A Case for Strengths-Based Diagnosis

[Obligatory disclaimer that I am not (yet) a licensed therapist and that the following is my personal opinion, informed by practice and academic study.]

Recently in a class on adult psychopathology, my professor was discussing the strengths and weaknesses of the DSM (Diagnostic and Statistical Manual of Mental Disorders), the text used to diagnose mental illnesses and categorize them for the purposes such as research, insurance billing, and sharing information among professionals.

One of the weaknesses he mentioned was one I’d actually never heard before: that the way the DSM diagnosis is written and shared does not include any space for also “diagnosing” the client’s strengths.

At first, this seemed irrelevant to me, not in the sense that thinking about your client’s strengths is not important, but in the sense that I didn’t see how it matters for a diagnosis. It almost seemed a little patronizing: “Yes, you have major depressive disorder and social phobia, but hey, at least you seem like you’re pretty resourceful and good at expressing yourself!”

But then I rethought that.

Here’s an example of a DSM-V diagnosis:

296.35 (F33.41) Major depressive disorder, early onset, recurrent episode, in partial remission, with atypical features

300.4 (F34.1) Persistent depressive disorder, early onset, with atypical features, with intermittent major depressive episodes, without current episode, moderate

V62.89 (Z60.0) Phase of life problem

It’s honestly difficult for me to imagine looking at this information with anything other than relief. For me, diagnosis has always meant one thing first and foremost: You’re not a terrible person; you just have an illness.

But to other people, seeing something like this can communicate a whole lot else. You’re sick. You’re fucked up. There is nothing redeeming about you. You can’t do something as simple as not being so sad. This is especially true when someone is already predisposed to interpret information about themselves in a negative light, because, well, that’s what mental illness always does.

In that moment, it can be really helpful to have confirmation–not just from a friend or loved one, but from a professional whose job it is to assess you–that you do have strengths and positive qualities.

So, here are some reasons incorporating strengths into diagnoses might be a really good thing.

  1. Giving hope and affirmation to the client.

Just like it can be nice to go get a dental checkup and hear, “You’ve been doing a great job at preventing cavities, but you need to floss more consistently in order to keep your gums from getting irritated,” it can be nice to hear, “Based on what you’ve told me, I believe that you’ve had a major depressive episode for the past few months. However, you’ve clearly been very good at reaching out to friends and family for support, and it sounds like you have a lot of people rooting for you to get better.”

Therapists and psychiatrists say “nice” things like this all the time, but writing it down as part of a diagnosis might be symbolically meaningful. To the client, that communicates the fact that their strengths are just as important as their diagnosis–important enough to be written on the form or in the chart. It shows that their mental healthcare provider, whom they might feel shy around or even judged by, does see them as a whole human being with strengths as well as a diagnosable illness.

  1. Providing possible avenues for treatment.

A psychiatrist may diagnose a client and then refer them to a therapist (therapy combined with medication tends to be more effective than either in isolation). Now what? The therapist can look at the diagnosis, or ask the client what it is, and proceed from there.

What if the diagnosis included something like, “Client reports that volunteer work helps them distract themselves from symptoms, and that writing in a journal has occasionally been helpful”? The therapist now has some potential ways to help the client. Or the diagnosis might include, “Despite severe symptoms, client shows a high level of insight about the possible origins of their depression.” The therapist now knows that lack of self-awareness isn’t the problem–symptom management might be.

I continue to be amazed that none of my therapists ever asked me if there’s any way I could incorporate writing into my depression recovery, or if there are any ways I’ve been incorporating it already. Writing is my life. Usually I’ve either said as much in therapy, or I haven’t because nobody ever asked me what I like to do or what makes me feel good. Why not?

  1. Reducing negative bias from providers.

I can’t make definitive statements without more research, but based on what I understand about bias, I can imagine that consistently viewing a client as “major depressive disorder with atypical features and moderate persistent depressive disorder” does things to one’s perception of that person. Not positive things.

It is difficult (if not impossible) to effectively help someone you view as deficient or weak. First of all, your likely pessimism about the person’s recovery will almost certainly be perceived (and possibly internalized) by them. Second, any roadblocks that come up in treatment will likely be interpreted as “resistance” or “not really wanting to get better” or “not being ready to do the work of therapy.” In fact, maybe it’s that your approach isn’t actually helpful to them. Third, without a conscious awareness of the person’s strengths and assets, what exactly are you using to help them recover? Therapy isn’t about “healing” people so much as helping them discover their own resources and help themselves. If you don’t even know what those might be, how could you possibly help the client see them?

