Real World Clinical Social Work Blog: The Chicken, the Egg, and the DSM

by Dr. Danna R. Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way  

     There is something inherently redundant about having a conversation about diagnosis. As social workers, we agree that there is a lot about diagnosis that is incredibly problematic. We also find ways to work in systems that make use of, if not over rely upon, diagnosis. We try and exert astounding amounts of energy thinking both diagnostically and holistically, often occupying multiple states of conceptualization at the same time. We create treatment plans in accordance with diagnosis and create goals with it in mind, too. We do a crazy dance to keep the client from knowing what we are thinking diagnostically, while attending to diagnosis in supervision and in team meetings. We bill according to it, we think about medication in light of it, and we often create interventions with it in mind. All the while, we are actually feeling quite uncomfortable with the fact of diagnosis and questioning its destructive power.

     I have a client who was diagnosed with ODD when he was seven years old. He kicked a kid (really hard) and was discharged from his school. When he was nine years old, he was diagnosed with Asperger’s syndrome, before it was understood as a place on the autism spectrum. He didn’t have a lot of friends and often wandered around the school playground alone. When he was sixteen, he was diagnosed with bipolar disorder and was put on several anti-psychotic medications, including Lithium, Abilify, and Risperdal. Perhaps this trajectory of diagnoses sounds extreme. I can assure you, it is not. In fact, it is startlingly common.

     Today, he is not on any medication and feels terrified to see a psychiatrist, though he could probably really benefit from an antidepressant for his very low moods. When he talks about being diagnosed with Asperger’s, he talks about how this infiltrated his sense of self. He was told that he was poor at socializing, that his eye contact was sub-par, that he fixated on one or two subjects and needed to diversify his interests in order to ever make friends. He spent years of his life socially isolated, in his bedroom, playing video games. He imagined that he could never develop socialization skills because he simply didn’t have them. Born wrong.

Chicken. Egg. Egg. Chicken.

     Let’s hypothesize that his original ODD diagnosis scared him about his own power and aggression so much that he decided that the best way to self regulate, at a young age, was to turn totally inward. In turning inward, he shut down his desire for connection and for attachment. The desire was so overwhelming that he stopped even looking people in the eye and took comfort, only, in the musings of his own mind. As a byproduct of this comfort, he started to find a few powerful interests. He fell in love with the possibility of space travel and Vatican history. The topics are somewhat obscure, sure. But they also guaranteed him the self regulation he was looking for. If he had become obsessed with video games, he would have wanted to talk to other kids about it. But he had come to believe that he was terrifying to other kids and that he might hurt them. So, really it was best to have odd interests that didn’t interest others.

     Entering early adolescence, the loneliness became unbearable. He found that he was devastated by the loneliness, poorly versed in how to connect with others, and would drink and use excessive amounts of drugs to drown out his inhibitions. When high on drugs, typically cocaine, he would lose complete control of his impulses. He once walked down a busy set of train tracks just to see what would happen. Another time, he spent more than $1,000 of his very low income parents’ money to throw a huge party. The bipolar diagnosis, of course, made sense.

     We know that diagnosis is reductive and doesn’t really honor the complex idiosyncrasy of the human mind. We also know, on some level, that it can be used as a form of social control. For example, African American men are diagnosed with schizophrenia at levels that are four to five times more than other groups. Following the diagnosis, of course, is the intense medication. That means that there are portions of our population that are being medicated for diagnoses that are unevenly distributed between ethnic and socioeconomic groups. That is just plain dangerous.

    But we also know that we can’t surrender it completely. For a social worker in a school, the only way to even get a student an IEP (individualized education plan) is through the use of a mental health diagnosis. For many who are suffering the negative psychological impact of ravaging poverty, the only way to receive Social Security disability benefits is through use of a diagnosis. For veterans, the only way to become service connected for therapy is through diagnosis. So, we just do it. We do what we have to do and we fill out the DSM code and move on.

     I think I am wondering if we can ever really move on, though.

     I am not suggesting that we give up on diagnosis. That, too, would be as reductive as diagnosis can be. It would also negate the number of people who feel unbelievably relieved by diagnosis because it helps them to better understand themselves. I do think, though, that we need to seriously question a few things. First, can we ever diagnose someone and return to thinking of them in a way that is free of that diagnosis? Second, is there a way we can use diagnosis that keeps us from being completely complicit in a system that oppresses our clients? Third, is there a way to use diagnosis that will allow us to remain steadfastly aware of the actual underlying debilitating impact of racism, sexism, poverty, and discrimination?

     I am not sure of the answers to these questions. I know that when I am thinking diagnostically, I am fleeing the intimacy of a clinical encounter. For example, when my client above doesn’t make eye contact with me, I find myself wondering if he really does have Asperger’s syndrome. In that curiosity, I am removed from how the material we are talking about is painful and making eye contact only makes him feel more unbearably vulnerable. When I have a client who can’t keep a job, I start to wonder about whether or not that client has a borderline level of instability. Instead of working on the grief, rejection, and destabilization that come from not sustaining employment, I start to intellectualize. I picture my big purple book, which used to be gray, and flip a list of bullet points in my mind.

     I have never had a clinical moment that was deepened by diagnosis. I have, on the other hand, had many moments when the work was diluted, cheapened, and oversimplified by it. I have never seen a social worker care more deeply about a client following a diagnosis. I have, on the other hand, seen many social workers stop thinking critically about a case the second the words, “Oh, they are just anxious, narcissistic, depressed, obsessive, histrionic,” are uttered.

     I think we need to wonder about whether diagnosis is a necessary or tolerable evil or if diagnosis is actually creating stories of struggle and strife for our clients. What if my client had never gotten the original ODD diagnosis? Would his trajectory have been the same? I am sure it would not have. That is true for the, literally, millions of kids who are being diagnosed and medicated now. The diagnosis is telling the story. The story is not informing the diagnosis. Within, behind, in front of, every diagnosis is a complex soul trying to make sense of the world.

     Let’s remember that some of those souls even wrote the actual DSM. The DSM writers, committees, thinkers, are all people who are struggling to make sense of the world. Perhaps the DSM is a symptom of their anxiety or of their acting out. I know they wouldn’t necessarily be diagnosed with anything, because they wrote the book.

     What I am trying to say is that the book is symbolic of a search, but should not eclipse the search of others. It is achingly ironic, because the fact of diagnosis is that it leaves us feeling quite internally split. Should we? Shouldn’t we? That level of internal splitting feels horrible to us. You all know the feeling well. If diagnosing fragments your professional soul and vision, imagine how deteriorating it is to the mind that does not know to question the supposed objectivity of it. It fragments, confuses, and then defines in ways that we must start to truly consider if we are going to create full assessments of our clients’ histories, stories, and battles.

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way. Get the book at Amazon.com.