Tag Archives: mental illness

D is for Diagnosis

I finally jumped through one of the final hoops I need to get full licensure. This morning I took, and passed, the state licensing exam. I could have done this as soon as I finished school at the end of 2017, but I did not. I put it off. So, here I am, ready to be done with supervision, primed to strike out on my own.

Anyway, one of the questions I’ve encountered on the practice exams goes something like this:  If your agency requires you diagnose a client, what are your alternatives? a) talk to your supervisor and tell her it’s against your ethics to diagnose someone b) talk to your colleagues and let them know you ethically can’t diagnose someone c) refuse to diagnose a client d) all of the above. The correct answer, apparently, is d) all of the above.  As a counselor, ethically I am not to diagnose anyone.

I’ve been trained to diagnose using the DSM, or Diagnostical and Statistical Manual, a compendium of mental health disorders cataloging the signs and symptoms of everything from adjustment disorder to xenophobia, anxiety to trichotillomania. It’s not an activity I take lightly. People seek help with mental health because they are looking for ways to feel better, to combat the distress they are experiencing. I want to empower clients to improve their lives. I don’t want to overwhelm them with a label that carries negative connotations, a diagnosis that scares them or strips them of their power and self-efficacy.

Giving someone a diagnosis is a double-edged sword—a client’s DSM diagnosis allows them to seek services utilizing their health insurance. No one has to go bankrupt to afford mental health care. If providers get paid, clients can keep coming back, and not just to counselors in private practice, but also to community mental health agencies such as the crisis center I wrote about yesterday. The money we receive from insurance companies enables us to serve a wide variety of folks, many without the means to pay privately for anything, let alone mental health care.

But a diagnosis is also a label, and a mental health diagnosis can follow someone for life, influencing not only how they think about themselves, but how others might perceive them. We’ve made a lot of progress in the past few years to destigmatize mental illness, and many more people are seeking counseling as a matter of course. Being in therapy doesn’t carry the stigma it used to. But still. Perceptions linger and diagnosing (and thus labeling) a college freshman as bipolar can have lifelong consequences. They can begin to see each themselves as more illness than person, begin to limit themselves or be limited by others, including overprotective parents and well-meaning professionals.

I don’t want to give anyone a label that will hold them back in life. I want to help clients find ways to learn, love, and live their best lives, to understand what’s happening with their mental health, and I want them to be able to keep coming back, even if they can’t afford it. So, I have to give them a diagnosis if they use insurance to pay for counseling.

But, a diagnosis should only be a means to an end, not the final word on who anyone truly is or a limit on what they can achieve or who they can become.

C is for What Constitutes a (mental health) Crisis?

When I am not seeing clients in my private practice, I work as a clinician in a mental health crisis clinic run by a community mental health agency. I ended up at the crisis clinic by serendipitous accident. I had applied for an internship with said local agency, completely oblivious to the very existence of the crisis center. I imagined that during my internship, I would be meeting with clients one-on-one several hours a week for the year. Instead, I got to do something quite different.

How does someone end up in the crisis clinic? Community members who may be experiencing a mental health crisis can come to us, free of charge, for up to five days at a time. In those five days, we provide a safe environment, connections to community resources such as housing, CD (chemical dependence) treatment, case management for ongoing mental health support, medication management/stabilization, appointments with primary care providers and dentists, connections to youth services. A good number of our clients are without stable housing. Many spend most nights on the streets or at the drop-in center. Few have jobs. Most struggle with addiction, and I think it’s safe to say the vast majority experienced a major trauma in their lives: abuse, neglect, death of a parent or sibling or child, sex trafficking, even torture.

Most of our referrals come from the local hospital’s emergency department; many referrals come from our own agency’s counselors and case managers who work with hundreds of clients with mental health issues such as schizophrenia and bipolar disorder. Other referrals come from a variety of community agencies: housing, doctor’s offices, domestic violence shelters, the county crisis line, other mental health agencies in town.

But, what constitutes a mental health crisis? How does someone end up with us? When someone is feeling suicidal and unable to keep themselves safe, they may get a bed with us. If a person has made an unsuccessful attempt on their life that hasn’t required hospitalization, they could end up with us. We might get a young man who is experiencing his first psychotic break and his family has no idea how to help him. We may take in a young woman who recently lost custody of her children and is feeling despondent. Often, we have clients who are coming off of meth or detoxing from alcohol and are psychotic enough that they cannot be left alone yet not so gravely disabled that they require involuntary hospitalization. Others have previously diagnosed mental health issues that are not being well managed by medications. Some have urges to throw themselves into traffic or in front of a train but are oriented sufficiently to be coherent and logical and thus not detainable.

Interestingly, but probably not surprisingly, homelessness does not constitute a mental health crisis. We are not a program that bridges people to housing. Homelessness is so pervasive and intractable, we’d be holding folks for years if they were waiting to be housed. Occasionally, if someone is at risk of severe decompensation if they were to return to the streets, we’ll keep them for a few extra nights in order to transition them into a supervised living situation.

Nor do we provide respite. People can’t come to stay with us in order to heal from surgery or to get a break from their intolerable living situations. We are not a hostel, though one time we had a client in who had managed to use crisis centers like ours as way stations in his travels across the country. Desperate times call for desperate measures, and given the current housing and homelessness crises, folks get creative in order to feel safe, to be fed, to sleep in a bed. Many know what to say to get the ER social workers to call us. And why not? Doesn’t everyone deserve to feel safe? To sleep with a roof over their head? To have a hot meal and a hot shower?

A lack of housing may not constitute a crisis sufficient to warrant a bed in a crisis center, but I’m sure it would feel like a crisis if I were the one on the outside of that door. And that is exactly why I continue to work with folks in crisis long after my internship has ended. I am all too aware that life is a precarious balance.