Beyond the Label: When Diagnosis Becomes the Story

Oct 21

18 min read

Why understanding someone's mental health should be the beginning of support, not the end of the conversation.

By Allen Scott MA MBACP | Integrative Psychotherapist

I've sat with clients who have spent years trying to understand why they feel the way they do. I've listened to people describe emotions that seem to arrive without warning, relationships that feel impossible to navigate, and patterns of behaviour they recognise but struggle to change. I've also witnessed, both professionally and personally, how receiving a mental health diagnosis can bring enormous relief. For someone who has spent years feeling misunderstood, finally having an explanation can provide recognition, validation and a language for experiences that have been difficult to put into words. Yet I've also seen how quickly that initial relief can turn into uncertainty, particularly when the diagnosis arrives without a clear explanation of what happens next. The question that often follows is remarkably simple: “So what do I do now?”

It is a question that has stayed with me throughout my work as an integrative psychotherapist and has shaped much of my research. A client once told me, “This is what BPD does to me.” Another said, “My BPD is controlling me.” More recently, someone reflected, “I think this is my BPD talking.” I understand why people speak about themselves in this way. When emotions are overwhelming or relationships repeatedly become painful, a diagnosis can offer something to hold onto. It may bring a sense of order to experiences that previously felt chaotic, allowing someone to recognise patterns and begin making sense of them. But I have become increasingly aware of how easily a diagnosis can move from describing someone's difficulties to defining their identity. What begins as this helps explain what I experience can gradually become this is who I am. More concerningly, the same shift can happen in the minds of the professionals and services responsible for helping them.

When diagnosis becomes the story

Borderline Personality Disorder (BPD), also known in some UK services as Emotionally Unstable Personality Disorder (EUPD), describes a pattern of difficulties that can include intense emotional distress, difficulties with relationships and identity, impulsivity and, for some people, self-harm or suicidal thoughts. These experiences are real, sometimes profoundly painful, and deserve to be taken seriously. A diagnosis can help someone understand what is happening to them and may provide access to appropriate specialist treatment. I am not arguing that diagnosis has no value, or that people who find it helpful should be discouraged from using it. What concerns me is the meaning that can become attached to the language, particularly when terms such as personality disorder or emotionally unstable begin to influence how someone understands themselves. To be told that your personality is disordered can sound like being told that something fundamental about who you are is wrong. For someone who may already be struggling with shame, self-criticism or a fragile sense of identity, this can be particularly difficult to absorb.

Over time, the diagnosis may become the explanation for almost everything. Anger becomes “my BPD”, fear becomes “my instability”, and difficulties in relationships become “my disorder”. Rather than helping someone explore their experiences, the label can sometimes close down curiosity about them. Yet a diagnostic category cannot tell us what a person has lived through, how they learned to cope, what they fear, what matters to them or what they hope their life might become. Research has established a substantial association between childhood adversity and BPD, particularly experiences involving emotional abuse, neglect and disrupted early relationships, although not everyone diagnosed with BPD has experienced childhood trauma. Understanding someone's personal and relational history does not make diagnosis meaningless, but it can stop the diagnosis becoming the end of our understanding.

This became particularly clear during my MA research at the University of Roehampton, where I explored the lived experiences of four highly experienced Dialectical Behaviour Therapy (DBT) therapists working within a specialist NHS service. Although they worked within a service where diagnosis played an important role in referrals and treatment pathways, they were deeply aware of its limitations. One therapist described diagnosis as “clinical shorthand”, before adding, “It doesn't tell me anything about their life experiences.... You know, you got to meet the person for that.” Another spoke about how easily the category could become reductive, obscuring the person behind it. Their concerns were not simply about terminology. They reflected the experience of meeting people whose lives, histories and difficulties were far more complicated than any single diagnostic description could capture.

For me, this is an important distinction. We need language that helps us communicate about mental health difficulties, understand patterns of distress and make informed decisions about care. But language should remain a tool for understanding rather than becoming a substitute for it. A diagnosis can be useful shorthand, but shorthand should never become someone's biography. When the label becomes the whole story, it risks shaping not only how someone sees themselves, but also what professionals expect from them and what services believe they are able to offer.