Many therapists try to think of their clients’ positive traits in addition to their “negative” ones. However, formalizing and structuring this process as part of a diagnosis might make it sink in better, and become more embedded in one’s general impression of a person. The questions we generally have to ask while diagnosing someone are fairly negatively oriented–”Do you ever have trouble falling asleep? How often? To what extent does this impact your daily life?”. What if we also asked, “What helps you sleep better? How do you cope with being tired after a night of insomnia?” Maybe that can help shift a therapist’s perspective of this person from “insomniac” to “person with difficulty sleeping, who has reached out to friends for help with daily tasks.”

  1. Preventing provider burnout.

I dislike talking about my work because people are consistently amazed at it in a way that annoys me. “How could you deal with hearing these awful things?” they ask. “Isn’t it really depressing to work with all these people?” It isn’t, because thanks to my training, I’ve internalized a strengths-based perspective. When I think about the people I’ve worked with, I don’t see poor suffering depressives and trauma victims. I see resilient, determined individuals who are working to overcome their challenges in the best ways they can.

I think that some people in this field burn out because they can only see the suffering and the oppression and the unfairness of it. I also see those things, obviously, because they’re sort of a big deal. But if that’s all you see when you sit with a client, not only will that be reflected in your treatment of them, but it’ll also impact your own ability to persevere.

If every time a therapist made a diagnosis, they had to intentionally remind themselves of the client’s strengths, that might go a far way in helping them remember that there is hope and everything is not absolutely bad.

As I’ve mentioned, plenty of mental health professionals already incorporate a strengths-based perspective into their work. But this is more common in areas like social work, where diagnosis is rarely used and actually often criticized, anyway. I certainly don’t remember any of my psychiatrists or PhD-level therapists spending any time asking me about my strengths or coping strategies. They gave me my diagnosis, and that was mainly it as far as assessment goes.

One might argue that strengths assessment has no place in the DSM because it needs to be standardized and reliable. However, reliability may be a problem for the DSM regardless, meaning that different professionals assessing the same client may disagree in their DSM-based diagnosis.

One might also argue that the DSM is “about” mental disorders, not “about” a client’s overall set of traits or strengths. I’ll grant that. Regardless, I think that formally incorporating individual strengths into clinical assessments in therapy and psychiatry may be helpful. May be.

Criticizing Psychiatry Without Throwing the Baby Out with the Bathwater

So, I read this article in The Atlantic called “The Real Problems with Psychiatry” and…I’m torn. The article is an interview with this guy Gary Greenberg, a therapist who has previously written a book called Manufacturing Depression: The Secret History of a Modern Disease and has now followed that up with The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry.

Now, to be clear, I haven’t read either of these books. I might, just to see the full depth of his arguments. But I decided to read the interview anyway and assume that he accurately represented his own claims in it.

Parts of the interview, I think, are really on point. Greenberg discusses the history of the DSM (the manual used to diagnose mental disorders) as a way for psychiatry as a discipline to establish credibility alongside other types of medicine. He criticizes the DSM on the grounds that the mental diagnoses that we currently have may not necessary be the best way to conceptualize mental illness, and he thinks that once we gain a better understanding of the brain we will find that they have little to do with the physical reality of mental illness:

Research on the brain is still in its infancy. Do you think we will ever know enough about the brain to prove that certain psychiatric diagnoses have a direct biological cause?

I’d be willing to bet everything that whenever it happens, whatever we find out about the brain and mental suffering is not going to map, at all, onto the DSM categories. Let’s say we can elucidate the entire structure of a given kind of mental suffering. We’re not going to be able to say, “here’s Major Depressive Disorder, and here’s what it looks like in the brain.” If there’s any success, it will involve a whole remapping of the terrain of mental disorders. And psychiatry may very likely take very small findings and trump them up into something they aren’t. But the most honest outcome would be to go back to the old days and just look at symptoms. They might get good at elucidating the circuitry of fear or anxiety or these kinds of things.

I don’t know if he’s right. But I suspect that he might be.

He also makes a great point about the fact that we often assume that anyone who acts against social norms, for instance by committing a terrible crime, must necessarily be mentally ill:

It’s our characteristic way of chalking up what we think is “evil” to what we think of as mental disease. Our gut reaction is always “that was really sick. Those guys in Boston — they were really sick.” But how do we know? Unless you decide in advance that anybody who does anything heinous is sick. This society is very wary of using the term “evil.” But I firmly believe there is such a thing as evil. It’s circular — thinking that anybody who commits suicide is depressed; anybody who goes into a school with a loaded gun and shoots people must have a mental illness.

