When making a diagnosis of a mental health disorder it is extremely important to look at the context of the person’s entire life. While many mental health disorders expand far beyond the everyday circumstances of life, and dive to much a deeper, biological issue, some mental health disorders can best be explained as bi-product of multiple life influences.
As a therapist, mental health professional, or other person attempting to understand diagnosis, the context of a person’s life should be fully understood by any clinician making a diagnosis. It is incredibly easy to get complacent and just wave the Depression, BiPolar, any diagnosis wand. I am a huge proponent of waiting on making a diagnosis, when possible, until more information is evaluated. Sometimes a diagnosis is needed immediately, as lives are in danger, courts need documentation, an immediate change in someone’s life of a traumatic nature, etc. While these do occur, for many mental health professionals rushing on making a diagnosis is common place.
Good professionals spot many disorders immediately when they walk in as the symptoms are indistinguishable and can only be a few things. However, everyone has been fooled in one way or another, missed a diagnosis, or as more information became present, the diagnosis may have evolved. It is best practice to not rush a diagnosis when possible, as the more information that is gathered the more accurate the diagnosis.
As all therapists know, you don’t get all the information from a client on day 1. Although, sometimes sessions are a word vomit of 30 years of pent up emotions unloading. Most first sessions are basically interviews between client and therapist to understand one another, build trust, and get the basics. Think of it like a non-sexual first date. Regardless of the information exchanged on day 1, more background will be coming in the future sessions. Gathering as much information and context on the life of a person will help to insure the diagnosis is accurate and not just a reflection of a temporary mood.
Why Context is Important In Diagnosis
Certain behaviors indicate a specific disorder, or category of disorders. However, just because a person is exhibiting the criteria for a disorder does not necessarily mean he or she has that disorder. While the DSM does a great job clarifying that behaviors need to be present for “x” amount of time, or that a diagnosis is not made under certain circumstances, there is still a degree to where sometimes diagnosable behaviors are totally appropriate, and can just be explained as an appropriate reaction to life events.
Let’s say Timmy comes into my office for an appointment because he has been bummed out. He says he isn’t sure if he wants to live, has no joy, problems sleeping, no appetite, nothing brings him joy, and he just wants to be alone. Sound like he has Major Depressive Disorder? Major Depressive Episode at the least? Yes, he absolutely meets the criteria for being diagnosed with a depressive disorder. Better get my diagnosis wand out and document this!
Wooooo there partner, slow down your magic diagnosing wand a second. All you have done is identify that Timmy meets the criteria of a depressive disorder. Did you ask about any of the reasons for these symptoms. A simple question, “Is there anything that has happened in your life that has been hard?” Also, how long has this been going on?
Timmy responds, “Well, this week was rough: my brother just died, my wife left me, I got diagnosed with cancer, my dog ran away, I got fired from my job, and I need a root canal.” Yikes, Timmy might have just had the worst week in the history of the world. Honestly, he should be showing the signs of depression. I am kinda depressed just making him up.
The feelings he is having are normal. Serious, ABSOLUTELY, but I would say expected. In fact, if he wasn’t showing these signs I would be more concerned. Timmy still needs counseling to cope with his life stressors, But at this point a diagnosis is not really going to be extremely beneficial. As a believer that medication is a last option for all mental health disorders, which medication requires a diagnosis, in this context diagnosis may not be necessary. Timmy can possibly make it through this tragic week and not need a diagnosis if he processes and his symptoms improve. Timmy needs help from a counselor, but maybe not a diagnosis at this time, if things continue this way it will likely be an obvious diagnosis.
What is Context?
Context is basically anything impacting someone’s life. This can include many things and will vary from person to person. Everyone has different people, events, and circumstances.
Factors Impacting Context of Mental Health Disorders
- Family: Love them or hate them, family is a huge factor in everyone’s life. If your family is deceased, that could also be leading to some of your mental health issues. Also, family can place a significant amount of stress on us. They also can be a huge ally and help a person overcome mental health issues.
