In December of 1993, I stood in the psychology section of Barnes and Noble on 17th Street in New York City, caressing a copy of the DSM-III. The book had a stiff, textured, moss-green cover, and it was heavy. In fact, it had gained weight—360 pages of weight, to be exact—since its earlier incarnation as a slipshod, 134-page DSM-II with tattered credibility. But I didn’t know any of these insider details back then. All I knew was that after receiving a mood disorder diagnosis from my first therapist, I wanted answers to questions that had been troubling me. Would I always feel sad? What had caused this problem? When would I get better?
“Doing a little light reading over the holidays?” a middle-aged cashier wearing a Santa hat joked as I handed him the DSM. He processed my credit card, and I pushed the corners of my mouth into what I hoped looked like a nondepressed person’s smile.
A few months earlier, soon after my 24th birthday, I’d walked onto the rooftop of my apartment building at three in the morning and shivered at the roof’s edge. My English literature diploma had proved useless on the job market, my boyfriend had broken up with me, and my mother had left my father to move in with a woman I’d always thought of as a family friend. That night, I’d finished off a bottle of wine by myself. Gazing down at rows of matchbook-sized cars on East 72nd Street, I began recalling some of the problems that had shadowed me since childhood: low self-esteem, chronic loneliness, and a painful, unshakeable sense of my own incorrigible weirdness. Below, the sidewalk beckoned. I imagined stepping into the space beyond the ledge, shifting forward, and letting gravity do the rest.
Although the moment passed, it scared me enough to get me into therapy. A week later, seated across from a petite woman with rhinestone eyeglasses, I shared how close I’d been to taking that small step into empty space, a space I wouldn’t have been able to walk back from.
“I’m really, really glad you’re here,” she’d said. Her gentle voice had communicated concern as she’d asked me questions and waited patiently while I’d stuttered my responses. We’d talked about my drinking habits and my feelings about my parents’ separation.
“Do you have a sense of your goals for therapy?” she’d asked.
“I want to feel normal,” I’d said, though I had no idea what normal felt like.
At our fourth session, she’d given me a receipt to submit to my insurance company so I could get reimbursed for her fees. Below my name, she’d written “major depressive disorder.” When I saw the diagnosis, a chill had spread from my diaphragm through my pelvis. I’d heard of the disorder but had never imagined I might have it. The thought, well, depressed me.
But it also motivated me to travel half-way across the city to Barnes and Noble in search of the DSM, lug it home, and begin sifting through its pages. Major depressive disorder wasn’t in the table of contents, which rather than listing diagnoses alphabetically, had them grouped into impenetrable categories. I searched for a glossary and found only headings, blocks of type, appendixes, contributor lists, and decision trees. Then, out of the blue, partway through the bound stack of sawdust-scented pages, I glimpsed it: my disorder. If I could understand this thing that had nearly pushed me off the roof’s edge, maybe I could avoid a repeat scenario in the future. Intently, voraciously, I began reading.
But words and phrases like hypersomnia, psychomotor agitation, and markedly diminished interest left me perplexed. Clarifications and examples, correlative conjunctions and negations, all got tangled up into a knot of jargon in my brain. Big lists and small ones—some alphabetical, others numerical—had been Frankensteined together into a lengthy, convoluted listicle with mind-numbing powers. Forty-five minutes later, still stumped, I raised the book over my head and shook it, half-hoping a decoder key would fall out onto my lap.
If I ever become a therapist, I thought, this will all make perfect sense.
Eventually, I did go to grad school to become a therapist, and the DSM’s criteria lists did make a bit more sense. Once licensed, I began using protocols and assessments to help me diagnose other people’s mood disorders, anxiety disorders, and addictions. But I’d be lying if I said that even then, parsing the world of diagnosis was no longer a challenge for me—one made infinitely more difficult when insurance reimbursement got factored into an already complicated clinical equation.
Shortly after graduating, I ran groups in a forensic substance abuse clinic with men on parole, most of whom had been convicted of sex offenses. Because the clinic received Medicaid reimbursement for substance-abuse treatment only, every new client’s diagnosis had to fit into a substance-use disorder category, even if they’d never used substances. When I complained about this to my supervisor, he’d replied, “If we don’t see these guys, no one will. Reread the client’s file, talk to their parole officer, find a substance-use issue somewhere. It can be mild. Or else you can put ‘in sustained remission.’”
