🔥 What’s in a name?

Unpacking Diagnosis culture for Mental Health Awareness Day

I have written before about my frustrations with Mental Health Awareness events. While I fully support the sentiment, I get far too irritated with a myriad of things. This includes but is not limited to; organisations saying a lot but not doing enough, empty platitudes posted online from former high school bullies, and the fact that the average person doesn’t *really* seem to be as ‘mental health aware’ as they think they are.

But today’s newsletter is about something that’s become increasingly common as Pop Psychology is on the rise, and a topic that is certain to ruffle a few feathers. Today I share some spicy takes on our current cultural obsession with diagnoses, and why I feel it’s not always the answer.

🛋️ Rise of the Armchair Psychologist

In 2011, journalist Jon Ronson wrote a fascinating and extremely popular non-fiction novel called The Psychopath Test. The story took us on a journey into the mental health profession, shedding light on the elusive concept of the ‘psychopath.’ They were not the crazed serial killers that Hollywood would have us believe but normal people who walk among us undetected, as either benign oddities or sinister agents, often in positions of power, that lack empathy for their fellow humans.

After I read this book, I became obsessed with the idea of psychopaths. And like many others, I sought the thrill of being a secret psychopath hunter, attempting to spot them in the wild based on the criteria shared within the book. The problem is that when you’re not fully educated on the topic, you can start to see psychopaths everywhere.

The book preluded the online pop-psych movement by a number of years - it could be argued that it was one of the cultural moments that influenced it.

Today ‘pop psychology’ is alive and well, with hundreds of podcasts diving into the subject of psychopaths and many other mental health topics. All across the internet there is a barrage of information that allows us to potentially diagnose ourselves and others using little other more than a checklist. As luck would have it, this was exactly the kind of thing that I believe Ronson was trying to deter us from in the book.

Knowledge can be powerful but a snapshot of insight without proper context can be dangerous.

I later went to see Ronson give a talk on his book and unsurprisingly he was inundated with questions about which celebrities he thought were psychopaths; Trump’s name was suggested by the audience more than a few times… But the real turning point in my perspective was after he was joined on stage by a woman named Eleanor Longden who had been institutionalised when she told a friend, and later a medical professional that she heard voices.

The voices were not a threat to her; just a minor inconvenience. She had no history of self-harm, mental illness, or violence and yet this fact led to her diagnosis of schizophrenia - a much talked about but often misunderstood condition. At face value we might feel that this was the right decision to get her the help she needed. However, her diagnosis made things significantly worse for her. At the lowest point, Eleanor was her stripped of her rights, hospitalised and placed on mind-altering drugs. I strongly encourage you to check out her TED Talk for more detail on this.

This was diagnosis culture at its worst. It’s a story that has stuck with me ever since and made me question our attitudes to mental health, and more pertinently our reactions when it resembles mental illness.

Despite all of our attempts at awareness, we still make the grave oversight that the mind is extremely complex and that a ‘cure’ is not always the goal.

🌹A rose by any other name

My own ‘diagnosis’ journey has also led me to similar conclusions. Throughout all my years of therapy I have never actually received a formal diagnosis.

Often when we begin therapy, we expect that a diagnosis will be the outcome and ultimately, it is the entire point of seeking help. We want someone to tell us what is wrong with us to validate all the reasons we act the way we do and explain why we feel or appear different to others. But it’s often not that simple.

Not everyone who seeks therapy ends up having a pathological condition. Not everyone who does exhibits ‘typical’ symptoms, or in Eleanor’s case symptoms that significantly impact their lives. In some areas of therapy, with specific types of conditions, diagnosis is a route that selected professionals endeavour to avoid.

This is not because they don’t wish to help or believe that the diagnoses aren’t valid and/or don’t exist. It’s because it’s not always that helpful to the patient.

This approach feels particularly controversial in our current cultural landscape where we demand clear categorisation and labels. It was only a matter of time until our obsession with labels - particularly as a shorthand for who we are - was extended to how our brains and emotions function.

It could be argued that the more definitive the label, the clearer we are about who and what we’re dealing with. And it’s validating. We often don’t feel comfortable advocating for ourselves until we have evidence to back us up.

It does however make the messy grey areas of mental health conversations more messy. For example, the average workplace HR department will not make reasonable accommodations for a colleague until they receive a formalised diagnosis - which means that a lack of diagnosis, or indeed self-diagnosis might not be taken seriously and can limit their care.

