Why Therapists Are So Reluctant To Give Diagnoses

When I was a therapy client, I found myself very frustrated by my therapists' refusal to diagnose me. It was all very well that they wanted to treat me as an individual, not a diagnosis, but I wanted to know what I had. It felt like the therapists were just being difficult. Obviously, I was a unique person with my own unique circumstances, but my problems weren't completely unprecedented. You have the DSM! Use it!

And then I started doing life coaching.

Obviously, I am not legally allowed to diagnose or treat anyone with anything, and am also not trained in psychiatric diagnosis, so it's possible that real therapists are getting something out of this that I'm not. But my experience is that, not only am I not allowed to do diagnosis, I'm not sure why I'd want to. I'd go so far as to claim that diagnosis is much more useful for clients than it is for therapists.

From the client perspective, diagnosis is very helpful. You get what's called the Rumpelstiltskin Effect: the benefits of having a diagnosis, separate from any treatments or accommodations the diagnosis gets you.

Getting diagnosed gives you a short phrase you can use to describe what's going on with you when someone asks. A diagnosis allows you to make a special claim for other people's sympathy and tolerance: you have a different problem, not the routine problems everyone is expected to be able to cope with. It also preserves your privacy. "I had a manic episode" or "I had a psychotic break" allows you much more dignity than "I started to believe that I was the reincarnation of Jesus Christ and was the only person who could save the world from demons, and for complicated reasons this wound up with me naked in my front garden drawing a pentacle with a garden gnome."

Having a diagnosis also gives you more control over your own treatment. You can find self-help books aimed at people with the same problems as you. You can find online communities of people who share your mental problems.¹ You can even read the clinical guidelines for your treatment and advocate for yourself if you're not getting evidence-based care.

And... diagnoses also help people feel understood. It's kind of mysterious how this happens, because descriptive diagnoses² are just saying your experiences back at you with a Serious Doctor Voice. But "I have generalized anxiety disorder" really does feel different from "I'm a fearful person." It feels serious and legitimate. It feels like your problems aren't because you're a bad person or a failure. It feels simultaneously like you're different from other people, and like there are other people like you. When you have diverse and seemingly unrelated symptoms—as in autism or a personality disorder—it crystallizes all your symptoms as part of the same problem.

Of course, some people don't benefit from a diagnosis, and prefer to think of their problems from a nonmedical frame. But those people usually aren't sitting in the therapist's office going "come on, doc, just tell me what I HAVE."

But from the therapist or life coach perspective, diagnoses are remarkably unhelpful.

Scott Alexander once wrote:

The DSM is written mostly by academics, which is why it gets so excited about distinctions like schizoid personality versus schizotypal personality. If it were written by clinicians, it might better reflect the sort of cases that make it into a hospital.

There would, for example, be an entire chapter on the scourge of ‘My Boyfriend Broke Up With Me’ spectrum disorders... And the sufferers of ‘This Patient Probably Has Some Kind Of Complicated Neurological Problem But Neurology Is Tired Of Trying To Figure It Out So They Have Declared It To Be Psychiatric’ might at last get some relief.

But the biggest change to the medical lexicon would be the introduction of ‘Poverty NOS’.

From my own experience as a life coach, I'd add other diagnoses. 'All My Friends Are Really Cool, But I Don't Want To Date Any Of Them, So If I Want To Meet A Spouse I Have To Go On First Dates With Other People, Nearly All Of Whom Are Way Less Cool Than My Friends, So I Don't Wanna And I'm Single And It Sucks', for example. 'I Would Like To Be Trans, Or Not To Be Trans, And I Need Permission From An Established Authority To Do So'. And of course let's not forget the horrors of 'American Immigration System NOS.'

People's suffering comes from a complicated and idiosyncratic context, none of which shows up in a DSM-V diagnosis. If I'm talking to someone who—say—is scared of bringing up his preferences to his friends and girlfriend, I'm going to ask myself questions like "is his fear rational, because his friends and girlfriend are all assholes?" and "in what situations was he able to bring up his preferences in the past? Could we make this situation more like those?" and "what does he think will go wrong if he brings up his preferences?"

I am absolutely not going to ask myself "does this man technically fit criteria for generalized anxiety disorder?" Who cares?

My job is to help my clients solve their problems. It doesn't matter to me if their problems are normal or unusual, if they're "healthy" or "sick", or whether insurance companies would deign to cover them seeing a real mental health professional. What matters is all the stuff that doesn't wind up in the DSM because it's so specific to the individual.

Alice might be so miserable she can't get out of bed because she's very lonely. Bob might be so miserable he can't get out of bed because he’s in a self-perpetuating cycle where his life is awful so he never does anything so his life is awful. Cedar might be so miserable they can't get out of bed because they're freaked out about the AI apocalypse. All three might qualify for a diagnosis of clinical depression, but what I should do about them is completely different!

Alice needs to be told that humans are social creatures and it is unreasonable to expect to be happy if you’re totally socially isolated; in the short run, she needs to talk to me about her feelings so her loneliness is less acute, and in the long run she needs brainstorming about small steps she can take to find friends. Bob needs to set small, achievable goals to make his life better, such as five minutes of cleaning, a daily walk, or returning to a hobby that made him feel good about himself; I might also want to help him find a psychiatrist. Cedar needs their concerns taken seriously; I will also need to brainstorm with them different frameworks they can use to make the most of the time they have. If I tried to get Alice to do a daily walk, or Bob to read Camus’s The Plague, they would rightly feel I was ignoring the central issue.

Diagnosis presents the problem as internal to the person: your brain chemistry is screwed up, so of course you have depression. But even this early in my life coaching practice, I’ve discovered that that isn’t always so. Sometimes I’m like “your problem is [poverty]/[a complicated undiagnosed neurological problem]/[the American immigration system]. I can’t do anything about that. If it makes you feel better to complain to me for an hour a week, feel free, but I can’t help you with your actual problem.” If I were primarily concerned about diagnoses, I think it would be harder to notice when people have problems I can’t help with.

That said, I have found diagnosis useful sometimes. Some clients have OCD, panic disorder, chronic insomnia, bipolar disorder, or another mental health condition with an evidence-based treatment I am not qualified to provide. If I suspect these conditions, I tell the client that they should go see a mental health professional who provides evidence-based treatment (and help them find one if they want help). If I were a real therapist, I would presumably make those diagnoses and switch from general listening and problem-solving to manualized treatment (or a referral to a psychiatrist).

Why the difference? If you have OCD, you should seek exposure and response prevention therapy from a qualified therapist; if you don’t have OCD, exposure and response prevention won’t help you. If you have depression, you should try doing rewarding activities, figuring out whether your thoughts are rational, and improving your relationships with others—all of which are also useful if you are nonclinically kind of sad. From my perspective, it is useless to distinguish depression and nonclinical sadness.

It makes sense that I have a different relationship to diagnosis than my clients do. Clients already know that they're poor, or that they’re lonely, or that experts are very concerned about the reckless way AI is being developed, or that the American immigration system is a Kafkaesque nightmare. But "some people think the same weird way and have the same weird problems you do" is novel information.

I, on the other hand, enter a life-coaching call for the first time with no context on my clients' lives. Their poverty, loneliness, existential angst, and immigration woes are all new to me. So a diagnosis can be distracting from the individual features of the situation—which are precisely what I need to pay attention to if I want to really help.

1. And if you have BPD, you can rapidly learn to avoid online communities of people who share your mental problems.

2. i.e. those that describe clusters of symptoms (“fever”) instead of a particular cause (“the influenza virus”)