At my next job, I worked at Bellevue Hospital with people suffering from mental health issues related to the collapse of the Twin Towers. When a client’s problems were unrelated to the terrorist attacks, or to cleanup work at Ground Zero, I found myself in an ethical dilemma: blur the lines when I give the diagnosis to help someone access care, or risk being part of the reason why this person’s access to the program is denied.
I’d become a therapist and studied the DSM to bring clarity and healing to people’s lives, and instead I found myself using diagnosis for other reasons: to leverage resources, maintain the status quo, and sometimes, however inadvertently, to muddy the clinical waters.
There had to be a better way.
What’s Wrong with This Person?
Most clinicians have struggled at some point with this same double bind: they want to help, but they’re required to do so using flawed tools within a flawed system.
“What’s wrong with this person? That’s the question the DSM continuously asks us to focus on,” says Lisa Ferentz, clinical social worker and founder of the Ferentz Institute. “There’s zero diagnostic criteria that allows us to assess for the strengths and resiliency in our clients.”
Research has shown that we have an inborn tendency to fixate on problems—a negativity bias that evolved to help our species survive by keeping fears and unpleasant experiences at the forefront of our minds. Arguably, a similar negativity bias has pervaded the DSM since its inception, in the early 1950s. Maybe it’s even helped it survive, too. As the world’s most sophisticated catalogue of psychological problems, it lures us into an endless quest for the right answer, the appropriate solution, the next diagnostic holy grail—the clinical incantation powerful enough to lessen our clients’ suffering by naming it accurately and precisely. Whatever the reasons for its continuing presence on our bookshelves, according to Ferentz, it sets clinicians up to train their sights on dysfunction when focusing on strengths might lead to better treatment outcomes.
“Traumatized clients already have an inner DSM,” she asserts, “at least when it comes to how they make sense of themselves: I’m crazy, broken, damaged, bad, weird, abnormal. They carry these self-diagnoses around with them constantly. They don’t need an actual DSM to reinforce that. As therapists, we have an ethical responsibility to counteract the negative ways our clients see themselves.”
Early in her career, while working with a volatile, depressed woman trying to retain custody of her eight-year-old daughter during a painful legal battle with her ex-husband, Ferentz learned this lesson firsthand. “One session, I remember thinking, Oh! She has borderline personality disorder. I didn’t mention it to my client, but the minute I diagnosed her that way in my head, our relationship changed,” Ferentz recalls. “From then on, when I opened my appointment book and saw her name, my stomach dropped. My countertransference intensified. I think that’s what the DSM does—it creates assumptions and expectations that make it easy to pigeonhole a person sitting across from you, so you’re waiting for them to think and feel and behave in ways that are commensurate with the DSM’s criteria lists. Technically, she fit criteria for BPD, but that wasn’t the problem: the problem was the diagnosis put a glass ceiling on the extent to which I thought she could grow.”
If this client walked into her office today, Ferentz says she’d have a radically different perspective. “I’d frame the push-pull between us as the attachment-trauma dance, not a function of BPD. I’d view her negative self-talk from an IFS perspective. I never give a client a BPD diagnosis anymore. I don’t even conceptualize people that way. Instead, I consider the possibility that their behavior and relationship dynamics are connected to a history of insecure attachment. If my hunch is confirmed after I get a family-of-origin backstory, I might give them a PTSD diagnosis—or maybe generalized anxiety, depressed mood, or addiction—but only if it’s required for insurance purposes.”
All Shades of Diagnostic Gray
In a 1995 Networker article, “Diagnosing for Dollars,” staff writer Mary Sykes Wylie colorfully describes the phenomenon of medicalization as a “sleight of hand whereby an unpleasant but vague and often ephemeral mental state can, by giving it a name, be magically transmuted into a biological, physical entity, and then acted upon as if it were virtually a Newtonian object in space.” Medicalizing a cluster of symptoms turns a non-thing into a thing—which can impact a client’s state of mind, sense of identity, and behaviors.
