A Case for Strengths-Based Diagnosis

[Obligatory disclaimer that I am not (yet) a licensed therapist and that the following is my personal opinion, informed by practice and academic study.]

Recently in a class on adult psychopathology, my professor was discussing the strengths and weaknesses of the DSM (Diagnostic and Statistical Manual of Mental Disorders), the text used to diagnose mental illnesses and categorize them for the purposes such as research, insurance billing, and sharing information among professionals.

One of the weaknesses he mentioned was one I’d actually never heard before: that the way the DSM diagnosis is written and shared does not include any space for also “diagnosing” the client’s strengths.

At first, this seemed irrelevant to me, not in the sense that thinking about your client’s strengths is not important, but in the sense that I didn’t see how it matters for a diagnosis. It almost seemed a little patronizing: “Yes, you have major depressive disorder and social phobia, but hey, at least you seem like you’re pretty resourceful and good at expressing yourself!”

But then I rethought that.

Here’s an example of a DSM-V diagnosis:

296.35 (F33.41) Major depressive disorder, early onset, recurrent episode, in partial remission, with atypical features

300.4 (F34.1) Persistent depressive disorder, early onset, with atypical features, with intermittent major depressive episodes, without current episode, moderate

V62.89 (Z60.0) Phase of life problem

It’s honestly difficult for me to imagine looking at this information with anything other than relief. For me, diagnosis has always meant one thing first and foremost: You’re not a terrible person; you just have an illness.

But to other people, seeing something like this can communicate a whole lot else. You’re sick. You’re fucked up. There is nothing redeeming about you. You can’t do something as simple as not being so sad. This is especially true when someone is already predisposed to interpret information about themselves in a negative light, because, well, that’s what mental illness always does.

In that moment, it can be really helpful to have confirmation–not just from a friend or loved one, but from a professional whose job it is to assess you–that you do have strengths and positive qualities.

So, here are some reasons incorporating strengths into diagnoses might be a really good thing.

  1. Giving hope and affirmation to the client.

Just like it can be nice to go get a dental checkup and hear, “You’ve been doing a great job at preventing cavities, but you need to floss more consistently in order to keep your gums from getting irritated,” it can be nice to hear, “Based on what you’ve told me, I believe that you’ve had a major depressive episode for the past few months. However, you’ve clearly been very good at reaching out to friends and family for support, and it sounds like you have a lot of people rooting for you to get better.”

Therapists and psychiatrists say “nice” things like this all the time, but writing it down as part of a diagnosis might be symbolically meaningful. To the client, that communicates the fact that their strengths are just as important as their diagnosis–important enough to be written on the form or in the chart. It shows that their mental healthcare provider, whom they might feel shy around or even judged by, does see them as a whole human being with strengths as well as a diagnosable illness.

  1. Providing possible avenues for treatment.

A psychiatrist may diagnose a client and then refer them to a therapist (therapy combined with medication tends to be more effective than either in isolation). Now what? The therapist can look at the diagnosis, or ask the client what it is, and proceed from there.

What if the diagnosis included something like, “Client reports that volunteer work helps them distract themselves from symptoms, and that writing in a journal has occasionally been helpful”? The therapist now has some potential ways to help the client. Or the diagnosis might include, “Despite severe symptoms, client shows a high level of insight about the possible origins of their depression.” The therapist now knows that lack of self-awareness isn’t the problem–symptom management might be.

I continue to be amazed that none of my therapists ever asked me if there’s any way I could incorporate writing into my depression recovery, or if there are any ways I’ve been incorporating it already. Writing is my life. Usually I’ve either said as much in therapy, or I haven’t because nobody ever asked me what I like to do or what makes me feel good. Why not?

  1. Reducing negative bias from providers.

I can’t make definitive statements without more research, but based on what I understand about bias, I can imagine that consistently viewing a client as “major depressive disorder with atypical features and moderate persistent depressive disorder” does things to one’s perception of that person. Not positive things.

