced by his tongue-in-cheek definition of narcissitic personality disorder:

"Narcissist: psychoanalytic term for the person who loves himself more than his analyst; considered to be the manifestation of a dire mental disease whose successful treatment depends upon the patient learning to love the analyst more and himself less." --Thomas Szasz, U.S. psychiatrist, in The Second Sin, "Psychoanalysis" (1973).

Clients, too, can unintentionally misuse diagnoses. If taken too seriously, they not only describe past behavior, they justify present ones. "I'm bulimic," is the first thing Sara says during our initial interview. While indeed this diagnosis accurately describes her daily vomiting, her painful body image, her and her bingeing, it the finality of her tone as she makes this statement that concerns me.

In listening to her story, I wonder if being bulimic is becoming as much a part of Sara's identity as being a woman. I know that being female carries with it certain behavioral expectations. Being bulimic will as well. Will she feel like she's lost part of her self (however painful) if she gets better?

Each person with bulilmia is unique. So is each person with panic disorder, depression or any other diagnosis. A therapist who describes his client as an illness rather than an individual will treat her as such. A client who describes herself as "a bulimic," rather than acknowledging that she "has bulimia," runs the risk of trapping herself in a dysfunctional identity.

Austrian satirist Karl Kraus said, "Language is the mother of thought, not its handmaiden." Let us always take seriously the words we use to describe ourselves, and our clients. Whether we realize it or not, these words will dramatically influence what we do and say. Diagnosis is a starting place, a loose framework that can begin to provide some meaning to what seems to be a random assortment of pain.

As clinicians, we can benefit from an awareness of the subjectivity, and the limitations, of diagnoses. While they describe the symptoms, they do not capture the person. Let us use them as a starting point, and view assessment as something that takes place throughout the course of therapy, changing with the ebb and flow of growth. Let us also approach each new client with fresh eyes separate from any diagnoses they may bring with them.

Let us use diagnoses for what they do best. At its best, it captures the symptomatology of the client and gives the insurance company (and perhaps a budding therapist) a framework by which to evaluate treatment. At its worse, it can be used as a label or an excuse.

The true work of therapy is not in diagnosis, but in understanding. As individuals on either side of the couch, let us dwell on the unique aspects of each person's psyche. Let our language respect the survival strategy that often lurks behind self-destructive behaviors or devastating symptoms. After all, it is the differences, the patient's personal strengths and abilities, the strengths of character that have served her well, that provide the key to treatment and to recovery.


Joni E. Johnston, Psy.D., is a clinical psychologist in private practice in Del Mar, California specializing in women's issues. She is the author of Appearance Obsession: Learning to Love the Way You Look (Health Communications; 1994) and the upcoming Lessons From the Other Side of the Couch. She is a weekly relationship columnist for Woman's World Magazine (Dear Joni) and is a corporate consultant in sexual harassment and sex discrimination.


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