Meanwhile, TikTok has created entire communities through sharing information on what lesser known symptoms look like for certain conditions and in turn, have helped people figure out that there’s a reason for what they’re experiencing - and that it’s very real. It has however resulted in a wave of online misinformation and existential panic.

Idealistically, labels and categories are important because they help us make sense of the world. They help us know ourselves, understand how we fit in, and how we should interact with others. Yet for every person who proudly identifies with their label, I personally have always found it a bit of an oddly closed-minded phenomenon riddled with caveats.

Liberal-thinking is often conflated with acting against restrictive ideas and values. To put people into neat little boxes and attribute a series of fixed behaviours and values to them feels like it goes against this idea. If we are to understand that neurodivergence and mental wellness are a spectrum, accept gender and sexuality as fluid, and believe our human values are constantly evolving and changing, it seems strange that in the last 20 years we’ve gravitated heavily towards the concept of labels. It applies a notably conservative template to liberal autonomy.

If we consider a diagnosis a label that’s definitive and unmoving, it ultimately creates rules and criteria that people have to meet and uphold. It risks oversimplifying people’s problems and doesn’t take into account individual experiences that sit outside of this. And when people don’t fully fit inside the box, it can lead to further exclusion, purism, generalisations and misconceptions.

📣 Once more for the people at the back; mental health is a spectrum

Historically, mental healthcare has followed a similar medical model to other types of healthcare. A list of symptoms will be presented and professionals would match this with the most likely known condition - in this case, it would be listed in the Diagnostic and Statistic Manual of Mental Disorders (known in the industry as the DSM or DSM-5).

The way many mental health disorders and conditions are defined has changed a lot over the years, particularly as more has been understood about trauma, neurodivergence, personality disorders, and developmental disabilities.

The diagnosis would then be used to tailor a care plan for a patient but even much of this can be down to the individual. The other obvious caveat is that judgement can differ from professional to professional.

We know that some types of therapy work for some better than others, that people have to experiment with medications before they find one that’s best for them, and that some people have multiple, overlapping complex issues which simply can not be treated with a single solution. While there are trends, patterns and clusters of behaviour that allow professionals to make decisions, it’s rarely a ‘once size fits all’ approach.

With all that said, for some a diagnosis can be life changing. It can help a person understand themselves more fully, and realise they are not alone. They can get better educated on ways to better manage their symptoms and seek appropriate medication and support.

This is why many adults, especially women, are now seeking out diagnoses for ADHD and autism; both of which notoriously present differently in women and have been grossly overlooked in the mental health profession due to a lack of research. Not to mention the lack of understanding around lesser known symptoms that can be debilitating without proper treatment.

The issue is that even getting a diagnosis in the first place is not a sound process.

✅ Flawed approaches create flawed outcomes

First of all, the waiting list for NHS mental health support is LONG. Whether you’ve been referred for counselling or waiting to be assessed for a specific condition, it can be a 2-year waiting list before anyone will even speak to you.

Once you get your foot in the door, you will often be required to fill out some kind of self-assessment to ‘score ‘ yourself against a list of credentials. I would like to make it very clear that I am not a mental health professional, but as someone who has spent a lot of time being passed around the healthcare system, I think that self-assessment is objectively a terrible way to diagnose anyone for anything.

It’s like asking somebody in A&E to rate the pain they’re feeling on a scale of 1 to 10. One person’s 10 is not going to be the same as another’s. So many different factors can affect our answers too. People think and behave differently, therefore what’s an ‘acceptable’ score for something like ‘spending more time alone’ or ‘poor concentration’ is entirely subjective.

While undergoing CBT via the NHS I was asked to complete a self-assessment at the start of every session. If I scored too ‘highly’ on any given week it would be determined that I was ‘getting better’. By the end of one particular course of my sanctioned 10 sessions, my scores were the reason given as to why I could not continue my current therapy as I was considered ‘well enough’ to be discharged from the system. Needless to say, that was not the case. I was pretty much told I’d need to start the whole process again.

How can you possibly measure someone’s wellness via generic, routine questions? Especially when they will be responded to differently depending on how you’re feeling or whatever else you have going on that day? Since then, I have not trusted a single diagnostic process where a self-assessment is the sole diagnostic tool. They are too flawed and can skew the data in a way that allows the potentially vulnerable to slip through the cracks.

