The DSM and the Diagnosis Dilemma

This post is not an easy one to write, and I know I'm not going to get everything right. But it's still important to get this topic out in the open, so here it goes...

When people hear the term DSM, they might picture a huge imposing textbook with hundreds of pages dedicated to mental health diagnoses—and they’d be right. The Diagnostic and Statistical Manual of Mental Disorders, often called the DSM, is essentially a diagnostic guide for mental health professionals. It provides a common language and standardized criteria for classifying mental disorders, helping clinicians identify and name what their clients are experiencing. It’s a tool meant to guide diagnosis and treatment, and for many, it’s seen as an essential foundation of mental health care.

The DSM has been updated multiple times since its first publication in 1952 to reflect advances in mental health research and cultural shifts. The most recent version, the DSM-5-TR (Text Revision), builds on the DSM-5 released in 2013, refining diagnostic criteria, updating language for cultural sensitivity, and adding diagnoses like Prolonged Grief Disorder, Attenuated Psychosis Syndrome, and Unspecified Mood Disorder. While these updates aim to keep the manual relevant, they also highlight the challenges of capturing the complexity of human experience in a single book, sparking debates about whether the DSM truly helps people or simply creates new labels.

This tool is widely used across the field of mental health. Psychologists, psychiatrists, therapists, social workers, and researchers, rely on it. It influences everything from clinical treatment plans to research studies and even legal proceedings. At its core, the DSM aims to make the invisible visible—to give names to struggles that might otherwise go unspoken or misunderstood.

But with great influence comes great responsibility, and the DSM has been no stranger to controversy. While it can validate and empower individuals by giving them a name for what they’re experiencing, it also has the potential to stigmatize. Diagnoses can become labels that follow people, defining them in ways that are limiting or even harmful.

As I reflect on my career thus far and how my views have evolved, I find myself questioning the DSM’s role in the therapeutic process. It’s not that the DSM is useless—far from it—but I’ve come to realize that its importance may not be where I initially thought it was. In this post, I’ll share my journey from treating the DSM like a sacred text to viewing it as a tool that’s helpful in specific contexts but certainly not as crucial as I once believed. Along the way, we’ll explore why focusing on symptoms—not just diagnoses—is the key to truly effective mental health care. And, yes, we’ll talk about the giant elephant in the room: insurance.

My Early Relationship with the DSM

When I was a graduate student, the DSM was my go-to guide, my problem-solver, my mental health dictionary. Anytime I encountered something I didn’t understand, I’d whip it out, flip through its meticulously organized pages, and search for answers. I had pages marked, sections highlighted, and notes crammed into the margins. The DSM was a lifeline in those early days, giving me the confidence to navigate the complexities of mental health.

As an intern and later as a first-year professional, I clung to the DSM even tighter. Every intake assessment, every treatment plan, every case consultation seemed to start with, “What diagnosis fits this?” I treated it like the holy grail of mental health practice. If a client described their symptoms, I felt compelled to find the perfect diagnostic match, as if the DSM held the key to unlocking their path to wellness.

To me, the DSM was definitive. It was the ultimate tool for understanding and categorizing mental health. I trusted it implicitly because, frankly, I didn’t know enough not to. Diagnosis felt like the cornerstone of effective treatment, and I couldn’t imagine approaching therapy without it.

But here’s the thing about those early days: I didn’t yet understand how much more there was to mental health than a label. I was focused on the diagnosis itself, not necessarily the unique person sitting across from me. It’s not that I lacked compassion or curiosity—I just genuinely believed that the DSM was the roadmap to treatment. And like many young professionals, I leaned on it because I was still finding my footing.

It wasn’t until years later, as I gained experience and saw numerous clients, that I realized the DSM’s role isn’t quite what I thought it was. Sure, it’s helpful. It provides a shared language and framework. But it’s not the be-all and end-all I once believed it to be. The DSM is a tool, yes, but the real work? That lies in understanding the person, not just their diagnosis.

Looking back, I can appreciate the DSM for what it gave me in those early years—structure, clarity, and a way to build my knowledge. But I’ve since learned that the DSM is just one piece of the puzzle. And sometimes, it’s not even the most important one.

What Matters More Than Diagnosis

As I near my eighth year in practice and my fourth as a licensed clinician, I’ve come to a realization that has completely shifted the way I approach mental health care: diagnosis isn’t as important as I once believed. In fact, it’s often not important at all when it comes to truly helping someone. What matters far more are the symptoms a person is experiencing and how those symptoms show up in their unique life. This is what we call the subjective experience, and it’s different for every single person.

