Karen Levin, Ph.D Speech Therapist, Johannesburg

Diagnosis

We do not need a diagnosis in order to be able to work with a child. We only need to know what he or she can and cannot do. No matter what the diagnosis, we consider  each patient as an individual. No two persons with the same diagnosis are identical. Although useful, diagnoses can be dangerous and misleading too.

 

Making a diagnosis leads to a label which leads to "Othering"

When one labels a person, then that person is 'othered', in other words, made to be seen as something other than the norm. We - or society - decide what the norm is and if a person does not fit our expectations, then they are 'othered'. And when a person is considered abnormal,  there are terrible consequences. People judge, exclude, marginalise, and avoid "others". "Others" are stigmatised, ridiculed, institutionalised, laughed at, abused, and oppressed in many, many ways.  This is not bleeding-heart talk. This is a very real and dangerous social phenomenon. As a speech therapist, I have seen my patients hurt. I have seen language impaired children being laughed at; adults with intellectual disabilities being made to live with people that they don't like; people who stutter taking on menial positions because of their fears of being ridiculed in the workplace; children who lisp being teased; and adults who cannot communicate well being abused by their employees or caregivers. Labelling people makes them othered.

Lack of consensus

Give a child to 5 professionals and it is most unlikely that they will all agree on a diagnosis. There are a number of formal publications that we use to guide our decision-making. Not everyone agrees with the guidelines. Also, we have few measures that accurately and objectively determine the criteria by which diagnoses are made.

Terminology changes

And the guidelines change. For example, in the old DSM-4, there was a category called 'Aspergers syndrome'.  It was a useful category for many people and there are hundreds of people who have identified themselves as having Aspergers (even calling themselves 'Aspies').  Along came the revised DSM-5 and Aspergers no longer exists.  So Aspies no longer exist. And so  treatments for people with Aspergers do not exist. And we have to discard huge amounts of research on Aspergers.  The bottom line is that diagnoses are not forever.

Communication impairments are not an individual problem

Communication does not reside in one person. The very definition of communication is that it occurs between people. So a diagnosis places the problem in the individual. What about the mom who can't understand her child? What about the boss who is uncomfortable when his employee stutters? What about the dad who speaks for his child who is unintelligible? It does not seem fair to locate the diagnosis in the person with the impairments.

Diagnosis makes clients behave according to the diagnosis

When one labels a person, that person is expected to behave according to that label. We lower hopes; expect less; and we condition the patient's behaviour such that it fits the label. Dangerous and unfair indeed!

Is a diagnosis important?

 Yes and no.  I need a diagnosis so as to be able to be paid by medical aids who insist that we use a code based on a diagnosis (the ICD codes). I need a diagnosis often to help to get my patients placed in a school. In some countries, it is essential to have a diagnosis so that one qualifies for services. I need a diagnosis to be able to read research and understand the impairments. But I am not ruled by diagnoses. In fact, in my day to day clinical work,  I am pretty sure that I can say that the diagnosis is not at all relevant.  I work with what I see.  I determine what my patient can and cannot do, and how this affects his or her ability to live in the world.

This is what I do, no matter what the diagnosis:

1.  Work on the impairments to try to make communication more effective.

2.  Harness the strengths of the patients to make communication more effective.

3. Work with my patient on participating in the world as an equal communicative partner, no matter how severe the impairments are.

 

Of great importance is that there are no methods that we use that are specific to types of problems. I can use every method or technique that is available to me with any patient. I have knowledge of what works and with whom; I adapt my therapy to the needs of every individual. I don't need a diagnosis in order to decide how to proceed. Rather, I use intricate information about the individual patient to make these decisions.