podcast

Irene, a freshman psychology student, discusses the nature of mental health diagnosis with her mom, a clinical social worker. They talk about the importance of diagnosis in therapy and the challenges of accurately diagnosing patients. They also discuss the stigma associated with certain diagnoses, such as borderline personality disorder. Irene and her mom reflect on their own experiences with mental health and how it has influenced their perspectives as practitioners. Overall, they emphasize the need for individualized approaches to diagnosis and treatment. Hi, everybody. I'm Irene, a freshman psychology student at Iowa State. Considering the mental health crisis America is in, the nature of mental health diagnosis seems more critical than ever. Today, I'm going to talk with my mom, who is a clinical social worker, about dimensional and categorical diagnosis. Hey, Mom. How are you doing? I'm doing really good. I'm looking forward to this conversation. So, I have a couple questions prepared for you, just to talk a little bit about diagnosis. In your job, how much diagnosis are you doing? What capacity does that play in your job? Maybe I could tell you, listeners, what my job is. I am a social worker, but I'm a clinical social worker, so I see clients for outpatient therapy. And my youngest client is four, and my oldest is 87. So, I have about 30 clinical hours a week with one-on-one patients, and then I do two different group DTC classes to make up a full work week. I am responsible for making original diagnoses sometimes for people who have been referred to the University of Iowa hospitals and clinics, like, for the first time. Like, let's say they go to their, like, their primary care doctor, and they're having some mental health problems, and they're referred to a therapist. So, sometimes I'm the first person doing an assessment for mental health, and then I'll do sort of a full, you know, diagnostic, like, where I'm asking them about specific symptoms and sort of looking for, okay, is this for the flavor of depression or anxiety? Is there any trauma going on? Is there any sort of psychosis? Could this be an adjustment disorder or something that's more... Sometimes I'm doing that, like, the first assessment. So, the first time that you meet with patients, a lot of the times, would you say they're undiagnosed? Sometimes that happens. Other times, someone is coming back into therapy and maybe has many different working diagnoses. Okay. I think it's really... Yeah, I'd like to talk to you about that a little bit. Okay, and I look at their chart, and there's, like, six different things that they've been previously diagnosed with, some of which are opposite of each other. Right. So, how do you figure out with that patient, then, what diagnosis you're going to really take seriously? Say you were to have somebody come in who has been diagnosed with PTSD, and then you also see that they have a personality disorder. I understand that a lot of times those will coexist, but are there times where you see two diagnoses diagnosed together that you feel are maybe incompatible or one of them is inaccurate to the patient? And then I think that it's hard because I think a lot of times, once someone has been diagnosed, they carry that with them for the rest of their life, which I think is not always the case. I think that there's a lot of people who get incorrectly diagnosed, and I think a lot of people also are able to heal from their mental illness, and maybe it's not maybe very healthy for them to then be identifying with it so closely. So, do you counsel patients on that ever? Yeah, I'm interested in a bunch of things that you just said. One thing being, I think it's important to remember that everybody who works in the field, I've noticed, sort of diagnoses people in a different way. Some people like to be really precise, and I think you would say like very categorical. Like, according to them and what the patient told me today about their symptoms, this is their diagnosis, and they kind of put that. So, everybody kind of has a unique way of doing it. I, myself, like to go for something that's kind of the least stigmatizing for the client because of their symptoms. Like, sometimes I have a client come, and they say, I was diagnosed when I was 22 as bipolar. I'm bipolar. And then when I talk to them about how their mental health has unfolded, like let's say they're a person in their 40s, like over the past two decades, it becomes pretty clear to me as a mental health professional that this person has like, yes, some mood regulation issues, maybe some emotional intensity going on, but it is not meeting clinical standards for bipolar disorder. Okay. Right? But then you've had this client maybe taking bipolar medication and identifying as bipolar for two decades when what is actually happening is perhaps like trauma or an emotional regulation problem, emotional intensity, mood regulation. So, that's why I kind of try to say to the client, like, so you've been previously diagnosed with these things. Like, how do you conceptualize your mental health? Like, I really try to help the client understand how they see what's going on with themselves. Right. And then I can talk to the clinician, like, oh, okay. Like, for instance, if I diagnose PTSD, I often don't diagnose anything else with that. Okay. Right? It's probably more dimensional in nature just because you are more focused on the specific symptoms that are causing the patient distress rather than maybe even what the diagnosis is. Yeah. Because at the end of the day, yeah, I mean, at the end of the day, like, it doesn't matter if the