Learning to think about diagnosis—not just learn how to diagnose

This is Part 5 of the DSM series — the final installment.
Previously: If Not the DSM, Then What?
Start from the beginning: The DSM Shapes Every Therapist's Practice

After spending four installments examining the history, authority, structure, and limitations of the DSM, I want to end somewhere more constructive. Because critique is only useful if it helps us imagine something different. And I want to be careful about what I mean when I say there were things I wish I had been taught.

My counseling program did not teach me to ignore context. It did not teach me to see clients as collections of symptoms. Quite the opposite.

I was taught to consider the whole person—to think about culture, identity, relationships, trauma, development, environment, power, and lived experience. Those perspectives are foundational to how I understand therapy, and I'm grateful for that education. What felt strangely incomplete was something else.

I don't think I was adequately prepared for the role diagnosis would actually play once I entered the mental health system.

Diagnosis occupied this strange space in my training. It was important enough that we needed to learn how to diagnose. But it wasn't always treated as something we needed to deeply understand. We learned the criteria. We learned how to differentiate disorders. We learned how to write a diagnosis. And then, essentially, we were expected to go forth and use this system with actual human beings.

But where was the sustained conversation about what diagnosis means? Where were we taught how to explain a diagnosis to a client without presenting it as an objective truth about who they are? Where did we learn how to talk about the limitations of diagnostic categories without undermining the potential usefulness of diagnosis? Where did we learn how to respond when a client felt profoundly relieved by a diagnosis? Or when they felt stigmatized by one?

What about when a client wanted a diagnosis because it might finally give them access to accommodations, treatment, or recognition? What about when a diagnosis didn't quite fit—but the system required us to choose one anyway?

These are not peripheral questions. They are questions clinicians encounter in actual practice. And the more I have learned about diagnosis, the more I have wondered why they weren't treated as a more central part of learning to become a clinician.

Learning to Diagnose Is Not the Same as Learning About Diagnosis

There is a difference between learning how to diagnose and learning how to think about diagnosis.

The first is largely procedural: Can you determine which diagnostic criteria are met?

The second is conceptual, ethical, cultural, and relational: Do you understand what you are doing when you assign that diagnosis?

I think we need both.

A clinician should know how to recognize diagnostic criteria and understand the diagnostic system well enough to use it responsibly.

But they should also understand that diagnostic categories are historically situated constructs; that their boundaries are contested; that reliability and validity are different questions; that culture influences the expression and interpretation of distress; that diagnoses can have both benefits and harms; and that the category assigned in a chart is never the complete story of the person.

These aren't abstract philosophical concerns. They affect what happens in the therapy room. A diagnosis can influence how a clinician understands a client. It can influence how a client understands themselves. It can affect what services become available. It can follow someone through medical and educational systems.

And it can become part of someone's identity. If diagnosis has all of these consequences, learning to use it responsibly requires more than memorizing criteria.

The Strange Place Diagnosis Occupies in Counselor Education

This is what continues to strike me as odd. The DSM occupies an enormous amount of space in the mental health system.

It shapes documentation. It shapes reimbursement. It shapes referrals. It shapes communication between providers. It shapes research. It can determine access to services. It can become part of a person's medical record. And it can profoundly affect how clients understand themselves.

Yet in counselor education, diagnosis can sometimes occupy a surprisingly small and compartmentalized part of the curriculum. We are expected to learn how to use it without necessarily spending equivalent time learning how to think critically about it.

The result can be a strange disconnect.

We are taught to see the person in context—and then handed a classification system that can encourage us to pull experiences out of that context and organize them into categories.

We are taught cultural humility—and then asked to make judgments about what constitutes disorder, impairment, or dysfunction across radically different cultural and social contexts.

We are taught to recognize the complexity of human experience—and then expected to compress that complexity into a diagnosis for the chart. Again, I don't think these are necessarily always contradictions. But I do think they require much more explicit teaching than they often receive.

The DSM doesn't have to be the enemy of holistic counseling. But if it is going to be part of our professional lives, we should understand the tensions between diagnostic classification and the ways we are otherwise taught to understand people.

What I Wish We Had Practiced

I wish my education had included more opportunities to sit with the messy cases.

