The F Code

I don’t know about other therapists, but after twenty-plus years of trying to understand clients in all their uniqueness, I find myself still gravitating to the brand-name labels, matching each person to a disorder or two: depression, anxiety, PTSD, etc. After awhile, the labels turn translucent and he or she becomes only pain-based and developmentally ungrown, whether it’s fear, or loss of feeling and identity, or child’s psyche stuck in an adult body and time.

One antidote, I suggest, to seeing the client as owning or being a disorder is the Intake form’s symptom list. You’d have to be inept to think that a client who checks fifty to ninety percent of the following conforms to any disease entity:

Crying spells, always worried, work difficulties, stomach upset, feeling grouchy, nightmares, excessive drug use, trouble sleeping, feeling lonely, loss of weight, not enjoying things, suicidal thoughts, feeling inferior, loss of sexual interest, no one understands me, unable to relax, can’t concentrate, feeling fearful, don’t like being alone, lack energy, feel like hurting someone, excessive medication use, wake up too early, buying sprees, feeling embarrassed, survived a traumatic event, money problems, relationship concerns, lacking in confidence, shaky hands, excessive drinking, poor appetite, depressed, feeling panicky, irritability, shy with people, muscle twitching, nausea or vomiting, can’t make decisions, can’t make friends, headaches, abusive relationship, binge eating, very restless, anxious inside, weight gain, impatient with people, low self-esteem, no need for sleep, gambling too much, unwanted thoughts / impulses, change in medication, unable to have fun, feelings easily hurt, sexual problems, can’t hold a job, always tired, feeling tense, problems with children, problems with parents, poor physical health, fighting and quarreling, dislike my body, full of energy, overly ambitious, easily excited, quick-tempered, guilty, angry, hopeless, feel rageful, excessive overeating, isolate / withdrawn, cutting / self-harm, racing thoughts, increase in sexual desire, repetitive behaviors, memory problems.

Or the client who says: “I’m a hot mess. I’m totally neurotic.” Or “Purpose. Time Management. Boundaries.”

I’ll admit, in weirdness and embarrassment, that I gradually transition from mild anxiety to relief when a client, narrating his childhood and adolescent history, proceeds to pile on one mess after another of birth crisis, traumas, abuses, “thirteen different elementary schools,” foster system, being bullied, neglected by immature parents, returned to them, series of mom’s brutal boyfriends, child's adultification, incest to drug partying to acquaintance rapes, starved souls turning different from youth on. By the time he’s named the full smorgasbord, I’ve relaxed, knowing I’m looking at no disorder names, only deep lostness that needs to be found, deep wounds that need to be brought out. Had he delivered one problem or one main childhood event – “I panic, I have social anxiety, I have depression, my parents split up when I was three” – I’d feel a little unmanned: Do I have the corresponding one masterstroke to heal it?

The fact is that every single client is this smorgasbord. A simple way to see it is to picture one circumstance – dad’s spending all his time at work and at the gym – and consider his daughter’s injury and adaptation to it at home, when with her friends, at school, in her feelings as she tries to go to sleep, in her emotionalized thoughts about herself, her fantasies, in the weight of her social presence during the day, in the way of being with her mother, in time-as-scar-tissue and determinations over weeks and years, in the person she has become. A single circumstance becomes countless identities and symptoms embedded in her everywhere, forming her life. Now picture three or five or ten or a hundred losses of attention or love early on.

Our office’s symptom list is one page, three columns. If there were many more such pages, you know the client could fill them all.

DSM F-Codes: May they die a lonely death.