What the Fonagy review tells us about diagnosis and support

The independent review into mental health conditions, ADHD and autism, chaired by Professor Peter Fonagy and published on 9 October 2026, brings renewed attention to the relationship between diagnosis, mental health needs and access to care. The review considers increasing levels of mental distress, particularly among young people, alongside the pressures facing services, lengthy waiting times and concerns about the quality and consistency of some diagnostic pathways. Importantly, it calls for a shift towards a more needs-led approach, where appropriate support can begin without always requiring someone to wait for a formal diagnosis. It does not suggest that diagnosis should be abandoned or that specialist services are unnecessary. Rather, it recognises that people's needs are often more complicated than the categories through which services organise care.

What interests me most about the review is not simply the debate about whether we are diagnosing too much or too little, although that is an important discussion. It is what happens afterwards. Someone may spend months, sometimes years, trying to understand their difficulties and seeking an assessment for ADHD, autism, BPD/EUPD, PTSD, depression or another condition. Receiving a diagnosis may finally bring the recognition they have been searching for, but it does not automatically provide therapy, practical adjustments, specialist treatment or the relational support they may need. In some cases, it simply marks the beginning of another journey through referrals, waiting lists, service thresholds and professional directories. Having been given a name for their difficulties, people are then expected to understand an unfamiliar mental health system and work out for themselves where they belong within it.

This is where I believe our approach needs to change. Mental health difficulties do not begin when someone receives a diagnosis, and neither should meaningful support. The review's emphasis on prevention, early intervention and support within communities, schools and everyday environments is particularly important because people's wellbeing is shaped by much more than their contact with clinical services. Relationships, family circumstances, education, housing, employment, financial security and opportunities for social connection can all influence someone's mental health. Specialist treatment is essential for many people, but recovery and emotional wellbeing also depend on the environments in which they live. We should be asking how to offer people the right support at the right time, rather than allowing diagnosis to become the destination towards which every pathway leads.

Read the independent review into mental health conditions, ADHD and autism on GOV.UK .

When the system becomes another obstacle

There is a contradiction within our mental health system that I have come to think of as the selection paradox. Someone receives a diagnosis suggesting they may require specialist psychological treatment, yet that same diagnosis can make accessing help more difficult. They may be considered too complex for general counselling or primary care services, while specialist services have lengthy waiting lists or eligibility criteria they cannot meet. Sometimes people are told they need to become more stable before engaging in longer-term therapy, even though developing emotional stability is one of the reasons they are seeking treatment. What should be a pathway towards understanding and support can become another experience of rejection or exclusion, particularly for people who may already have learned to expect that their needs will be too much for others.

This is something I have witnessed personally. Someone close to me experienced considerable difficulty accessing appropriate therapeutic support after receiving an EUPD diagnosis. During an assessment I attended, there was a strong emphasis on personal responsibility, commitment and the importance of change. I do not disagree with those principles. Therapy inevitably involves personal responsibility, and meaningful change often requires sustained engagement with difficult emotions and behaviours. But what seemed to be missing was an equally clear explanation of how the person was going to be supported in making those changes. The available structured DBT programme was financially out of reach, while other therapists felt unable to work with the complexity involved. Eventually, a therapeutic relationship was found where genuine understanding could begin, but the process of reaching that point had been unnecessarily difficult.

What stayed with me was how much the diagnosis appeared to influence what professionals believed was possible. Of course, not every therapist is equipped to work with every presentation, particularly where significant risk, suicidality or complex mental health needs are involved. Recognising the limits of our competence is an important part of ethical practice, and specialist support must remain available for those who require it. But there is a difference between making a careful clinical judgement and allowing diagnostic assumptions to determine what someone can access before their individual circumstances have been properly understood. We should also recognise how difficult this can be for clinicians working within overstretched systems, where resources, referral pathways and service criteria may limit what they are able to offer, even when they want to help.

The question, then, is not simply why individual professionals sometimes struggle to offer support. It is whether we have created a system in which people must repeatedly demonstrate how unwell they are before they can receive help, rather than providing meaningful support when difficulties first emerge. The Fonagy review's call for a more responsive, needs-led approach makes this question especially relevant. Diagnosis should help us understand what someone may need; it should not become another obstacle between the person and the care that could make a difference.