• The cases where the diagnosis wasn't obvious.
• The cases where several diagnoses seemed plausible.
• The cases where the symptoms made sense in light of someone's circumstances.
• The cases where cultural context complicated the picture.
• The cases where a behavior could be interpreted as either pathology or adaptation depending on the lens being used.
• The cases where a diagnosis might help the client access something they desperately needed while also carrying potential stigma.
• And especially the cases where the diagnosis required by the system didn't fully capture what we understood clinically.

Because those are the situations in which the limitations of diagnostic categories become real. They are no longer an academic discussion about the DSM.

They become an ethical and relational question: What story are we telling about this person, and what happens because we tell it?

We Also Need to Learn How to Talk About Diagnosis With Clients

This may be the piece I feel most strongly about. Diagnosis isn't just something clinicians do to paperwork. It is something we do in relationship with people.

Eventually, someone is going to ask:

"Do you think I have depression?"

Or:

"Do you think I'm autistic?"

Or:

"What does this diagnosis mean?"

Or:

"Does this mean I'm always going to be like this?"

Or:

"Why did another therapist say I had this and you don't?"

These conversations require more than diagnostic knowledge. They require language. They require humility. They require an understanding of stigma and identity. They require us to be able to explain what a diagnosis can tell us—and what it cannot. And they require us to recognize that the meaning of a diagnosis belongs partly to the person receiving it.

For some clients, a diagnosis can be deeply validating. For others, it can feel like a life sentence. For some, it provides access to community and accommodations. For others, it may become a source of stigma or self-limitation. Sometimes it does several of these things at once. I don't think clinicians should decide in advance what a diagnosis will mean to someone.

We should ask. And we should be prepared for the answer to be complicated.

Diagnosis and the Question of Culture

This is also where the cultural humility we are taught in counseling programs needs to connect more explicitly with diagnostic practice. Mental health symptoms don't occur outside culture.

People have different ways of expressing distress, understanding emotions, communicating suffering, relating to family, interpreting unusual experiences, and defining what constitutes a problem in the first place. The DSM itself acknowledges the importance of cultural context through its discussion of cultural concepts of distress and the Cultural Formulation Interview (American Psychiatric Association, 2022). But knowing that culture matters in theory isn't the same as knowing how to navigate its implications when assigning a diagnosis.

A clinician can be aware that culture matters and still unconsciously interpret culturally shaped behavior through a diagnostic framework developed within a particular social and historical context. That is why cultural humility cannot simply be a separate competency we check off while learning diagnosis.

It has to change how we diagnose.

We need to be willing to ask:

• What does this behavior mean within this person's cultural context?
• Would this be considered distressing or impairing by the client?
• Who is defining the problem?
• What assumptions about normality am I bringing into this assessment?
• What might I be missing because I am interpreting this person's experience through categories I learned to regard as universal?

These questions don't make diagnosis impossible.

They make it more responsible.

Diagnosis, Neurodivergence, and the Problem of "Normal"

This becomes particularly important when working with neurodivergent people.

A person can experience genuine difficulties with attention, executive functioning, sensory processing, communication, social interaction, or regulation. But difficulty does not automatically tell us what the appropriate response should be.

Is the goal to eliminate the difference? To help the person function within an environment that doesn't accommodate them? To change the environment? To build skills? To reduce unnecessary demands? To increase access and accommodation? To help the person understand themselves differently?

Often, the answer is some combination of these.

A neurodiversity-affirming approach asks us to consider the interaction between an individual and their environment rather than locating every difficulty exclusively within the person. This is consistent with broader social and ecological understandings of disability, which emphasize the role of environmental barriers in producing disabling experiences (Oliver, 1990).

This is another place where I wish diagnostic education had gone deeper.

I wish we had spent more time examining the difference between:

• difference and disorder
• impairment and mismatch
• support needs and deficits
• adaptation and dysfunction
• accommodation and treatment

Those distinctions aren't always simple. But they matter.

Formulation Is Part of the Missing Bridge

This is where formulation becomes so important to me.

Diagnosis asks us to classify. Formulation asks us to understand.

A diagnostic formulation might tell us that someone meets criteria for Major Depressive Disorder. A broader clinical formulation might also tell us that the person is grieving a major loss, living with financial insecurity, isolated from community, working in an exploitative environment, carrying years of relational shame, and exhausted from trying to meet expectations that don't fit their capacities.

Both pieces of information can be true. But they do different things.