It has to be acknowledged that when it comes to self-assessments, there is conscious and unconscious bias. The desperation to get help does affect our judgement which is why we should rightly critique this approach; particularly if money is exchanging hands. I knew that I would have had to score my mood and wellness lower if I wanted to continue my mental health treatment. It’s not a reach to suggest that someone who has an awareness of the criteria could similarly score themselves in such a way that incorrectly confirms or camouflages the problem.

If mistakes are made at the first hurdle, the obvious repercussions are that people will not receive the right treatment. Sure, mis-diagnosis or over-diagnosis can be a small side-effect to actually being able to identify people who need support. However, incorrect diagnosis can be problematic, especially in a field where many symptoms can overlap or bear striking similarities to other conditions.

And although it is extremely rare, there are very small proportions of people who do in fact seek diagnosis or treatment for more nefarious purposes - whether it’s weaponising mental health language, excusing anti-social behaviour or justifying the mistreatment of others. We’ve all heard the theory that often therapy can teach abusers how to be BETTER at abuse.

I want to reiterate at this point that I am not a person who believes that diagnosis is bad, that certain conditions are not real or that people are wilfully exaggerating their struggles. I do think some conditions absolutely do require diagnosis because there is support that make lives easier.

However because diagnosis is often the beginning of a very long and sometimes confusing journey, getting it right must be taken very seriously.

We should not be seeing mental health labels thrown out willy-nilly and people sent home from the GP with little more than a bottle of anti-depressants. We need to do better.

❓Is diagnosis always the answer?

This brings me back to one of the sessions I had with my therapist, where I enquired to her about a specific label that I thought fit me quite well. She asked me in detail why I thought I identified with this and what such a diagnosis would do for me.

Had it impacted my ability to function throughout my life? Would I want to seek further treatment? Would I feel like it was something I would accept or want to change? Would I be prepared for all of the outcomes, both positive and negative if I chose to share this with people?

This is where I need to disclose that part of my mental health struggles had been around the obsessive idea that there was something ‘wrong’ with me and that my behaviour wasn’t ’normal’. To receive a diagnosis (even though a label should never be anything to feel ashamed of) could potentially confirm my fear.

Without going into too much personal detail, that might not have been helpful for me and my ability to move forward. We concluded that day that perhaps a diagnosis wasn’t the answer, or at least for me.

Most notably, I also believe it would have limited my potential for growth. A diagnosis can make it all too easy to say ‘this is the way I am and I cannot change that’. Some are satisfied with that approach but I have always felt that there should be flexibility for a person to learn, grow, and change - but in a way that also doesn’t deny the other parts of themselves.

For me, a diagnosis had the potential to ‘trap’ me in amber forever; a person with unmoving struggles, with limitations, and an inability to adapt in a world that perhaps wouldn’t ever make the mutual effort to fully adapt to or understand me.

One unspoken downside of diagnosis is also the discrimination and the stigma. By god there is stigma.

During a particular period of what I can only assume was me having some kind of ‘noble’ delusion, I decided to be more open about some of my more peculiar idiosyncrasies in the hope that it would normalise mental health conversations and help people ‘get’ me a little more.

(I won’t get into the specifics here but they sit in the realms of anxiety behaviours.)

Some people were cool with it. Some people opened up to me about their own stuff. Others made jokes that made my problems feel less scary and serious, while others were very supportive and sympathetic.

But there were people who leapt on it and used it as a source of manipulation and ridicule. They would do stuff they knew would make me feel stressed and unsafe for their own amusement and often projected onto me their own assumptions. It goes without saying that those people are arseholes - but sadly there are a great deal of arseholes out there, so how does one protect themselves?

As much as we try to educate ourselves around mental health, we all have preconceptions about certain conditions - and not all of them are positive. In fact, there is still an astounding lack of information around the mental illnesses we feel are less ‘palatable’. We aren’t as tolerant when faced with behaviours we find frightening or unusual, and less so about the ones that personally inconvenience us.

This is particular a bugbear of mine in the age of armchair psychology, where we now also conflate a person’s negative qualities and traits with what we understand about different conditions. It’s like me and psychopath hunter’s all over again!

