Last week, I found it interesting and heartening to hear Dr Suzanne Garfinkle-Crowell speak on BBC Women’s Hour about her new book, Girlhood Translated. Dr Garfinkle-Crowell, a psychiatrist, notes the increase in what might be described as ‘therapy speak’, or medicalised language, among the teenage girls she sees in her practice. As well as considering the cultural factors that might contribute to this phenomenon, she reminds parents and caregivers that the young people using this language, whether ‘accurate’ or otherwise, are attempting to communicate something about their experience that they may not otherwise have words for. She urges adults to lean into the experience behind the diagnosis, rather than becoming preoccupied with whether the label itself is correct.

In the same week, Tanya Byron spoke on BBC’s All in the Mind about the potential over-pathologisation of ‘normal’ distress, asking whether we are sometimes too quick to label it. She argued that the language around diagnosis matters: that we risk minimising the experience of people with significant mental health difficulties by overusing clinical terms, while also blurring the distinction between everyday emotional experiences and clinical conditions.

I enjoyed both discussions, and both led me to reflect on how I, as a person-centred therapist, and as a person experiencing the human condition, frame the distress that I and others sometimes experience.

When exploring my own experience, I notice that I tend to lean away from medicalised language. Instead, I have a preference for exploring the nature, cause, patterns and consistency of an experience. I might ask myself questions such as: When do these feelings tend to arise most frequently? What is the quality of the physical sensations, and where do I experience the feeling in my body? What could this be telling me?

When working with clients, however, my approach is different. When clients come to me wondering if they might meet the criteria for a certain diagnosis, whilst I do tend to lean in with curiosity to the experience behind the label, I will not contradict or guide them away from the label itself, particularly as many clients find having a word to conceptualise their experience to be helpful- but moreover, because I am interested in my client’s unique relationship to that label.

One argument, however, seemed to me to be conspicuously absent from both podcast discussions. It is a rather fundamental question:

What is a clinical condition, anyway?

Whilst I haven’t yet had the chance to read Garfinkle-Crowell’s or Byron’s publications, the podcast discussions prompted me to wonder whether we sometimes move too quickly into a conversation about who should or shouldn’t qualify for a diagnosis, without first examining what a psychiatric diagnosis actually represents.

In medicine, we might ordinarily expect a disease to have some identifiable pathology or underlying mechanism: something that can, at least in principle, distinguish the disease from health and from other diseases. Psychiatry has historically aspired to develop similarly discrete disease entities. Yet this remains an unresolved scientific problem.

Most contemporary psychiatric diagnoses are not defined by a biological test, laboratory finding, or identified pathological lesion. Rather, they are generally constructed from patterns of reported experience, observed behaviour, duration, severity and associated impairment. The National Institute of Mental Health itself describes current mental disorder diagnosis as being based on clinical observation and the identification of symptoms that tend to cluster together. Its Research Domain Criteria (RDoC) initiative was developed in part because researchers are seeking ways of understanding mental health and psychopathology in terms of underlying psychological and biological systems rather than relying exclusively on existing diagnostic categories, but this is still work in progress.

This does not mean that mental distress is imaginary, that psychiatric conditions are ‘not real’, or that biology is irrelevant, and evidence does show that some psychological difficulties are associated with biological, developmental, genetic, environmental and social processes. However these processes do not map neatly onto the diagnostic boxes we currently use.

Indeed, a substantial body of work has questioned whether most psychiatric diagnoses represent discrete entities with natural boundaries. Kendell and Jablensky, for example, argued that there is little evidence that most currently recognised mental disorders are separated from one another, or from normality, by clear natural boundaries.

There is also the question of reliability. If a diagnosis represents a discrete underlying disease, we might reasonably expect trained clinicians assessing the same person to reach broadly consistent conclusions. Yet DSM-5 field trials have shown that diagnostic agreement is far from perfect.

This matters when we talk about ‘over-diagnosis’ or ‘over-pathologisation’. If diagnostic categories are themselves imperfect attempts to describe complex and overlapping patterns of human experience, the question cannot simply be:Does this person meet the threshold for the disorder?

And perhaps this is particularly important when thinking about individuals who are self-diagnosing.

A young person who says, ‘I have anxiety’, may or may not meet the criteria for an anxiety disorder. But that does not mean that the statement is meaningless simply because the diagnostic label is inaccurate. It may be an attempt to communicate something quite specific: I am frightened a lot of the time. I can’t switch my thoughts off. My stomach hurts before school. I don’t know why I feel like this. Other people seem to have a word for this experience, and that word helps me make sense of it.

Likewise, someone who says, ‘I’m depressed’, may be using a clinical term to describe an experience of sadness, exhaustion, hopelessness or disconnection.

Perhaps the ‘clinical’ language gives them words for their experience that they may not have otherwise. Or perhaps, in a world full of clinical criteria, they cannot trust words like ‘sadness’, ‘hopelessness’ or ‘fear’ to carry enough weight to warrant a response of caring attention from caregivers or professionals.

For me, this returns to something fundamental about the person-centred approach: curiosity about the person before the category.

Instead of asking only, ‘What disorder is this?’, we might also lean with curiosity into considering:‘What is this experience like for you? When does it happen? What seems to bring it on? What makes it better or worse? How long has it been happening? What does it mean to you? What has happened in your life? And what are you trying to tell me when you use that particular word to describe it?’

And, most importantly, we offer a client our caring attention no matter what they present- whether it meets a diagnostic criteria or not.