“People tend to think about diagnoses as if they’re actual, real entities,” says psychologist Steve Shapiro. “In fact, any diagnosis is just a hypothesis; it’s a cluster of symptoms. You could meet criteria for ADHD because you have a thyroid issue that has nothing to do with the way your brain works. Diagnoses are tools that inform a clinician’s thinking about treatment, but they don’t clarify causes or indicate how you should move forward. If you get lulled into believing a diagnosis is real, you may relate more to a theory than to a person.
“When I talk to clients, I might say, you could meet criteria for OCD,” Shapiro adds. “But that’s not to say you have this disorder. Even if you do meet criteria, it’s a cluster of symptoms. It’s not you. It doesn’t define you.”
Mistaking a diagnosis for a thing can reinforce a misconception that your feelings, impulses, and actions are beyond your control—or even beyond treatment. “I once had a young client who threw a chair at his teacher,” Shapiro tells me. “When I asked the kid’s parents what the consequence was for his action, the mom looked puzzled. ‘Consequence?’ she’d said. ‘He has ADHD.’”
“‘It’s not his fault,’ the dad had clarified. ‘He has an impulse control disorder.’”
“They were thinking, This thing is physical and organic; our child has no agency or responsibility for what happened.
“‘You’re saying, it’s understandable that your child threw a chair at his teacher, given his diagnosis?’ I asked the parents. They nodded in agreement. Then I said, ‘True, it’s understandable. But is it acceptable?’ Inadvertently, they were subcontracting important aspects of parenting out to the child’s psychiatrist, but medication management isn’t a substitute for learning to curb harmful behaviors.”
Even with the problem of medicalization, Shapiro points out, we still need to speak succinctly in our profession and have some semblance of a shared language—a benefit of the DSM’s official nomenclature. “I’ve had therapists say to me, ‘I don’t use that word—defense or resistance or borderline—it’s pathologizing.’ When I ask what they say instead, they usually reply with some version of, ‘Well, I just refer to it as those-things-the-client-does-that-are-hurting-them-now-that-they-learned-to-do-to-protect-themselves-since-they-were-kids-over-time-because-of-their-traumas. But why would you say 75 words when you could use a single word, or diagnosis?”
And, of course, another benefit of working with a thing over a non-thing—meaning, a thing that’s been given a name—is that your clients can now get their cognitive arms around it.
Cambridge-based psychologist Ethan Seidman told me a story about the drawbacks of getting too attached to your opinions about diagnosis, whether you’re someone who sees it as bringing more bad than good into clients’ lives, or more good than bad. Apparently, if we’re comparing benefits and drawbacks, the final word on diagnosing clients comes in all shades of gray.
“I once had a client who for years had berated himself for being ‘lazy’ and ‘unmotivated,’” Seidman explains. “I referred him for neuropsych testing, which confirmed an ADHD diagnosis. This was a huge relief for him. Suddenly, he wasn’t the problem—he was just a guy with a mind that operated differently. From that moment on, our work involved understanding and accepting his mind as it was. He now had a framework for making sense of his behaviors, which allowed him to learn strategies to manage his symptoms and develop more self-compassion.”
Seidman recalls an emotional session when his client—who had a longstanding fascination with planes—finally gave himself permission to pursue a pilot’s license and fulfill his childhood dream of flying. Unfortunately, he soon discovered that his application for a Federal Aviation Administration medical certificate would likely be turned down because of his diagnosis.
“My client sought out a psychiatrist known for helping applicants address concerns with the FAA. The psychiatrist recommended he go off his meds for five years before submitting his application, saying this might increase his chances of getting approved,” Seidman recalls. “But that wasn’t an option for him—he functioned poorly when he didn’t take his meds. Of course, he was heartbroken. In the meantime, he’d read all my treatment notes before passing them on to the psychiatrist, which led to a shift in our work. ‘I’ve been complaining about the same things every week. I guess a part of me thought getting a diagnosis and coming to therapy would magically make me happy,’ he admitted. ‘But I realize now I’m the one who has to actively change things, and now I know what those things are.’ First, the diagnosis helped him, then it hurt him, then it took our work in a whole new direction that helped him again.”