When we focus too heavily on a diagnosis, we risk overlooking the nuances of how symptoms impact an individual’s life. Anxiety in one person might mean a constant sense of dread and physical tension, while in another it manifests as racing thoughts and difficulty concentrating. Both could technically fit the criteria for an anxiety disorder, but their needs and experiences are completely different. That’s what matters in treatment—the person’s lived reality, not the label.

I’ll give you an example from my own life. Over the years, I’ve had people casually say to me, “You probably have ADHD.” I get it—I can struggle to focus on one topic at a time, and my thoughts sometimes jump around at lightning speed. But here’s the thing: that’s not ADHD. That’s how my anxiety shows up. My brain doesn’t shut up, and my thoughts cycle so rapidly that it feels like I’m juggling ten things at once.

How do I know it’s not ADHD? Because I’ve seen what happens when I take stimulant medication commonly prescribed for ADHD. Spoiler alert: it’s not good. Stimulants keep me awake for nearly 36 hours straight, which is not exactly ideal for someone trying to calm their mind. On the other hand, an SSRI—commonly used to treat anxiety—makes my brain feel noticeably quieter and more balanced. This personal experience highlights an important truth: we don’t treat diagnoses with medications; we treat symptoms.

The Complexity of Overlapping Symptoms

One of the biggest challenges I’ve encountered in my practice is the sheer complexity of mental health symptoms. So many diagnoses share overlapping symptoms that it can be difficult—sometimes impossible—to tease them apart. It’s not uncommon for someone to meet the criteria for several different diagnoses, which can lead to confusion, misdiagnosis, or even treatment plans that don’t fully address their needs.

Take something as seemingly straightforward as difficulty concentrating. It could point to ADHD, sure, but it’s also a hallmark symptom of anxiety, depression, and even trauma. How do you differentiate between these possibilities? The truth is, it often comes down to context—how the symptom shows up in someone’s life, what other symptoms accompany it, and, most importantly, how the person themselves experiences it.

This is where the DSM falls short. While it provides diagnostic criteria, it doesn’t account for the individuality of human experience, that subjective experience. Two people with the same diagnosis might have entirely different symptom profiles and needs. For example, one person with anxiety might struggle with intrusive thoughts, while another deals with constant physical tension. Both fall under the broad category of anxiety, but their treatment approaches would look different.

This overlap is one reason I’ve grown skeptical of the DSM’s role in guiding treatment. I’ve seen clients whose symptoms fit multiple diagnoses, and I’ve seen how trying to squeeze someone into one category can lead to clinical oversights. For example, a client might come in with symptoms of depression, but as we dig deeper, it becomes clear that their low mood and fatigue are actually tied to undiagnosed PTSD. In this case, focusing too much on the label can mean missing the bigger picture of untreated trauma.

The reality is, people are complex. Mental health doesn’t fit neatly into a bullet point list, and trying to force it to can do more harm than good. Instead of zeroing in on the diagnosis, I’ve learned to focus on what’s actually happening in the client’s life—their experiences, struggles, and strengths. This approach allows for a more holistic understanding of their needs and leads to treatment that truly supports them.

What this means for me as a clinician is letting go of the need for certainty. Diagnoses can feel definitive, but they’re often just educated guesses based on incomplete information. When we recognize that, we can shift our focus to what really matters: helping people feel better, no matter what their symptoms are called. Because at the end of the day, it’s not the diagnosis that heals—it’s the connection, understanding, and care we offer in response to someone’s unique experience.

The Role of the DSM in Insurance

If there’s one place the DSM holds undeniable influence, it’s in the world of insurance. Whether it’s therapy, medication, or other mental health treatments, most forms of care require a diagnosis in order to be covered. Without a diagnosis code, insurance companies won’t approve therapy sessions, certain medications, or specialized mental health treatments, leaving clients with two choices: pay out of pocket or forgo care. This reality makes the DSM an essential tool—not necessarily because it is crucial to treatment, but because it is required to navigate the financial and logistical aspects of accessing care.

Diagnosis as a Means to Access Treatment

Here’s how this plays out in practice: A client comes in seeking support and we (the clinicians) will be billing their insurance in order to be reimbursed for providing our services to the client. This is how we (the clinicians) get paid and make a living. Before we can dive into their experiences or even determine what kind of treatment would be most helpful, clinicians have to assign a diagnosis. Not because we think it’s the most clinically relevant thing at that moment, but because without it, therapy won’t be covered/reimbursed by the client's insurance. It’s a frustrating reality—one that forces clinicians to think about diagnosis in a way that feels more administrative than therapeutic. Quite honestly, my opinion is that a thorough mental health diagnosis cannot be made until you've met with your client at least four times and until you've had the opportunity to review relevant records.

