Diagnosis and Trauma-informed care

Recently, a new psychotherapy client asked me: “What’s my diagnosis?” This certainly is a valid and appropriate question as you’re embarking upon therapy. However, a formal DSM-5 diagnosis rarely, if ever, captures the entire story; moreover, from a trauma-informed point of view, it can distort and pathologize a person’s suffering.

People generally seek out therapy because they are experiencing distress in their lives. Often, people will find their careers, friendships and family relationships negatively impacted by this distress, which translates, in concrete terms, into dysfunctional and negative behaviors. This same client told me: “I get so angry, I won’t stop until someone else is in a bad mood. I hope I’m not a toxic person.”

The question “what’s my diagnosis?” speaks to several challenges in the mental health field which I regularly encounter. Most problematically, from my point of view, is that it equates emotional and psychic distress with a concrete medical concern, such as a broken bone, which can be placed in a cast, and given a fairly reliable prognosis. It implies that a predictable course of treatment will remedy the presenting issue. It frames mental health diagnoses as “brain diseases,” which can be addressed by drug treatments which target specific neurotransmitters. While this idea is appealing, the evidence behind this is thin and flawed, and in reality, it often looks like what I recently heard referred to as “doing surgery with boxing gloves on.”

Trauma-informed care succinctly changes the focus from “What’s wrong with me?” to “What happened to me?” This also significantly reframes a statement such as “I hope I’m not a toxic person.” The truth is that most, if not all of us, carry with us a part (or multiple parts) that is wounded, and therefore finds itself “acting out” or “toxic.” And we all carry shame around those parts/behaviors, which is often buried deep and a source of deep pain.

Training in trauma-informed modalities, especially Internal Family Systems (IFS), has made a profound impact in how I view diagnosis and how I approach treatment. The IFS model posits that we are all made up of multiple parts that play different roles; many of our parts are protectors that protect us from having overwhelming and untenable emotional experiences. From an IFS perspective “... we see DSM diagnoses as various ways of describing the behaviors of activated parts.” (Anderson, F. G., Sweezy, M., & Schwartz, R. C., 2017, p.13)

Back to the client referred to above: her symptoms and behaviors are certainly in line with a diagnosis of Borderline Personality Disorder (BPD) (for reasons beyond what is outlined in this article), and I did share this with her. Being trauma-informed adds dimension and nuance to this diagnosis. It is no longer solely an issue of her “toxic” behaviors; it also addresses in a deep and compassionate way her genuine experience of deep suffering. This is the experience of being seen/being witnessed, and is the beginning of healing.

(A more comprehensive overview of the IFS model is on the IFS website www.centerforselfleadership.org.)

References
Adverse Childhood Experiences. (n.d.). Retrieved from https://www.psychologytoday.com/us/blog/breaking-the-silence/201901/adverse-childhood-experiences
All Parts are Welcome. (n.d.). Retrieved from https://www.selfleadership.org/outline-of-the-Internal-family-systems-model.html
Anderson, F. G., Sweezy, M., & Schwartz, R. C. (2017). Internal family systems skills training manual: Trauma-informed treatment for anxiety, depression, PTSD & substance abuse. PESI Publishing & Media.
Diagnostic and statistical manual of mental disorders. (2013). American Psychiatric Publishing.
Greenberg, G. (2019, March 19). Psychiatry's Incurable Hubris. Retrieved from https://www.theatlantic.com/magazine/archive/2019/04/mind-fixers-anne-harrington/583228/
Herman, J. L. (2005). Trauma and recovery. W. Ross MacDonald School, Resource Services Library.
Kirsch, I. (2009). Emperor's new drugs: Exploding the antidepressant myth. Basic Books.
Kolk, B. V. (2015). The Body Keeps the Score. Penguin.
Simons, P. (2019, March 13). Mental Health Concerns Not "Brain Disorders," Say Researchers. Retrieved from https://www.madinamerica.com/2019/03/mental-health-concerns-not-brain-disorders-say-researchers/