Clinical formulation is generally understood as a collaborative way of making sense of a person's difficulties by integrating their history, circumstances, patterns, strengths, and current context rather than simply assigning a diagnostic label (British Psychological Society, 2018).

And importantly, formulation isn't supposed to be a hidden diagnosis with more words. It is a hypothesis. Something we develop together. Something we can revise. Something that should remain responsive to the person in front of us.

That feels like the bridge I was missing. I want us to be taught how to place diagnosis within a much larger process of understanding.

The Questions I Wish I Had Been Taught to Ask

What follows isn't a formal clinical model. It isn't a replacement for diagnosis, and it isn't a new checklist that every client needs to fit. It's my own synthesis of questions I find useful across different therapeutic traditions.

Think of it as a map for curiosity. Not seven boxes. Not a formula. Just places to look.

1. What happened?

Before asking what's wrong, ask what happened.

• What experiences shaped this person?
• What relationships taught them what to expect from other people?
• What environments did they grow up in?
• What did they have to adapt to?
• What losses have they experienced?
• What messages did they receive about their body, identity, emotions, needs, gender, sexuality, disability, success, or worth?

Trauma-informed approaches emphasize the importance of understanding the effects of experiences involving threat, violence, loss, and disrupted safety (Herman, 1992). Liberation psychology adds another dimension by asking how social and political conditions shape people's psychological experiences and possibilities (Martín-Baró, 1994).

This doesn't mean assuming that everyone has a hidden trauma that explains everything. It means resisting the idea that behavior emerges without context.

2. What is this person navigating now?

History matters. But so does Tuesday afternoon.

What is happening in this person's actual life right now? Work. School. Parenting. Caregiving. Money. Housing. Health. Relationships. Discrimination. Isolation. Community. Access to resources. Political conditions.

Sometimes the most important information isn't in the person's childhood history. It's in their current circumstances.

Structural competency encourages clinicians to consider how social and structural conditions become relevant to health and clinical care (Metzl & Hansen, 2014).

That means asking not only:

"How can this person cope with their circumstances?"

but also:

"Are these circumstances themselves contributing to the problem?"

Those questions aren't interchangeable.

3. What conditions help this person function?

I want to move beyond asking what someone cannot do. I want to know when they can do it.

• When do they feel most regulated?
• When do they become overwhelmed?
• What environments support them?
• What environments deplete them?
• What kinds of communication work best?
• What sensory conditions matter?
• How much transition time do they need?
• How much social interaction is sustainable?
• How much recovery time do they need?

This is especially important in neurodiversity-affirming practice. A person may have dramatically different capacities under different conditions.

Rather than asking only:

"Why can't they do this consistently?"

we can ask:

"What changes when they are able to do it?"

That question can reveal environmental fit, executive-function demands, sensory factors, energy limitations, communication differences, or the cumulative effects of masking and overload.

• Sometimes the intervention is skill-building.
• Sometimes it is accommodation.
• Sometimes it is reducing demands.
• Sometimes it is changing the environment.
• And sometimes it is helping someone stop interpreting an environmental mismatch as evidence that they are defective.

4. What is happening between people?

People don't develop in isolation. Our relationships shape what we expect, what we fear, what we believe we deserve, and how we respond to conflict and connection.

Relational-cultural theory emphasizes the central role of relationships, connection, mutuality, and the ways relational disconnection can contribute to psychological distress (Jordan, 2011). So I want to ask:

• Who does this person feel safe with?
• Who do they feel responsible for?
• Where do they feel seen?
• Where do they feel controlled?
• What happens when they have needs?
• What happens when they say no?
• What happens when someone disappoints them?
• What happens when conflict occurs?
• Can the relationship repair?

Sometimes what looks like an individual symptom is part of a relational pattern. A person may not simply be "anxious." They may be anxious in this relationship.

They may not simply "have trouble with boundaries." They may have learned that having boundaries leads to punishment or abandonment.

They may not simply be socially withdrawn. They may be protecting themselves from repeated rejection.

The relationship belongs in the formulation.

5. What meaning has this person made?

Events happen and then people make meaning from them. Over time, those meanings can become stories about identity.

Maybe: I'm too much. I'm lazy. I'm broken. I'm difficult. I'm failing. I'm incapable. I'm fundamentally different. I have to be useful to be worthy.