The person who is late all the time ‘probably has ADHD’. The awkward guy at work ‘seems autistic’. The person who is too anal about organisation ‘has some kind of OCD’. Your asshole boss is ‘bipolar’. Your ex-boyfriend is a ‘sociopath’. I could go on…

This not just incredibly unfair (even the worst people don’t deserve to have potentially serious life-changing diagnostic labels slapped on them without any proper evidence or mental health expertise…), it’s actually really harmful to those genuinely living with those conditions.

Even positive stereotyping is still ableist and damaging. If I see one more post about disabilities like ADHD or autism being a superpower I swear I will boke…

When we think about Eleanor’s example, life is already a struggle for these people. There is too much that people still don’t fully understand and are fearful of for everyone to live out in the open when it comes to mental health. Even if we do feel diagnosis is the right approach, do we feel comfortable having the world know about it?

🏷️A world that loves labels but hates adapting to them

While there is no rule stating that you have to disclose a mental health or neurodivergence diagnosis, people are often forced to do this anyway in order to both thrive and survive.

To receive the accommodations and understanding they truly need, people might feel pressure to disclose this to their employer, their school, friends, partners, and any other network or organisational body that might be responsible for their wellbeing. Culturally there’s still people who see diagnosis as confirmation of a threat or weakness.

And even within the most informed institutions, the stigma can still exist. Reliance on a diagnosis ‘can reduce professional curiosity’ and some professionals may be blinded by it to the extent that they won’t consider other treatments, medications or diagnoses for a patient whose symptoms do not improve.

Employers have also been known to weaponise employee mental health as reasons to not give people certain responsibilities because they ‘would not cope’ and fail to make workplace exemptions because ‘it wouldn’t be fair to others’.

I have been in the room when people have rolled their eyes as someone has stated they have anxiety, or have looked panicked when the subject of postnatal depression has come up. We still use ‘mental breakdown’ as a joke to describe a particularly bad day yet many will slowly back away if anyone dares to actually exhibit signs of one.

And the bottom line is that once you have a diagnosis, it sticks. Despite how ’well’ you might be, you may always be viewed as someone who is fragile, vulnerable, flawed, ill, or different because of some label. And that sucks?

Is the answer to do away with potentially limiting labels, or to better educate people around the reality of what specific conditions look like in all their variety?

🤠 Living authentically

With all that said, I fully understand why a diagnosis is important for some people in the same way that I understand why many wear labels proudly. Most people want to live authentically and fully show up as the person they are, without fear of prejudice or judgement.

But with all things considered I also still believe having an official diagnosis is, in some cases, less important than we think.

A diagnosis does not have to define us. It doesn’t have to be proof of understanding who we are.

After all, how do we ever know where a diagnosis ends and our personality begins? Sometimes what’s ’abnormal’ is actually just a very normal reaction for us that’s sadly culturally shunned.

Perhaps if we don’t quite fit into the box, we can acknowledge the ‘traits’ that help us identify with others who think and act the same, while also being aware of the triggers that cause us pain.

There is no right or wrong answer, it’s all down to personal circumstance and choice at the end of the day. As long as we can move towards understanding that diagnosis is the beginning and not the end of mental health awareness, then someday this event might not annoy me so much…

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More articles I’ve written around the topic of mental health

Some of these are older posts which I am making free to access for Mental Health Awareness Day. Please consider a paid subscription to read these all year round!

Hot takes on Mental Health Awareness Day - Is it really ok not to be okay yet?

Notes on self care - Is self-care necessary to our wellbeing or just a load of classist patriarchal garbage?

Breaking up with your therapist - What it’s like to come out of the other side of therapy and go it alone

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Further articles which made for good reading…

Some additional reading on some of the topics covered here with a variety of perspectives and hot takes…

Understanding: Complexities of Diagnostic Methods in Mental Health

It’s time to stop calling yourself high functioning -

Ellen Kate Boyle

on putting this outdated term to bed

ADHD is not a superpower - Ellen’s other half Craig writes about his experiences with later-in-life ADHD diagnosis

The weaponisation of mental health discourse -

Kari Bentley-Quinn

on the complexities of mental health awareness in the online world.

The case against mental health -

Rational Psychiatry

discusses whether the increasing conversations about mental health are really a shift towards the better.

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Tell me your thoughts below…