It is difficult (if not impossible) to effectively help someone you view as deficient or weak. First of all, your likely pessimism about the person’s recovery will almost certainly be perceived (and possibly internalized) by them. Second, any roadblocks that come up in treatment will likely be interpreted as “resistance” or “not really wanting to get better” or “not being ready to do the work of therapy.” In fact, maybe it’s that your approach isn’t actually helpful to them. Third, without a conscious awareness of the person’s strengths and assets, what exactly are you using to help them recover? Therapy isn’t about “healing” people so much as helping them discover their own resources and help themselves. If you don’t even know what those might be, how could you possibly help the client see them?

Many therapists try to think of their clients’ positive traits in addition to their “negative” ones. However, formalizing and structuring this process as part of a diagnosis might make it sink in better, and become more embedded in one’s general impression of a person. The questions we generally have to ask while diagnosing someone are fairly negatively oriented–”Do you ever have trouble falling asleep? How often? To what extent does this impact your daily life?”. What if we also asked, “What helps you sleep better? How do you cope with being tired after a night of insomnia?” Maybe that can help shift a therapist’s perspective of this person from “insomniac” to “person with difficulty sleeping, who has reached out to friends for help with daily tasks.”

  1. Preventing provider burnout.

I dislike talking about my work because people are consistently amazed at it in a way that annoys me. “How could you deal with hearing these awful things?” they ask. “Isn’t it really depressing to work with all these people?” It isn’t, because thanks to my training, I’ve internalized a strengths-based perspective. When I think about the people I’ve worked with, I don’t see poor suffering depressives and trauma victims. I see resilient, determined individuals who are working to overcome their challenges in the best ways they can.

I think that some people in this field burn out because they can only see the suffering and the oppression and the unfairness of it. I also see those things, obviously, because they’re sort of a big deal. But if that’s all you see when you sit with a client, not only will that be reflected in your treatment of them, but it’ll also impact your own ability to persevere.

If every time a therapist made a diagnosis, they had to intentionally remind themselves of the client’s strengths, that might go a far way in helping them remember that there is hope and everything is not absolutely bad.

As I’ve mentioned, plenty of mental health professionals already incorporate a strengths-based perspective into their work. But this is more common in areas like social work, where diagnosis is rarely used and actually often criticized, anyway. I certainly don’t remember any of my psychiatrists or PhD-level therapists spending any time asking me about my strengths or coping strategies. They gave me my diagnosis, and that was mainly it as far as assessment goes.

One might argue that strengths assessment has no place in the DSM because it needs to be standardized and reliable. However, reliability may be a problem for the DSM regardless, meaning that different professionals assessing the same client may disagree in their DSM-based diagnosis.

One might also argue that the DSM is “about” mental disorders, not “about” a client’s overall set of traits or strengths. I’ll grant that. Regardless, I think that formally incorporating individual strengths into clinical assessments in therapy and psychiatry may be helpful. May be.

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A Case for Strengths-Based Diagnosis
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13 thoughts on “A Case for Strengths-Based Diagnosis

  1. 1

    Your ending paragraph: “One might also argue that the DSM is “about” mental disorders, not “about” a client’s overall set of traits or strengths. I’ll grant that. Regardless, I think that formally incorporating individual strengths into clinical assessments in therapy and psychiatry may be helpful. May be.”

    Another incredibly beautifully articulated article from someone I would seek out if looking for therapy. Sounds like your conclusion to me, a lay-person, who has dealt with many people having serious mental problems, many strengths, as well, mostly that of being survivors of being born female, is simply, humane, wholistic common sense. I wish more like you around. I saw way too many people damaged severely by old-time therapy, leftovers from Victorian or other past times.

    Thanks for being, and writing, helping probably more than you may ever know.

  2. HFM
    2

    From a patient’s perspective, it was definitely helpful to have a strength-based framing presented to me. I came in at a level of “I can’t stop being sad”, which is a large amorphous problem, and I was guided to “Well, I actually deal quite well with random bad luck and with interpersonal problems, but when work isn’t going well I take it very personally. Other parts of my life are working, so I’m not broken. What can I learn from the coping skills I have developed in other parts of my life?”

    When you’re deep in the weeds, it’s hard to avoid catastrophizing, of the form “I’m broken and I’m screwed and I’ll be here forever”. It’s helpful to be reminded that you’re not completely broken, and that what you’re failing at is a subset of the whole.

