Diagnostic Labels: the Downside

Psychologists and other mental health professionals talk a lot about labels.  There are reasons, of course:  We all know what it means when someone is depressed, for example.  We can understand it as a state of mind aside from it being a diagnostic label.  We know that if someone is schizophrenic, it is a very sad situation.  Labels exist so people can communicate without needing a long explanation each time.  I get that, of course.  In my profession, we also say that to provide the right treatment, we need the right diagnosis; while there is leeway in the treatments that may be provided, there is truth also in the belief that the right diagnosis shapes the treatment options we consider.  To continue with the same example, you would not treat someone depressed in the same way you would someone with a psychosis; however, I would hope that many things would be the same—the caring, the respect, and the remembering that both are human beings with feelings.  It is this last point that I have been thinking about for a long time—for years really.

Those of us who believe that childhood influences who we are can be called psychoanalytic, psychodynamic, at times humanistic or existential.  We also call ourselves holistic, because we are not treating symptoms but trying to help people with the reasons for their unhappiness.  People who have had bad childhoods are well aware of the influence childhood events had and already understand this all too well.  Yet, mental health professionals sometimes forget about the person, his or her issues, and the life experience that brought the person to the point of having a label.  

For example, we all know what depression is and I have had numerous clients come in, self-diagnosed–correctly—with depression.  But what did it mean for these people?  And who was the person who was depressed?  I have had clients who have been through a painful experience, and one that would not end quickly, who were sad all the time and had trouble facing each new day; they were not self-blamers.  But I've also had clients who were depressed because they had very strong, shame-based personalities, and when something happened in life that triggered that shame or perfectionism, they fell into a deep depression.  Both types of client are depressed and need and deserve help, but they are not the same.  I have treated many people who suffered for years with depression who even had the chronic nature of it addressed, but not the issues that lie underneath. They could never measure up to their own beliefs of what they should be and therefore disliked themselves, and one painful symptom perpetuated the other. 

Others would come in and say that they suddenly developed panic attacks and had never had them, and that there was no reason they could think of.  The reason always lay in an aspect of their personality that was now triggered by life circumstances.  I cannot tell you how many young adults I have seen who faced a career choice that was not what the parents favored, and to them, it brought back all the shame and feeling of being disappointing they had when younger.  When this was simply clarified, the relief was significant.  Sometimes people had had their symptoms treated elsewhere and their stories had never been addressed.  We had to go back in time to determine what the trigger was and what came before, who the person was whom the life circumstance happened to.  When these issues are addressed with true compassion and empathy, and the person gains insight, not only the label can go away but more painful traits that make the person so vulnerable.

I remember a woman with agoraphobia, who had suffered from it for several years before coming in.  (I must stress that this example is a composite of many people, as all too many women had a similar story.)  I received a letter from her psychiatrist saying she needed behavioral therapy.  The woman said she was hopeless.  No one had ever asked her why, in her adult years, she developed a fear of leaving her home, or what had happened to cause this.  What was being treated was the agoraphobia, not this whole person with a whole life story.  As it turned out, she had been in an abusive relationship and, like so very many others, had been abused as a child.  She felt extreme shame because of the abuse she suffered, and it was underscored by her abusive husband.  She no longer lived with the abuser, but he still supported her and came around; this, too, is unfortunately very common.  By the time she developed agoraphobia, she felt like everyone could look at her and see that she was no good and was filled with shame.  As a secondary gain, she did not want to go out with her husband and deal with his advances and his insults.  When she gained insight, she was not only not agoraphobic but got a career, became independent, and had a very active social life.  .

What was so sad and frustrating to me was that issues of shame and perfectionism and the many other issues that go with them had been left unaddressed.  People were left thinking they had anxiety disorders, panic disorders, chronic depression, and agoraphobia, for example, without having had their issues addressed.  I cannot tell you how many women I have seen who fit the above description or how many cases of depression caused by people beating themselves up with shame, thinking they are filled with badness, and having panic attacks because they could not stand up for themselves.  After all, they already thought they were selfish and unworthy people.  Those of us who are holistic believe that the whole person matters more than the symptom, even though one does need to cope and get through things.  Those of us with this orientation like to look at and treat the whole person.  But I think all too often well-intentioned people do lose the person behind the label.  They treat the depression, the agoraphobia, the anxiety, the panic and almost forget the person.  What does this symptom or problem mean for this person?  I think sometimes we forget that the person has a life experience and a very important narrative.

So many women have these issues, along with gay people, cultural-ethnic minorities, those who were abused—and the list goes on.  I can’t tell you how many women I alone have treated who had agoraphobia who had been in abusive marriages, and before those relationships, ones with abusive parents; likewise, the number of people suffering depression and anxiety because of shame-based feelings that have become traits in their personalities.  There are tools for coping with depression and anxiety—and those are important to get through the day or night—but when it is time to facilitate healing, we really must remember the whole person sitting across from us who is in pain.  We don’t want to add to the pain by failing to see them or understand.  A know of a man diagnosed with a bipolar illness who wanted to tell his therapist about a dream he had been having, and he dismissed the client by telling him, “That’s just your bipolar illness.”  What was “just” the illness?  The dream?  This man felt erased by treatment and by his label.

While I understand the ways and occasions when labels can be appropriate and what they can convey, I do not have to like them, even though they have their place.  Truthfully, a schizophrenic does not have the same chances as a depressed person, but can we still not remember that some schizophrenics have a sense of humor and some don’t; some are considerate and some are not, and that they are people after all.  No matter how serious a label is, we can remember that the label is not the person.  The label is something the person has, not what the person is, and having and being are not the same.  A label can imply a long, tough course, a hard path; but still, we don’t have to discount it if the person has a pet peeve, gets angry like everyone else, or has certain issues.  I think at all times we need to remember that we treat people, not cases or labels.  We treat people, for certain issues, problems, and maybe sometimes labels, but we treat people.  The person’s problems are not the person, just what a person has.

In my book Fear of the Abyss: Healing the Wounds of Shame and Perfectionism, I discuss issues.  I chose these particular issues because in my eighteen years of practice these are the issues I usually see, regardless of the diagnostic label.  People fell into groups that seemed artificial, and I think those who share issues have much more in common.  Everyone has issues, and many are the same; regardless of the level of severity, people share certain ones.  I hope we can remember how very important it is to treat whole people with respect and empathy, rather than getting stuck on labels. 

I will end with a memory from when I was in graduate school doing a placement in a psychiatric hospital.  Some halfway houses had come to interview several patients who were about to be discharged, and one young man had not been accepted at the halfway house he interviewed for.  He was crying and felt humiliated and rejected.  I mentioned this to the psychiatrist, who laughed, saying that a neurotic, like any of us, would feel ashamed and rejected, but this man was after all psychotic and did not have those feelings.  I was a student and there wasn’t much I could do.  But the patient told me he felt rejected and stupid.  He told me he felt that way, and it is the kind of thinking displayed by the psychiatrist, dismissing what a person is or says because of a label, that makes me dislike them.