On the Difference Between Diagnosing and Understanding

The Diagnostic and Statistical Manual of Mental Disorders (“the DSM”) is a heavy book used by clinicians to diagnose psychiatric illnesses. According to the National Institute of Mental Health, in any given year over 26% of American adults qualify for having at least one of the psychiatric disorders described in the DSM. Since we’re talking about 60 million people in any given year, one might immediately question the very use of the term ‘disorder,’ since the word suggests something abnormal, something outside the common arrangement of things.

In any given year, 15 million adults qualify for some form of depressive disorder (code 296 in the diagnostic taxonomy of the DSM), and 45 million for some form of anxiety disorder (code 300). I say “some form” because the DSM differentiates subsets of these disorders on such factors as the number of times the “illness” has occurred in one’s life and its severity. (e.g. 296.21 for Major Depressive Disorder, Single Episode, Mild). People presenting with issues that can be captured by these depressive and anxiety codes form the main bulk of the practices of many mental health clinicians, including my own.

Many clinicians – and even unfortunately more than a few patients – have fallen victim to a reification of the diagnostic taxonomy, and confuse a descriptive cataloguing of the complicated aspects of human experience with an actual understanding of the genesis and meaning of someone feeling and thinking and behaving a certain way. Saying someone “has Major Depressive Disorder, Recurrent, Moderate” (296.32) says absolutely nothing about why this person is experiencing himself and life in such a way that lead him to have at least 5 of the 9 symptoms the DSM requires for someone to warrant the official diagnosis. And it says even less about what to do about it.

It does however definitively say something about how appropriate it is for someone to have at least 5 of those 9 symptoms: it says that this person is disordered. It’s in the very title of the manual. In our reification of the taxonomy we have not merely conflated description with understanding, we have perpetuated and reinforced our mainstream culture’s judgment and stigmatization and marginalization of suffering.

Of course pharmacological interventions certainly have their place in the treatment of many people. And yet one might argue that a psychiatric system built on the medicating of distressed people might at times benefit from a conflation of symptom description and true understanding of the meaning and cause – and thus in a deep sense the appropriateness – of one’s suffering. In the medical model patients are often understood (not merely described, but understood) as “having major depression.” In this formulation, there is a problem, and the problem is the symptoms, such as difficult feelings; medicate the patient so that the difficult feelings change and there’s no longer any problem. If the difficult feelings return, the problem has returned.

In contrast, in my own humanistic psychotherapeutic tradition – that is, a system that endeavors via an honest relationship to assist people in accessing their own natural movement towards healing and maturity – the intervention is founded upon the assumption that someone who is depressed or anxious is likely responding in an entirely understandable and very common way to the complexities of life, in particular of course to their own unique life and whatever they have learned to believe and assume about it. The symptoms that inform a diagnosis are thus seen as part and parcel of a complex and nuanced and entirely reasonable lived experience. Much of the work in psychotherapy is in understanding and gaining perspective on this lived experience, and building a new way of relating to it.

In all the hundreds of people I have worked with I have yet to really get to know someone – severely “depressed” or “anxious” though they may be – whose internal experience of life didn’t come to make perfect sense. And it is in this making sense, the making meaning, of one’s experience that we can move away from shame and blame (of self and others) and towards compassion and wisdom. And (as is true in both the therapeutic and spiritual traditions) true, non-judgmental understanding is the keystone of peace and grace.

Diagnostic constructs such as “Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features” (296.33) certainly have their place. They are very convenient. They tell an insurance company that a treatment is warranted and they quickly communicate some features of someone’s life. But let us – as patients and as clinicians – always remember that a convenient diagnosis is just that – a convenience that must not obstruct our efforts to deeply understand, honor, and relate wisely to the nuance within the human experience.