  3. 4

    The biggest problem I see with this idea is that diagnoses are supposed to be codeable and comparable – you can take two hundred people with atypical depression and do a study on them because they all have the same condition (hahahahaha).

    Something like “Client reports that volunteer work helps them distract themselves from symptoms, and that writing in a journal has occasionally been helpful” sounds more like a note than a diagnosis. How do you bill for that? 😛

    Maybe it would be better to use very generic qualifiers, like “depression, atypical, severe, with good coping skills”. Or “depression, atypical, severe, with high intellectual functioning”. Or “depression, atypical, severe, with good insight”.

    But to have it in a diagnosis, I would want some evidence that it interacts with the disease in an important way. “Good coping skills” seems like it would fit this; “nice to their friends” might not.

    Also, I’m not sure how insurance billing plays into this, but I think that’s a major incentive for people to start listing more negative qualifiers, and it might not incentivize positive qualifiers in the same way.

    1. 4.1

      You’re right–I think if something like this were to actually be incorporated, we’d need a much better classification system for healthy coping behaviors and positive environmental/psychosocial factors.

      I don’t actually think that stuff like this needs to be included in insurance billing, though. I think it could be useful for communicating with clients and their other providers, and possibly also for research (if the aforementioned coding system is developed). For instance, in an antidepressant trial, is there a difference in outcome between patients who were coded as having “good coping skills” versus the patients who didn’t receive that code? Is strong family support a moderating variable?

      Obviously, variables like that already get included in studies, but if they became a standard part of diagnosis, it’d be that much easier to compare across different studies.

    2. 4.2

      I know a lot of people who have moderate to severe mental problems (depression, anxiety, ADHD) and are very smart. They look okay relative to the population average but way below their potential. I could see strength-inclusive diagnoses strengthening the case that they have a medical problem in need of intervention because it would explain why they need medical intervention when they appear to be functioning.

  4. 6

    I have no expertise with therapy, but I have argued for a similar thought process when it comes to criminal justice. It can be very easy to focus almost completely on everything negative going on, but focusing on the negative can lead to feedback cycles of every increasing negativity.

  5. 7

    Really great article. I utilize a strengths based approach when dealing with my clients (I’m a social worker) and understand the frustration at having to focus on “What’s wrong” before we discuss their resiliency and strengths. I guess it comes down to insurance billing I’m regards to the DSM and diagnosis. I know that when I’m working at my facility I don’t use diagnosis, I simply see my clients. But, if (when) I have a private practice, I’ll have to use a diagnosis. Very interesting points. Definitely gives me something to think about! Thanks!

  6. 8

    How serendipitous! I actually wanted to ask you about your opinion about the DSM. 🙂

    I definitely agree that there should be a regular assessment of the client’s strengths, instead of only their mental illness. Mental health professionals should be assessing their clients for self-compassion, mindfulness, social support network and self-efficacy (just to name a few).

    One major issue I have with the DSM is how categorical it is. Most mental illnesses – if not all – are multidimensional. For instance, depression isn’t something you either have or you don’t; it lies in a spectrum ranging from mild to very severe. It includes: negative affect, social withdrawal, self-esteem, self-efficacy, sleep disturbances, etc.

    I don’t expect for a strength-based diagnostic system to be incorporated to the DSM soon. But I do hope all mental health professionals make a habit of strength-based or mental health-based assessments in the future. Positive Psychologists would be tickled pink on that day!

  7. 10

    Making strengths part of formal diagnosis could have quite a few benefits. Perhaps a start could be with simply documenting what sort of behaviors enable people to cope. This already gets done, in a negative sense, when it comes to things like self-medication. A psychiatrist could document a person’s physical activity, writing, doing art, doing volunteer work. It could be a huge benefit to be able to see that, among two people with the same diagnosis, one person prefers solitary means of coping and another seeks out social contact. Understandable it could be difficult, but classifying mental illness is a difficult task already. It would probably take a dedicated task force some time and wouldn’t be perfect at first, but over time it would improve.

    This does seem to be something that comes out in therapy *eventually* but making it something done at the start would help.

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