When making a diagnosis of a mental illness it is extremely important to look at the entire context of a person’s life. People often want to simplify down a person’s behavior to just DNA, learned behaviors, relationships, life events, pandemics, trauma, health issues, etc., etc., etc. Truthfully for virtually all people it is a combination of many factors. Sometimes one of these factors may represent a large portion of the mental health issues, but usually it is a blend of factors.

The context of a person’s life should be fully investigated by a clinician making a diagnosis. It is incredibly easy to get complacent and just wave the “diagnosis wand” because someone seems to meet the criteria of a disorder. Waiting on making a diagnosis, when possible, until more information is evaluated can allow for the most accurate diagnosis. Sometimes a diagnosis is needed immediately (insurance companies are often to blame). But when lives are in danger, courts need documentation, an immediate change in someone’s life of a traumatic nature, can all encourage a quick diagnosis. While these do occur, they are rare. For many mental health professionals rushing on making a diagnosis is common place and should be avoided. Be patient to be accurate.

Good professionals spot many disorders immediately, 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, and sometimes ever. 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 secure the appropriate diagnosis, if there is one, and that you aren’t just diagnosing a mood or momentary behaviors.

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. I can exhibit symptoms of depression without actually having depression. 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.

Case Study

Let’s say Timmy comes into my office because he has been super bummed out. He says he is very unhappy, 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, the damn pandemic, 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 and normal human reactions to these events. 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 beneficial. As a believer that medication is an absolute last option for all mental illness, for medication a diagnosis is required. 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 well and his symptoms improve. Timmy needs help from a counselor, but maybe not a diagnosis at this time, if things continue, or he needs insurance to cover services, a diagnosis may be needed at that point.

What is Context in Diagnosis?

Context is basically anything impacting someone’s life. Everyone has different people, events, and circumstances. Basically the who, what, where, when, why, and how of a person’s life. There really is not factor too small to have an influence on a person’s mental health. The more you know, the better you can understand.

Factors Impacting Context of Mental Illness

• 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 struggles. Also, family can place a significant amount of stress on us, or on the flip side a great support system. We inherent many learned behaviors from our family members, through observation (substance use, relationship dynamics, personality traits, etc.). When looking at abnormal behavior, and possible diagnosis learning about family dynamics and behaviors can be important understanding behavior. It can also help designing a treatment plan.
  
• Biology: Your family and biology may be different, if you are adopted, your family-life and DNA are different. The genetic predispositions a person has are significant to mental wellness. Are there any trends in diagnosis? (Mom has depression, grandpa was bi-polar, aunt is schizophrenic, etc.) 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. The more diagnosis in your family, the more likely you will be impacted as well, just like with cancer or other illness.
  
• 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 impactful. 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. Some can be eliminated, others may just need some boundaries to keep everyone safe.
  
• Physical Health: 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 illness or physical disability it can have an impact on mental health.
  
• What we Feed Our Body and Mind: The actual food we put in our body is significantly impactful. It is the building blocks of our body. A vast majority of serotonin is actually created in our gut. This is one of the chemicals that makes us feel good and fight mental illness. It is also important to look at substance use and how this is likely impacting mental wellness.
  
• Trauma: Experiencing some sort of trauma in your life can be significantly impactful. This can be anything that emotionally or physically threatens or harms someone, or someone close to them. It can also include the witnessing of trauma. Things like sexual assault, physical abuse, emotional abuse, a car accident, or robbery are common, but the spectrum is vast and trauma is one of the most influential causes in mental illness.
  
• 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 Vitamin D. Or, it could require a move around the world to find safety and satisfaction. Many people learn that when moving their problems, if not dealt with correctly are likely to follow them. Being happy with where you are is important.
  
• 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. This can happen when people try to extend the DSM beyond the culture it was created in.
  
• Other Factors: The causes of issues may not fall into of these categories, doesn’t mean that it is any less significant. Think about societal influences, like global pandemics, civil unrest, political upheaval, and much more as these are very impactful to a person’s ability to navigate life.

Best practice for gathering context when making a diagnosis of a mental disorder: The more you know, the more you can help. Sometimes it can be difficult to gain accurate information as a person may not be able to accurately share about their lives because a disorder (like schizophrenia or dissociative disorders) could make the recall of information virtually impossible. When a client is willing (AND ONLY THEN) can friends, family, or other professionals input be shared, which can also be very valuable.

To reference this article:

Mikita, D. (2021). The importance of context when diagnosing mental illness. Retrieved from Feel Awesomer: http://www.feelawesomer.com/2016/01/16/importance-context-diagnosing-mental-disorders/