Most mental health providers, myself included, are focused on helping clients understand and manage their symptoms. However, the current system requires that a client’s struggles be categorized into a diagnosis in order to justify treatment. This often leads to assigning a diagnosis simply because it is necessary for coverage, even when the client’s experiences don’t fit neatly into one defined category. It’s not about labeling someone unnecessarily—it’s about making sure they have access to the care they need.

The issue isn’t necessarily that diagnosis is useless—sometimes it provides helpful insight and guidance—but that it is often used more as a ticket to services than as a true reflection of what a person is experiencing. Mental health is complex, and the idea that every person seeking help must fit into a predefined diagnostic box to receive care doesn’t always align with what is best for them.

The Challenge of Prior Authorizations and Medication Approvals

Working closely with a prescriber in a community mental health setting has given me firsthand experience with just how much diagnosis dictates access—not just to therapy, but also to medication. Prior authorization processes with insurance companies frequently come down to one key question: Does the client’s diagnosis match the criteria required for this medication to be covered?

I can’t count how many times we’ve encountered situations where a medication that could clearly help a client isn’t approved because their diagnosis doesn’t meet a certain requirement. It doesn’t seem to matter if the symptoms they’re experiencing align with what the medication treats—it only matters if the diagnosis on file matches the insurance company’s predetermined list.

This is where the disconnect becomes particularly frustrating: clinicians treat symptoms, not just diagnoses. We prescribe medications to reduce distressing symptoms, improve functioning, and enhance quality of life. But insurance decisions are often made based on rigid diagnostic categories rather than on the reality of how symptoms present in an individual.

For example, let’s say a client is struggling with significant mood instability, difficulty focusing, and impulsivity. Their symptoms may fall under several different diagnostic categories, but their prescriber determines that a particular medication would be beneficial. If the insurance company decides that the medication is only covered for clients with a specific diagnosis—one that doesn’t perfectly match this client’s file—they may be denied coverage, leaving them with few options.

In these moments, it becomes clear that diagnosis isn’t always about clinical accuracy; sometimes, it’s about ensuring that people can access the care they need. This reality forces clinicians into a tricky position where we must balance what is best for our clients with what the system allows us to do.

A big Question...Is the DSM More About Treatment or Insurance?

Over time, I’ve started to wonder: Does the DSM serve clinicians and clients, or does it serve insurance companies? Of course, the DSM is a helpful tool in many ways—it provides a shared language, a framework for understanding mental health conditions, and a way to track patterns of symptoms over time. But its role in treatment often feels secondary to its role in justifying coverage.

This realization has led me to a somewhat jaded but honest perspective: The DSM seems to function as much for insurance purposes as it does for clinical practice. Without it, there would be no standardized way for insurance companies to approve or deny care, no common language for reimbursement, and no structured way to determine what services are deemed “medically necessary.” In some ways, it has become less of a guide for mental health professionals and more of a gatekeeping tool for access to care.

But I also recognize that this system exists for a reason. Insurance companies operate within specific structures and policies, and while those policies may be frustrating, they are not inherently designed to be barriers. They are designed to create guidelines for coverage, even if those guidelines sometimes feel restrictive or misaligned with clinical reality.

Final Thoughts

I don’t have all the answers, but I do believe there has to be a better balance. Insurance coverage is necessary to make mental health care accessible, but the current system shouldn’t force clinicians to prioritize diagnosis over client-centered care. The DSM is useful, but it shouldn’t be the sole factor in determining who gets help and who doesn’t.

Instead of a rigid, diagnosis-driven system, we need an approach that allows more flexibility—one that focuses on the symptoms and struggles that bring someone into treatment rather than just the label assigned to them. Until then, clinicians will continue navigating this imperfect system, doing what we can to ensure our clients receive the care they need, even when the rules don’t always make sense. And until then, I will continue to advocate for a symptom-focused approach to care—one that prioritizes the individual over the diagnosis. I will continue encouraging my clients and others not to define themselves by a label, not to shrink themselves to the bullet points in the DSM, and not to see a diagnosis as a life sentence. Instead, I want people to explore their symptoms, understand how they show up in their lives, and embrace the changes they want to make, rather than focusing on what this book says is unchangeable.

Therapy is transformative if we let it be transformative—if we see it as a path to growth rather than a system of limitations. Diagnosis should never be the thing that holds someone back from healing.