What my research with DBT therapists taught me

My research into DBT challenged some of my own assumptions about structured therapeutic approaches. Before becoming more involved with DBT through clinical training and research, I primarily associated it with mindfulness, emotional regulation, distress tolerance and behavioural strategies. These are important components, but comprehensive DBT is considerably more sophisticated than a collection of skills or techniques. Developed by Marsha Linehan, it combines individual therapy, group skills training, between-session coaching and therapist consultation within a coherent framework that emphasises both acceptance and change. It provides clear treatment priorities, behavioural understanding, validation and practical ways of responding to intense emotional distress. What became increasingly apparent during my research was that this structure did not replace the therapeutic relationship. For the therapists I interviewed, it helped make that relationship possible under conditions that could be emotionally demanding and uncertain.

The participants spoke openly about the emotional realities of working with clients experiencing significant distress, self-harm, suicidality and relational difficulties. They described anticipatory anxiety before beginning therapy, uncertainty about risk, the challenges of responding to anger or aggression, and the sadness of witnessing suffering that had often been compounded by previous experiences of services. One described the work as a “tightrope”, capturing the constant need to balance honesty, validation, boundaries and emotional presence. Another reflected on the contradiction of knowing intellectually that she could not be solely responsible for keeping someone alive while simultaneously offering therapy designed partly to reduce life-threatening behaviour. These accounts reminded me that therapists do not experience risk merely as something to assess or manage through procedures. They also experience it emotionally, often carrying feelings of responsibility, worry and uncertainty that can influence how they respond within the therapeutic relationship.

Yet the participants' accounts were far from dominated by anxiety or burden. They also described enjoyment, connection, hope and some of the most meaningful therapeutic relationships of their careers. One therapist told me, “I really enjoy starting a relationship with someone... I have formed some of my best relationships with people with EUPD.” Another spoke about loving her work because she had witnessed the difference therapy could make to people's lives. These experiences challenge the tendency to discuss BPD/EUPD primarily in terms of risk, difficulty and therapeutic demands. The very relationships that could feel emotionally challenging were also experienced as deeply rewarding, and the therapists' commitment appeared to be sustained partly by their ability to recognise the person and the possibility of change beyond the diagnosis.

Perhaps the most important insight from my research was that DBT's structure did not prevent therapists from feeling the emotional intensity of the work. Instead, it appeared to help them remain thoughtful, consistent and emotionally available within it. The framework provided a sense of direction when the relationship became difficult, while still requiring the therapist to exercise judgement, flexibility and genuine human presence. At times, participants described carefully acknowledging their own emotional responses within sessions, not as uncontrolled self-disclosure but as a way of modelling emotional regulation and maintaining honesty in the therapeutic relationship. They were not simply teaching clients how to manage emotions; they were demonstrating that difficult feelings could be recognised and worked through without necessarily destroying the relationship.

This has particular relevance for how we think about therapeutic models more generally. A coherent approach can provide safety and consistency, especially when the work involves uncertainty or risk. But a model should not become a place for therapists to hide from the emotional realities of their work. Equally, the therapeutic relationship should not be treated as something separate from clinical structure, as though we must choose between being genuine and following an evidence-based approach. My research suggested something much more interesting: the structure gave therapists something to hold onto without requiring them to hide behind it. That is a lesson I believe reaches well beyond DBT.

The importance of supporting the people who provide support

Another striking finding was the importance of consultation and shared responsibility. One participant advised, “Don't try and work with this client group alone... I've seen people get burnt out.” In comprehensive DBT, consultation teams are an essential part of the treatment model, providing a space where therapists can reflect on their decisions, consider difficult interactions and examine the emotional responses that arise in their work. Participants described consultation as a place where they could explore whether they were becoming too rigid or too accommodating, taking too much responsibility or withdrawing emotionally. Rather than leaving each therapist to manage these tensions individually, the team offered a shared space in which uncertainty, frustration and difficult clinical decisions could be thought about.

