I received an email the other day from a reader asking me what I thought the diagnosis for Sophie of In Treatment would be. The reader speculated either Oppositional Defiant Disorder or Bi-Polar Disorder, because of the suicide attempt. So I thought I would write about that today.
Back in the dark ages when I was first in grad school in clinical psychology, it was *very* unusual for a teenager to be given a major psychiatric diagnosis. Our understanding then was that teenagers are in the normal course of things pretty volatile and that distinguishing normal adolescent mood swings and behavior from pathology is very difficult. Having now had 35 years of clinical experience plus the opportunity to be up close and personal with my own children and their friends, I see no reason to change that notion.
The excuse given for burdening children and teens with these major diagnoses is that it gets them treatment earlier. But when that treatment all too often consists only of psychotropic meds with very little if any literature about their long term effects on development, one has to wonder if treatment is of net benefit to them. To say nothing of what it means to an adolescent to have a psychiatric label become a significant part of her identity. And we know that identity formation is one of the major developmental tasks of adolescence.
Sophie appears to be doing fine in school and she is a talented gymnast. There do not seem to be any behavioral concerns about her from either of those quarters of her life. She does have a great deal of conflict with her mother, but that is not of a magnitude or seriousness to warrant a diagnosis of any kind. To me, it appears that her symptoms are primarily in response to issues in her environment -- her father's neglect and acting out, the poor boundaries of her coach. I can't see any of her symptoms as other than at the outside of what teenagers sometimes do.
Sophie also responds very well to therapy. She forms a solid therapeutic relationship with Paul and makes significant progress. This argues against major mental illness.
So my inclination would be to avoid any major diagnosis -- if pressed I would likely use adolescent adjustment disorder. Given the research showing the over-diagnosis of bi-polar disorder and the questions many, including me, have about the appropriateness of making a BPD diagnosis in a minor, that diagnosis seems unwarranted altogether.
The basic message I would want to convey to Sophie and her parents is not that she is "sick" or "mentally ill", but that she is under considerable stress and that with help she can learn better means of handling stress so that her life works better for her. I would want to concentrate on empowering her in developing good decision making skills and other tools necessary for successful life as an adult.