patient's bipolar or not, if they're having some really serious problems with mood regulation, knowing that they're bipolar isn't necessarily helping them, whereas maybe some interventions that you can give the patient about how to be handling these intense emotions is actually going to be a lot more productive. Right. Because intense emotions can come with different diagnoses. Uh-huh. To me, it doesn't even matter what the diagnosis is. Right. It's like, okay, what are you presenting with in terms of what your distress and suffering is in the past week? You know? Uh-huh. And what can we do to kind of lower intensity and duration of symptoms? I mean, I keep what people's diagnoses are in my head, but sometimes I'll meet somebody and I'll diagnose them with something because I have to for insurance. I have to diagnose them with something for insurance. Right. And then, like, five months later, I'll think, that's really interesting. You know, I was really kind of conceptualizing that, like, as a psychotic spectrum disorder when I first met this person, like, thinking, oh, this person has psychosis. And now I see that this is kind of hypervigilance related to, like, really significant trauma. Uh-huh. But it takes a while to get the flavor of those things. It's sort of like, you know, you're at a lake and you're trying to see the bottom. You can kind of make out some things in the bottom, but then at some point the water kind of clears. And to me, like, okay, this is kind of what's going on with this person. Or a person may – you may think, oh, they have emotional regulation problems or some or whatever, and then you sort of start to realize the issue with this person is, like, they were neglected and abandoned when they were little tiny, and nobody kind of has taught them to have emotional literacy. Uh-huh. And so that's a different – And so then that's, like, an experiential problem that has led them to having these symptoms. I thought it was interesting, though. I'd like to touch back on what you said with PTSD. You were saying that if you have a patient with PTSD, you won't diagnose them with anything else. Is that because PTSD is so – the symptoms of PTSD are so comorbid with so many other mental illness, like anxiety, depression, maybe even an element of psychosis, that you feel like it is doing the patient a disservice to tack those on? Yeah, I mean, I just feel like PTSD is the bigger diagnosis, and then underneath that are all the other ones. Like, I mean, I don't know that you have a person with, like, diagnosable PTSD who also doesn't have some form of anxiety, maybe even if anxiety is specified. To me, this brings up an interesting point that perhaps, like, if the nature of mental illness in itself is dimensional, but we are forced to put some categorical boundaries on it, that what becomes important then is to identify what the most severe element of their mental illness is. Would you say that's true? I mean, helpful for who? Why is that important to diagnose it? Well, I think that what you were saying about, like, insurance and treatment, but I also think being able to have somebody identify sometimes, like, I would say an example would be maybe autism. And I know we've talked about this a little bit before, but I think that people can have a lot of confusion about their identity if there aren't early interventions done for their autism. And so being able to kind of recognize that you fall on that spectrum and be able to understand that that's maybe why you have some sort of different, like, communication or social problems can be helpful to the person to kind of be able to work with themselves a little bit better. I mean, I know for me it's been helpful to have a diagnosis because, you know, once you've been diagnosed with anxiety, then you don't feel like you're just, like, totally crazy. So I think that there are positives to having a diagnosis. I do, too. I just think that, I mean, I try to keep in mind what's going to be helpful for my client. You know, and I think that there are clients who, like, I need to know what's kind of with me in a way. You know, what has happened. And then, like, going through something is, you know, a lot about trauma and the physiological way the trauma works and how it can cause you to become dysregulated, like, in an incident or something. There are certain people that that type of information is really helpful for, right? And there's other people who they hear a diagnosis and it becomes incredibly stigmatizing for them, and then they all just see themselves as, like, a severely depressed person. Well, I have depression. It becomes too much a part of their identity. So I guess as a clinician, I really try to stay, like, alert to, is this a person that does good with having, like, a lot of information? It's going to help them? Or is this a person that might, like, kind of let this stigmatize themselves in a way that kind of creates a powerlessness to their diagnosis? Like, I think people respond differently. That seems like that would be a really tricky line to draw. Do you think that there are— I've gotten it wrong sometimes. Right. Like, I've said something to a client, and then, like, three months later they said, well, that one time you said, you know, like, I had this or that. And that's a lot of responsibility to have to your patients. And, you know, you were saying earlier, too, which I thought was interesting how differently you notice your peers in diagnosis. Do you think that the lack of standardization in the field is more of a downside, or do you think that there is an upside to having sort of so many different kind of unique