We inherent many learned behaviors from our family members, through observation. When looking at abnormal behavior, and possible diagnosis learning about family dynamics can be important to lending understanding of behavior.
- Biology: Your family and biology may be different, if you are adopted, your family and DNA are not the same. The predispositions a person may have is always important. Are there any trends in diagnosis? However, it must be noted that just because a trend might exist, does not in any way mean a person is absolutely going to develop a disorder. Or for that matter that anyone is immune from anything, and everyone can develop a mental health disorder.
- Home Life: Looking at a person’s living situation is crucial. If the place where you go to recharge and relax, home for many people, is unpleasant it will impact your mental health. Some times a change in living situation can eliminate many of the symptoms that may be causing the mental health issues.
- Job: How we earn a living is a huge part of our happiness and overall mental health. We, particularly in the US, spend more time at our jobs than anything else in our lives. Supervisors, annoying customers, not feeling heard, constant stress and worry, dealing with depressive issues, all of this and more are reports of job dissatisfaction. Taking pride in your work is a big deal. Feeling heard, respected, and contributing is awesome.
- Relationships: Frequently, people would be in my counseling office and I would say to myself, “I don’t think you need to be here as much as your __________ needs to be.” That could be spouse, boyfriend/girlfriend, parent, sibling, or other important person in the client’s life. Factoring in relationships is necessary because the relationships we hold often tell us a lot about ourselves.
- Physical Health: Being in “shape” is a subjective term. Technically, everyone has a shape of some sort. Looking at overall health, exercise, diet, etc. can be very insightful to understanding a person’s behavior. The spectrum of physical fitness is vast. A change in behavioral physical components like diet, exercise, and other areas can be very significant. Also, if a person has some sort of an illness or physical disability it can have an impact on mental health. The use of drugs, alcohol, and other medications can also impact this.
- Trauma: Experiencing some sort of trauma in your life can have a substantial impact on your overall mental health for many years to come. This can be virtually anything that emotionally or physically threatens or harms someone, or someone close to them. Things like sexual assault, physical abuse, emotional abuse, a car accident, or robbery are common, but the spectrum is vast.
- Location: While geographical sadness does appear significant, the reasons are varied. Some can be as simple as not getting enough sunshine in a dreary area and needing a Vitamin D lamp. Or, it could require a move around the world. Many people learn that when moving their problems, if not dealt with correctly are likely to follow you any where.
- Culture: What is normal and acceptable behavior in one culture may not be in another. For example, if a person is talking about speaking to and seeing spirits, that could look like Schizophrenia and be an accurate diagnosis. Yet, in another culture it may be a normal cultural belief to speak with spirits and does not warrant a diagnosis.
- Other Factors: The causes of issues may not fall into of these categories, doesn’t mean that it is any less significant.
For many of these issues, specific DSM-5 criteria has a specific diagnosis, like a person who has experienced trauma and PTSD. Other explanations of context, like being on drugs or alcohol are accounted for in other diagnosis. However, alcohol use which is not a diagnosis in appropriate settings for adults can have a big impact on certain people, and then can be diagnosable if the behavior becomes problematic.
Best practice for gathering context when making a diagnosis of a mental disorder:
Seek to Understand, Not be Understood.
This is an old Alcoholics Anonymous adage. I think this is a great way to approach gathering information in a counseling setting. Seek to understand what the person has to say. Ask questions, listen, and be genuine. The more you know about the person the more clear of a picture you have. All the pieces matter when trying understand the extremely elaborate human animal. Gathering information from other sources (family, friends, colleagues, etc.) can also be helpful but is not always possible.
To reference this article:
Mikita, D. (2016). The importance of context when diagnosing mental disorders. Retrieved from Free Psychology Help: http://www.freepsychologyhelp.com/?p=116&preview=true