Narrative therapy has long emphasized examining these dominant, problem-saturated stories and looking for alternative accounts that make room for people's values, skills, commitments, and preferred identities (White & Epston, 1990). This doesn't mean replacing a negative story with a positive affirmation. It means becoming curious about the story itself.

• Where did it come from?
• Who taught it?
• What experiences reinforced it?
• What does it leave out?
• Are there moments that don't fit?
• What does the person care about that is visible beneath the problem?
• What have they managed to preserve despite everything?

The goal isn't necessarily to tell a happier story. It's to tell a larger one.

6. What keeps the pattern going?

Once we understand history and context, we can look at what is happening now. What processes are maintaining the current difficulty? Maybe it's:

• avoidance
• rumination
• shame
• perfectionism
• isolation
• emotional suppression
• chronic overextension
• threat monitoring
• sleep disruption
• difficulty recovering from stress
• repeated relational ruptures

These processes don't belong neatly to one diagnosis. That is part of what makes process-based approaches useful: they can identify patterns that cut across diagnostic categories and may become targets for intervention (Hofmann & Hayes, 2019).

Consider a cycle like: Overload → exhaustion → reduced capacity → falling behind → shame → overcompensation → more overload.

The diagnosis doesn't tell us exactly where to intervene. The cycle gives us possibilities. Maybe we need to address perfectionism. Maybe we need to reduce demands. Maybe we need to work with shame. Maybe the person needs an accommodation. Maybe there is a relational pattern that needs attention. Maybe regulation skills would help. Maybe all of these are relevant. The formulation helps us figure that out.

7. What would make this person's life more livable?

This may be the most important question.

Not:

"How can we get this person back to normal?"

But:

"What kind of life do they actually want?"

For one person, that might mean returning to work. For another, it might mean leaving their job. For someone else, it might mean having enough energy to make art. It might mean community. A safer relationship. More autonomy. Less masking. More rest. A different relationship with their body. The ability to say no. A sense of belonging. Purpose. Joy. Flourishing.

Research on positive mental health has distinguished flourishing from simply being free of mental illness, emphasizing dimensions of well-being that include relationships, purpose, competence, and social contribution (Keyes, 2002). Psychological well-being research similarly emphasizes dimensions such as autonomy, positive relationships, purpose, personal growth, environmental mastery, and self-acceptance (Ryff, 1989).

These ideas matter because symptom reduction and a good life are not necessarily the same thing. Someone can have fewer symptoms and still be living a life they don't want. Someone can experience significant disability, grief, or distress and still have a meaningful, connected, purposeful life.

Mental health should leave room for that complexity.

What Does This Look Like in Practice?

Imagine two formulations of the same person.

A diagnostic formulation might say:

Client presents with anxiety, depressive symptoms, insomnia, and occupational impairment.

That's useful information.

But it doesn't tell me very much about the person.

A broader formulation might say:

Client has a history of relational invalidation and has developed a strong belief that their worth depends on productivity. They are currently working in an unpredictable and demanding environment that provides little opportunity for recovery. Increasing sensory and cognitive overload has led to exhaustion, reduced capacity, and difficulty meeting expectations. Falling behind then reinforces shame and fear of failure, leading to further overextension. Client wants a life with more sustainability, connection, autonomy, and creative time.

Now I have something to work with. The first formulation identifies symptoms. The second gives me a map. It suggests multiple possible points of intervention.

And it tells me something crucial: What the client wants their life to become.

The Diagnosis Can Still Have a Place

I'm not arguing that clinicians should simply stop diagnosing. That's not realistic for many of us. And it isn't necessarily desirable. Diagnosis can help people access services. It can facilitate communication between providers. It can be meaningful to clients. It can provide a shared language. And clinicians have ethical responsibilities that include recognizing and responding to serious mental health conditions. The answer, for me, is not diagnostic avoidance. It is diagnostic humility.

It is being able to say:

"This diagnosis is the category that best captures what we're seeing right now."

Without implying:

"This diagnosis explains who you are."

It is being able to say:

"This diagnosis may be useful for accessing the care or accommodations you need."

While also saying:

"It doesn't capture everything about your experience."

It is being able to hold the diagnosis and the context. The category and the person. The system and the story.

