The Diagnostic Trap


I rarely discuss diagnoses. Occasionally a patient asks me to tell them what they “have,” and I usually feel trapped between bad and worse options. In the past I tried many approaches to answering that question, and whatever I said always seemed like a good-enough idea, right until the words passed through my lips. From then on, the course of the session usually changed radically, and sometimes the treatment remained permanently derailed. Although directly answering the question was never particularly therapeutic, it did relieve the tension of the moment. 

Psychoanalysis can generate intense tension in session, and seductive options that might relieve that tension are always available. The problem is, tension within a therapy session is not something any psychoanalyst should be aiming to relieve. The analytic situation is valuable because it replicates tensions that take place in the real world, but in a place where those tensions can be observed and processed, rather than performed or defended against. Patients come to analysis because the defenses they have developed to relieve those tensions are now coming at too great an emotional cost. Thoughtful speech is the medium of change in psychoanalysis, and tension drives the process toward the kind of speech by which problems get worked through. 

In tense situations, we often use speech as a vehicle of action, rather than as means of thinking. For instance, when your friend tells you about her terrible breakup, you’ll caringly blend some cocktail of truth and fiction, in order to calm and reassure. You thereby relieve the immediate tension, and your friend will feel better in the moment. Of course, underneath the soothing, you both know that she will probably have to get real with herself in order to work some things out eventually, using a different kind of speech. Action speech can soothe a mind, but only thoughtful speech can grow one.  

Diagnostic discussions are particularly prone to deteriorating into action speech, particularly when a therapist feels personally attacked. When they feel devalued, inexperienced therapists tend to diagnose passionately and severely. Beginning therapists have a need to be seen as helpful and competent, and this need for affirmation can create a lot of problems early on, particularly in diagnosis. Early in my own training, I found myself reaching for labels when working with particularly grandiose patients around whom I felt useless, and over time I realized all therapeutic novices are unusually quick to unload the heavy diagnostic artillery in these frustrating situations. 

Telling the frustrating patient what he “has” in that situation is a bad idea, and an even worse idea is calling someone a narcissist, even if it seems accurate. Narcissistic diagnosis has become a kind of op-ed blood sport in American media as of late, and just as the ink-spilling diagnosticians have little to show for their emphatic efforts, therapists who call patients narcissistic can end up with no patients to help. 

When we give in to the urge to shell out weaponized diagnoses, particularly toward so-called narcissists, we open ourselves up to a darkly ironic side effect. People who make a living calling out narcissists often do so in an all-knowing, dismissive way, as if they know who all these hollow people really are. These writers tend to communicate an attitude of moral and intellectual superiority toward the toxic narcissist, and this condescending attitude mirrors the grandiose superiority that it intends to criticize. 

Unconscious self-portraiture is the diagnostic trap. When I tell a patient who he is, I may be telling him something about how I am, too. Therapists, like everyone else, first come to understand a person by paying attention to the emotions that person activates in them. When any observer describes someone, it can be quite difficult to tell where the observer ends and the observed begins. If diagnostic ideas are not communicated with the utmost discipline and tact, they can be quite hurtful and destructive. 

The good thing about being a patient is that you don’t have to worry about any of this. You don’t have to know what you “have” in order to get better, and your only real job is to use your psychoanalysis to make a better life. The esoteric shorthand of diagnosis helps me organize my thoughts and words, but diagnostic jargon is not designed to be of much use to a patient. The psychoanalytic process is not about acquiring a psychoeducation through some generic jargon; it is about using that process to discover a specific, unique way of thinking and speaking about the profound strangeness of being alive.