I came to understand this as something more than professional supervision or a strategy for preventing burnout. Consultation provided a second relational space that helped therapists sustain the first. The therapist supports the client while the consultation team supports the therapist. From an attachment perspective, this can be understood as a wider structure of relational security, helping the therapist remain steady and available. Psychodynamic thinking highlights the importance of recognising and exploring our own emotional responses, including feelings of helplessness, frustration or a wish to rescue, rather than allowing them to shape the work unconsciously. CBT and DBT contribute structured ways of understanding behaviour, evaluating therapeutic responses and maintaining clarity when situations become emotionally complicated. Person-centred thinking reminds us that genuine empathy, acceptance and congruence are not optional extras but essential aspects of meeting another human being.

For me, these are not competing explanations. They are different ways of understanding the same central challenge: therapists need to remain emotionally available and clinically thoughtful, particularly when the work becomes difficult. This is why I believe the wider counselling and psychotherapy profession has much to learn from DBT's emphasis on consultation, collaboration and clear therapeutic structure. Many practitioners work independently, often with limited access to immediate professional support beyond regular supervision. If we want more therapists to feel able to work safely and effectively with complex mental health difficulties, we need to think seriously about training, peer consultation, specialist advice, multidisciplinary relationships and appropriate referral pathways. Encouraging therapists to be less fearful of complexity is important, but we must also make sure they have the professional support needed to work competently and responsibly.

Imagining a wider path towards healing

When I think about our mental health system, I sometimes imagine a person pulling a series of increasingly heavy trolleys along a railway track, each carrying another diagnostic label: BPD, ADHD, autism, PTSD, depression or anxiety. Along the journey, they encounter assessments, referrals, clinicians, psychiatrists, medication reviews, benefits processes and waiting lists. These systems and professionals are not inherently obstacles; many provide essential support, and I have considerable respect for those working compassionately within services facing significant pressures. But when provision becomes fragmented, the person can end up carrying not only the weight of their difficulties but also the burden of navigating the systems intended to help them. With each referral or threshold, the track can seem to become narrower, until there are fewer routes available and the person is left wondering whether there is anywhere they can actually go.

I find myself imagining an alternative path alongside it, one that is wider, more connected and less dependent on someone reaching crisis point before meaningful support becomes available. This would not mean replacing specialist mental health services or assuming that compassion alone can address severe mental illness. It would mean recognising that mental health support should also involve counsellors, therapists, youth clubs, schools, families, peer groups, community organisations, housing services and opportunities for education, employment and social connection. It would mean building relationships between these different forms of support so that people are not repeatedly required to explain themselves, prove their difficulties or begin again each time they encounter another service. Above all, it would mean treating belonging, consistency, empathy and practical help as important aspects of mental health care rather than things that sit outside it.

This wider understanding of healing is consistent with my integrative approach to psychotherapy. Different therapeutic models can help us understand different aspects of someone's experience, whether that involves emotional regulation, attachment, trauma, patterns of thinking, relationships or a sense of identity. Integrative practice does not mean moving randomly between interventions or disregarding the evidence supporting particular treatments. It involves developing a coherent understanding of the person, recognising the strengths and limitations of different approaches and working collaboratively to decide what might be most helpful. There may be times when someone benefits from structured skills, clear goals and practical strategies, and other times when they need space to explore painful experiences, relational patterns or questions of identity and meaning. Often, these needs coexist, and good therapy requires the flexibility to recognise when different kinds of support may be needed.

My research also highlighted the potential value of group-based work. DBT therapists described how clients could learn from one another, sometimes offering recognition, challenge or understanding in ways that carried a different significance from the therapist's interventions. This makes me think about the possibilities for carefully designed, accessible group support within counselling organisations and community settings. Skills development, mindfulness, psychoeducation, reflection and peer connection can all contribute to helping people feel less isolated and more able to respond to difficult experiences. Such groups require appropriate training, safeguarding, supervision and boundaries, and they cannot replace specialist treatment where that is necessary. Nevertheless, they are one example of how we might begin to widen the pathways available to people rather than expecting everyone to navigate a narrow route through diagnosis and specialist referral.

The need for flexibility also extends to how therapy responds to trauma, culture, gender, neurodivergence and individual differences in communication or learning. The therapists I interviewed recognised that standard DBT materials and examples did not always feel accessible or relevant to every client. Their response was not to abandon the model but to consider how its principles could be communicated and applied in ways that made sense for the person in front of them. DBT continues to develop through trauma-focused approaches and research involving different populations, illustrating that adherence to a therapeutic model and thoughtful adaptation need not be opposites. For me, this raises a question relevant to all psychotherapy: are we asking people to fit the therapy, or are we making sure the therapy can meaningfully meet the person?