ways to be able to treat a patient? I mean, when I look at a diagnosis that another professional has given my client, like, it's helpful. Like, it's me in the ballgame kind of thing. So to a certain extent you appreciate a level of standardization, but I think it also—you probably appreciate the freedom that you have to be able to kind of interpret things individually with each patient. Yeah. I mean, I don't—I think it's just like everything else in this world. Like, sometimes, oh, that's really helpful. Like, I saw that thing in the notes. That helps me understand. And then sometimes I'm getting, like, I just had a teenager, you know, and they had, like, every single thing, like, oppositional defiant disorder, conduct disorder. They said consider, like, what's the personality disorder that they always— Borderline personality disorder? Oh, the ones for criminals. Oh, antisocial? Yeah, consider this. You know, and then I meet the kid, and his entire life has been trauma. And I feel like he has the heart of Buddha. He's, like, a sweet, wonderful boy. So sometimes I think that in the healthcare field, like, people maybe aren't intending to do this, but sometimes it can kind of be used as code about, like, patients that, like, some symptoms or some behaviors that people don't really like. And so in that way, sometimes I don't think it's serving the client. Yeah, and it's sort of—it's putting a judgment. Or, like, my aides that are kind of irritating might get, like, this borderline personality disorder one, and then you meet them, and I don't know. They don't necessarily seem that way to me. Like, many, many people have borderline personality disorder as a diagnosis way more than I think actually have that. Because then they'll come along every once in a while. And I'm like, oh, okay, this person seems like they're truly, like, suffering with a borderline tendency. So this kind of goes back to that, you know, question of categorical and dimensional. And I know we've talked about before, too, how there's been a push to make specifically personality disorders diagnosed more dimensionally. It sounds to me, I mean, like, you think that the stigma of borderline personality disorder is so pervasive. Do you think that if it were considered more dimensional, that that would sort of ease some of that stigma? Or do you think that we need to just maybe kind of revamp the way that we address personality disorders altogether? Yeah, I don't know. And keep in mind, listeners and my daughter, like, this is just my opinion and how I like diagnosing. And I'm not saying that everybody that diagnoses people with borderline personality disorder are, like, not nice clinicians or something like that. I'm not trying to say that at all. I just see that sometimes it gets used with this stigma. And, like, clients will go online and Google this stuff. And it's just, like, it's the most upsetting diagnosis to get. Yeah. There's a lot of shame and guilt and just hopelessness around some of those diagnoses. So I don't know. I guess I don't know what making it more dimensional would do. That's kind of a tricky one because, like you said, I mean, some people just are borderline. But you really wouldn't see that without trauma, right? I mean, isn't that literally one of the sort of criteria to be diagnosed borderline personality disorder would be a history of trauma? I mean, I think that's one of the markers that you can have, like a lot of them do. But I can't remember because I so rarely, like, diagnose people with it. But I think it's, like, whatever, there's, like, nine. There's, like, maybe I don't remember, seven. And you have to have five out of the seven present. I think there's nine. I think there's nine. I think you have to have five out of nine. Nine? Yeah. Okay. Yeah. So and, you know, but that's kind of what I'm saying. It's, like, okay, if you've had, like, a tough upbringing and a lot of trauma, if you have chronic PTSD, it's difficult to distinguish, like, certain behaviors that you might have with your dysregulated emotional and personal relationships, you know, from, like, a borderline behavior. People might say, oh, it's kind of cluster B tendencies. I guess that's kind of, like, a new way of being more dimensional. If you're comfortable talking about it, one of my kind of prompts, too, is just going to ‑‑ I was thinking we could maybe talk a little bit about our own experience with diagnosis and sort of what that has done in our own lives. So I know I said before, you know, too, that diagnosis for me, I think, made me feel a little bit, like, less alone, I would say, and I think that's a pretty common experience with that. But that being said, I also think that in some ways I've experienced what you talked about with, you know, people maybe too closely identifying with their diagnosis or I think that I've done a lot of healing. For instance, I have been diagnosed with panic disorder and I haven't had a panic attack since I was 18. So then at what point do I get to say that I don't have panic disorder, you know? Is there anything that you would like to say about, like, your own history with diagnosis and how that's affected you? Yeah. I mean, I think I feel like I've had diagnoses of depression, anxiety, and I think, but I think I have actually trauma from what I would consider a lot of little T traumas. Actually, I was just out at Grand Rounds and they were talking about how many women who've had children in NICUs and hard births actually meet criteria for PTSD. So I had, you know, depression after you were born and perinatally, so right after you're born and also while I'm pregnant. And now