Seidman’s story reminds me of a parable I heard at a meditation retreat once. A farmer’s son gets injured in the fields and can’t work anymore. “This is the worst thing that’s ever happened to us!” the farmer bemoans. A wise villager responds, “We must wait and see.” Soon, all the young men in the village—other than the injured son—are forced to go to war. “I was wrong! My son’s injury was a good thing,” the farmer concludes, to which the wise villager responds, just as he did before, “We must wait and see.”
Many factors contribute to whether a diagnosis is experienced as tragic or positive, harmful or helpful. A disorder’s relevance might shift with the latest scientific research. Diagnoses—and sometimes entire diagnostic categories—are shaped by cultural factors easily overlooked when dominant groups benefit from bias, or when previously marginalized populations achieve power and influence. Constructs change from one DSM edition to the next. Often, both therapist and client must “wait and see.”
“For all the times it’s a problem to diagnose, there are other times when it’s a serious problem not to diagnose,” Seidman concludes, summing up the paradox of diagnosis in a simple, maddening clinical koan.
When Diagnoses Are Weaponized
What makes the issue of diagnosing even more maddening is when it’s co-opted by businesses and corporations for non-mental-health–related purposes. In a 2022 Networker article, “A Therapist Confronts Cancer,” psychologist Anna Lock writes about discovering she had breast cancer at age 37. She went through grueling chemotherapy treatments. A year later, after being declared cancer-free, she suffered what’s known as a chemo flashback. Her training helped her recognize it—along with other symptoms she was experiencing—as PTSD. She sought out mental health support and over time, her symptoms decreased. But when she changed jobs and applied for supplemental life insurance, she received a letter denying her application.
“The reason they gave was my breast cancer and my PTSD,” Lock says. “I wasn’t surprised to see breast cancer on there; I knew I was considered a liability. But when I saw my mental health diagnosis, I was floored. How can you punish someone for getting the help they need to resolve a trauma response to a life-threatening illness?”
We’re warned to “do no harm” as therapists, but is that possible in a society where for-profit businesses use diagnoses against clients? Diagnoses aren’t just misused economically, either. They get weaponized against vulnerable and marginalized populations all the time. Sexualities and gender identities that fall outside the bounds of heteronormative standards have long been classified as perversions, pathologies, disorders, and disturbances, providing fodder for hate crimes and buttressing the structural marginalization of LGBTQ people.
In her book Decolonizing Therapy, psychologist Jennifer Mullan explores how the DSM, along with our mental health system, functions as an arm of white supremacy by overemphasizing pseudo-biomedical explanations for suffering and ignoring social contributors to illness, like systemic racism. “Black Americans,” she notes, “are around five times more likely than white Americans to be labeled ‘schizophrenic.’” What does that say about the function of diagnosis?
I try to imagine a different DSM. Maybe post-traumatic slave syndrome—author and researcher Joy DeGruy’s term for the enduring, multigenerational suffering and oppression of African Americans and their descendants in the US since slavery—makes it into the Trauma- and Stressor-Related Disorders section and begins shaping research and influencing government policies and decisions. Maybe a slew of new diagnoses like white-privilege disorder, gun-rationalization mania, and irresponsible-ejaculation personality disorder make it in, too, changing the cultural narrative as they show up with increasing regularity on invoices and insurance receipts, medication prescriptions and treatment plans. Would this alternate DSM be dismissed as absurd or biased? What if the field had accepted these diagnoses long ago, and they’d helped us give context to clients’ painful symptoms and dysfunctional behaviors?
A Never-Ending Adjustment Disorder
After my initial post-rooftop therapy sessions, whenever I saw a new therapist, I asked what diagnosis they were planning to use on my receipts and invoices. Sometimes, my therapist and I discussed the pros and cons of generalized anxiety disorder, PTSD, and dysthymia, but usually, we settled on adjustment disorder as the best label for whatever I happened to be going through. I was given adjustment disorder with anxiety, adjustment disorder with depressed mood, seasonal adjustment disorder, adjustment disorder with mixed emotional features, and even—my personal favorite—unspecified adjustment disorder. For that one, I got to fill in the blanks.