The Chart and the Person Are Not the Same Thing

This distinction has practical consequences. A chart may require: Diagnosis: Major Depressive Disorder. But my clinical understanding might include:

• grief
• chronic sleep deprivation
• workplace burnout
• social isolation
• trauma history
• loss of meaning
• perfectionism
• sensory overload
• financial stress
• and a profound need for rest and connection.

The diagnosis may be necessary for the system. But it is not the entirety of my understanding.

The diagnosis may belong in the chart. The formulation belongs in the room. And even the formulation should not become another unquestionable truth.

Formulation Is a Hypothesis, Not a Verdict

This may be the most important safeguard. A clinician can be wrong. We can misunderstand. We can overemphasize trauma. We can overlook culture. We can mistake adaptation for pathology. We can impose our own values about what a "good life" should look like. We can create an elegant formulation that makes perfect sense to us and absolutely no sense to the person sitting across from us.

So formulation has to remain collaborative and revisable.

We can ask:

"This is how I'm currently making sense of what you're experiencing. Does that fit?"

And the client might say:

"Not really."

Good. Now we have more information. The formulation changes. Clinical humility isn't a lack of expertise. Sometimes it is what expertise looks like.

What I Wish Had Been Different

So when I say I wish I had been taught differently, I don't mean that I wish my education had spent less time teaching me about the whole person.

I wish it had connected those lessons more explicitly to diagnosis. I wish we had been taught not only how to diagnose, but how to think about diagnosis.

I wish we had spent more time examining the gap between:

• the person and the category
• the symptoms and their meaning
• impairment and difference
• diagnosis and formulation
• clinical necessity and clinical certainty
• the diagnosis required by a system and the understanding required by a therapeutic relationship

I wish we had practiced conversations with clients about diagnosis. I wish we had examined difficult cases where the "right" diagnosis wasn't obvious. I wish we had talked more openly about what happens when the available categories don't fit.

I wish we had explored the ethical tension of assigning a diagnosis because an institution requires one when the category doesn't fully represent our clinical understanding. And I wish we had been given more permission to sit with uncertainty.

Because perhaps the most important thing I wish I had learned is this: Being able to assign a diagnosis does not mean we have completely understood the person.

Those are different accomplishments.

Maybe We Need to Teach Both

Perhaps the missing piece isn't another argument about whether diagnosis is good or bad.

Perhaps we need to teach clinicians how to hold two forms of knowledge at once.

Diagnostic knowledge

• What patterns are present?
• What criteria are met?
• What diagnoses might be relevant?
• What interventions or resources might follow?

Contextual knowledge

• Who is this person?
• What has happened to them?
• What meanings have they made?
• What relationships and environments shape their experience?
• What strengths and adaptations have helped them survive?
• What kind of life do they want?

Neither automatically replaces the other. But neither should be mistaken for the whole picture.

And if counseling education is going to prepare us to work inside a mental health system so deeply organized around diagnosis, I think we deserve to be taught how to understand that system critically—not simply how to operate its machinery.

Because learning to diagnose is one thing.

Learning what diagnosis means is another.

And I think clinicians need both.

Practicing Between Stories

Maybe that's ultimately one reflection of what I mean by practicing between stories. Between the diagnostic story and the client's story. Between the story the institution requires and the story that makes sense of a person's actual life. Between individual responsibility and structural reality. Between pathology and adaptation. Between surviving and flourishing. Between what is and what could be.

The DSM can give us a category. A formulation can help us understand a person. Neither one tells us everything. And perhaps that's the lesson I most wish I'd been taught: No diagnostic manual can replace curiosity.

People are always more complicated than the categories we use to describe them. Our job isn't to pretend the categories don't exist. It's to remember that they are categories. And the person sitting in front of us is a person.

That distinction is small enough to fit into a sentence—and large enough to change how we practice.

This is Part 5 of the DSM series — the final installment.
Previously: If Not the DSM, Then What?
Start from the beginning: The DSM Shapes Every Therapist's Practice

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing.

British Psychological Society. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. British Psychological Society.

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.

Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clinical Psychological Science, 7(1), 37–50.

Jordan, J. V. (2011). Relational-cultural therapy. American Psychological Association.

Keyes, C. L. M. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43(2), 207–222.

Martín-Baró, I. (1994). Writings for a liberation psychology. Harvard University Press.

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126–133.

Oliver, M. (1990). The politics of disablement. Macmillan.

Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069–1081.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. W. W. Norton & Company.