Greenberg also discusses how mental diagnoses have historically been used to perpetuate injustice, such as the infamous “disorder” of “drapetomania,” which was thought to cause slaves to try to escape their masters, and the fact that homosexuality was once considered a mental illness (and other types of sexual/gender variance still are).

He also talks a lot about how the DSM and its categories are tied in with all sorts of things: scientific research and mental healthcare coverage, for instance:

To get an indication from the FDA, a drug company has to tie its drug to a DSM disorder. You can’t just develop a drug for anxiety. You have to develop the drug for Generalized Anxiety Disorder or Major Depressive Disorder. You can’t just ask for special services for a student who is awkward. You have to get special services for a student with autism. In court, mental illnesses come from the DSM. If you want insurance to pay for your therapy, you have to be diagnosed with a mental illness.

The point about needing a DSM diagnosis in order to receive insurance coverage is really important and cannot be overstated (in fact, I wish he’d given it more than a sentence, but again, he did write books). As someone who plans to eventually practice therapy without necessarily having to formerly diagnose all of my clients, this matters to me a lot, because it may mean that I might have to choose between diagnosing and working only with clients who can afford therapy without insurance coverage (which, at at least $100 per weekly session, would really not be many).

But sometimes Greenberg makes a good point while also making a terrible point:

One of the overlooked ways is that diagnoses can change people’s lives for the better. Asperger’s Syndrome is probably the most successful psychiatric disorder ever in this respect. It created a community. It gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed. It can also have bad effects. A depression diagnosis gives people an identity formed around having a disease that we know doesn’t exist, and how that can divert resources from where they might be needed.

First of all, we don’t “know” that depression “doesn’t exist.” We know–or, more accurately, some of us suspect–that the diagnosis we call “major depression” might not map on very accurately to what’s actually going on in the brains of people who are diagnosed with it. What we call “major depression” is a large cluster of possible symptoms, and since you only have to have some of them in order to be diagnosed, two people with the exact same diagnosis could have almost completely different symptomology. Further, because depression can vary like a spectrum in its severity, the cut-off point for what’s clinical depression and what’s not can be rather arbitrary. It’s not like with other types of illnesses, where either you have a tumor or you don’t, either you have a pathogen in your bloodstream or you don’t.

Second, Greenberg doesn’t seem to extend his analysis of the effects of the Asperger’s diagnosis onto other disorders. There is absolutely a community of people who have (had) depression, eating disorders, anxiety, and so on. Those communities are absolutely valuable. My life would be demonstrably worse without these communities. They haven’t “diverted resources” from anything other than me wallowing in self-pity because I feel like I’m the only person going through these things–which is how I used to feel.

Right after that:

What are the dangers of over-diagnosing a population? Are false positives worse than false negatives?

I believe that false positives, people who are diagnosed because there’s a diagnosis for them and they show up in a doctor’s office, is a much bigger problem. It changes people’s identities, it encourages the use of drugs whose side effects and long-term effects are unknown, and main effects are poorly understood.

Greenberg is correct that false positives are a problem and that diagnosing someone with a mental illness that they do not have can be very harmful. However, his dismissiveness of the problem of false negatives–people who do have mental illnesses but never get diagnosis or treatment–is stunning coming from someone who is a practicing therapist. Untreated mental illnesses are nothing to mess around with. They can lead to death, by suicide or (in the case of eating disorders) otherwise. Even if things never get to that point, they can ruin friendships, relationships, marriages, careers, lives. While I get that Greenberg has an agenda to push here, some acknowledgment of that fact would’ve been very much warranted.

In short, Greenberg seems to make the logical leap that many critics of psychiatry and the DSM do; that is, because there is much to criticize about them and because it’s unclear how valid the DSM diagnoses are, therefore depression is “a disease that we know doesn’t exist” and antidepressants are harmful (that’s a whole other topic, though).

Antidepressants may very well be harmful. Diagnostic labels may also very well be harmful, for some people. But I think the stronger evidence is that untreated mental suffering is harmful, and sometimes therapy just isn’t enough and cannot work quickly enough–for instance, for someone who is severely depressed to the point that they can’t possibly use any of the insights they may gain in therapy, or to the point that they are about to commit suicide.

I hope that one day we’ll have all the answers we need to minimize both false negatives and false positives. But for now, we don’t, and I worry that attitudes like Greenberg’s may prevent people from getting the help they urgently need, as much as they may simultaneously promote vital criticism and analysis of psychiatry and the DSM.


Note: I didn’t fact-check everything Greenberg said in the interview because I’m hoping that The Atlantic employs fact-checkers. But if you have counter-evidence for anything in that article, even parts I didn’t quote here, please let me know.