Adjustment disorder has somehow eluded the stigma of a “what’s wrong” negativity bias. Try asking yourself, “What am I having a hard time adjusting to right now?” There’s always something. The struggle to adjust is universal and constant. Our lives unfold—to a greater or lesser degree—as one long, never-ending, ever-changing adjustment disorder—a series of gains and losses, reorientations, and creative adaptations to predictable and unpredictable events.
Because I now work in private practice rather than at a substance-abuse clinic or hospital, I have more freedom in how I diagnose clients. When I see a new client in the middle of a divorce, grieving a death, changing careers, or moving a child into their college dorm, adjustment disorder often seems like the safest, least stigmatizing option, all things considered—including my desire to “do no harm.” I’ve heard many clinicians lament adjustment disorder’s supposed six-month insurance eligibility expiration date, but I have yet to hear back from a client that their claim was denied because their adjustment disorder diagnosis had expired.
The Real Diagnosis
Integrative psychotherapist Sabrina N’Diaye tells me a story about a teenage client who began her session with, “I think it’s important for you to know that I have borderline personality disorder. I read all about it on TikTok, and I fit the criteria.”
N’Diaye recalls steadying herself. As the mother of two adult daughters, she’s familiar with the ways adolescents try on identities to discover who they are. As she learned more about her client, she came to believe the young woman was having relatively normal reactions to the challenges she was facing at home, at school, and with her friends and romantic partners, given her age and stage of development.
“Don’t you think maybe all teenagers have a little bit of borderline personality disorder in them?” N’Diaye had asked her.
“Maybe,” she’d responded, “but I have a severe case.”
“What makes it severe?” N’Diaye had pressed, not invalidating her client’s self-diagnosis, but not jumping on board with it, either. As she recalls, “We ended up using it as a starting point for exploring her self-concept and her fears about having intimate relationships.”
N’Diaye admits that she’s never been a big fan of quantifying experiences or putting people in boxes. In one agency, where reimbursement was based entirely on the DSM, she included a formal diagnosis when developing a treatment plan, but then identified what she thought of as the real diagnosis through a group process she and other clinicians in the practice had made a regular part of peer supervision and case management.
“We’d sit together in a circle seeking a psychospiritual diagnosis, one that reflected the client’s deepest needs. There was no manual or book for what we did—we were the book. We’d present a case, share what we knew about the client, their family, what they’d overcome, their trauma, and then we’d close our eyes. We’d sense this client through our bodies, nervous systems, and hearts. One of us might say, ‘Lonely soul seeking guidance,’ or ‘Heartbroken survivor in need of safety.’ The official diagnosis might be oppositional defiant disorder or bipolar disorder, but as a team, even if medication was involved, we’d focus on treating the loneliness, heartbreak, lack of safety—whatever we’d identified as the root of their pain.”
I try to imagine a group of professionals approaching a client like this: sharing important facts about them and then choosing—collectively—to shift their attention inward as they make space for their own inner, embodied connection to the client’s pain. I’m in awe after N’Diaye’s story, but a little jealous, too. I wonder if my past therapists put themselves in my shoes as wholeheartedly as N’Diaye and her colleagues did in theirs.
Which psychospiritual diagnosis would they have given me at age 24? Orphan seeking home? Lost child craving attention? Whatever description they might have come up with, I’m pretty sure it would’ve held some essential truth that my diagnosis of major depressive disorder had missed. Maybe, if I’d read it on my insurance receipt, I would’ve felt understood, like someone I respected knew what I was going through. Maybe I would have felt normal.
Illustration by Quiet Word
Alicia Muñoz, LPC, is a certified couples therapist, and author of four relationship books, including Stop Overthinking Your Relationship: Break the Cycle of Anxious Rumination to Nurture Love, Trust, and Connection With Your Partner (New Harbinger Publications, 2022). Over the past 16 years, she’s provided individual, group, and couples therapy in clinical settings, including Bellevue Hospital in New York, NY. Muñoz currently works as a Senior Writer and Editor at Psychotherapy Networker and as a couples therapist in private practice. She connects with her readers and followers through monthly blogs, newsletters, and podcasts as well as Instagram, Facebook, and Twitter. Muñoz is a member of the Washington School of Psychiatry, the American Psychological Association, and the Mid-Atlantic Association of Imago and Relationship Therapists. You can learn more about her at www.aliciamunoz.com.