I'm kind of conceptualizing a lot of what has happened to me since, you know, you were born as kind of some trauma experiences accumulating. I do think I get depressed, but I think most of what happens is my trauma kind of gets kicked off. Uh-huh. I would say I see that to be true for you. Knowing about trauma has helped me because even now knowing about trauma, sometimes when I'm sad about something, I'm like, what is wrong with me? Like, there's something wrong with me. And if I can remind myself, trauma is like, PTSD has like a physiological. But I think it's dangerous if I think too much, like I'm a person with trauma and I'm going to always be having this because now I have trauma and PTSD because people can heal from things. People can get better. People can become not depressed. People cannot have panic disorder anymore. Like, that's why we have mental health systems in place to try to look at what the symptoms are and help the person learn how to cope and resolve some things, right? Absolutely. One of my goals that I write for all my clients is long-term goals, like long-term remission of distressing symptoms of mental health. Uh-huh. And I think that that is possible for some people, at least a great diminishment. Yeah. Well, and one thing I really wanted to ask you, too, as, you know, because I'm interested in being in the field and, you know, we've both now addressed that we have some diagnoses under our belt. How do you think your own struggle with mental illness has affected your ability to be a mental health practitioner? Well, I'm sure there's some pros and cons, right? But I want to say one of the biggest pros is that I am not judgmental about things that my clients are going through. Like, I can remember one time after your dad left when I was really having my hardest time. Uh-huh. I mean, it was maybe about six months after he left because we had a dog, and I gave the dog some peanut butter on a spoon. Uh-huh. At the spoon on the ground by the couch. Right. For the next six months, the spoon stayed right in that position, and everyone was stepping over it. I could not pick up the spoon. I just looked at it, right? And then my friend came over who's cheerful and just really doesn't seem to struggle that much with mental illness, and she was like, why is there a spoon on the ground? And she picked it up, washed it, and put it in the, like, spoon thing in, like, under 30 seconds, and I was flabbergasted. How could this thing that I could not do for six months seem so easy to somebody else, right? Yeah. I think that that has really helped me when I'm working with clients, like, both in terms of, like, being able to empathize and not be judgmental when they're having troubles with, like, motivation or symptoms of depression, but also to be able to say, like, there was a time, yo, when I couldn't pick up a spoon, and then I was able to get better and go back to school, and now I have a really, you know, a career. That's where I have to be very responsible. Yeah. I think that it's interesting because I feel like from what I've heard you say to me, like, it seems like to a certain extent that's gone both ways, too. The experiences that you've had, you know, not being able to pick a spoon up for six months has helped you empathize with your patients, but I've also – you've said a lot about, especially working with addicts, specifically meth addicts, and how the judgments that you used to have have diminished and that now you really enjoy working with this super intense population. Yeah. I mean, I think working as a mental health professional is a real honor to be privy to people's innermost hearts and souls, and my clients have just taught me so much about humanity and humor and resilience. Yeah. I used to say terrible things, like, about meth heads and whatever, and I have to say some of my very favorite clients, you know, are struggling with meth addictions and just wonderful people and have taught me a lot about acceptance. Yeah, and I also am, you know, personally grateful to this experience that you've had working with addicts specifically because I think that I do feel more understood by you. You know, I have struggled so much with addiction and, you know, including amphetamines, and it just kind of – it warms my heart to think, you know, you've been able to help me so much, and I do have a gratitude to your patients because I'd like to think that your experience with them and them getting to show you, like, the humanity that there is within addiction has been able to help you kind of empathize with me and have our relationship be better, too. I mean, I love that you're saying that, and thank you for saying it. It makes me feel good, but I think that's another situation that goes back and forth is probably because I'm able to love you so much, and I'm getting emotional. Because I love you so much, and I see the humanity in you and how you are not defined by addiction or addiction behaviors or things that you have done for or on drugs. You're not – that's not the totality of who you are, and I think I've been able to bring that to the addicts. Yeah, it's taught me I can bring more acceptance back to you, and I mean, I think it's just a shout-out to me being able to look at yourself, look at your internal experience, be able to communicate that, have hope for yourself to move forward, be honest, and at the same time, you know, improve. Yeah. Accept your – yeah. Definitely. Well, I think that's kind of a tender place to cut it here today. Thank you so much, Mom. Yeah, your podcasters, they may not know it, but we talk like this on a fairly regular basis. This is true.