Ultimately, people need more than a diagnosis and a treatment plan. They need opportunities to build a life in which healing becomes possible. Clinical care is an essential part of that for many people, but relationships, stability, community, meaningful activity and a sense of belonging can matter just as much to the wider experience of wellbeing.

Why I created TaM

The gap between understanding someone's difficulties and helping them access suitable support has concerned me for a long time. It is something I have encountered in my clinical work, witnessed personally and reflected on throughout my research. It is also one of the reasons I created TaM. I wanted to explore whether technology could make the process of finding an appropriate counsellor or psychotherapist less confusing, particularly for people who already feel overwhelmed by the choices and terminology they encounter. Someone looking for therapy is often expected to know which approach they need, understand the differences between therapeutic models and navigate extensive directories of practitioners. Yet a person seeking help may never have heard of DBT, CBT, psychodynamic psychotherapy or person-centred counselling, let alone know which might be relevant to their experiences. I do not believe people should need that level of professional knowledge simply to begin looking for support.

Most people know something about what they are experiencing, even if they cannot describe it clinically. They may know that they struggle with relationships, feel overwhelmed by emotions, have experienced trauma or find themselves repeating patterns they do not understand. They may know what has helped before, what has not worked or what they would like to change. My thinking behind TaM is that these experiences should provide a meaningful starting point. Rather than requiring people to translate their difficulties into professional language, TaM is designed to allow them to describe what is happening in their own words. It then uses conversational AI to help identify counsellors and psychotherapists whose stated experience, skills and therapeutic approaches may be relevant to those needs.

TaM does not diagnose, provide therapy or replace professional assessment, and it cannot guarantee that any particular therapist will be suitable for an individual. It also cannot resolve the wider problems of NHS capacity, affordability or the availability of specialist services. Those limitations matter, as do the need for transparency, data protection and appropriate safeguards when technology is used in a sensitive area such as mental health. However, I believe there is value in exploring how carefully designed technology might help people navigate the first stages of finding support, particularly if it reduces the expectation that someone in distress must already understand the mental health profession before seeking help.

There is a clear connection between this idea and the message I take from the Fonagy review. We need to become better at responding to people's needs rather than requiring them to navigate every stage of support through a diagnostic category. Technology is not a substitute for empathy, clinical judgement or the therapeutic relationship, and I would be concerned by any suggestion that it should become one. But it may be able to help someone move from feeling lost among lists of services and professional terminology towards identifying possible sources of support. I'm launching TaM on 29 October 2026, with the hope that it can make this part of the journey more accessible, intuitive and human. For me, it is not about replacing the therapeutic relationship with technology. It is about helping people find their way towards one.

Beyond diagnosis: returning to the person

I return to the client who told me, “I think this is my BPD talking.” There are several ways I could respond. I could explore the symptoms associated with their diagnosis, explain emotional dysregulation or introduce a strategy for managing difficult feelings. Depending on the circumstances, any of those responses might be appropriate and useful. But I might also become curious about what sits behind the statement. What happened just before they began feeling this way? What are they afraid might happen? What does the response help them manage or protect themselves from? Have they felt something similar in earlier relationships or experiences? And, perhaps most importantly, what would they like to be different? These questions do not dismiss the diagnosis or suggest that the difficulties it describes are unimportant. They create space for the person to explore their experience without assuming that a label has already provided the full explanation.

This is where I believe good psychotherapy and a more compassionate mental health system share something essential. Both need to remain curious about the individual rather than allowing categories, procedures or models to replace understanding. We need diagnostic assessments that are thoughtful and clinically meaningful, therapies grounded in sound evidence and professionals with the training and support to work safely. But we also need earlier intervention, more accessible pathways, stronger community connections and a recognition that people's experiences are shaped by the environments and relationships in which they live. Diagnosis, therapeutic structure and even technology can all play valuable roles, provided they remain ways of helping people rather than becoming ends in themselves.

A diagnosis can provide recognition and language for experiences that once felt confusing or frightening. It can guide treatment, inform adjustments and help someone begin to understand patterns that have caused them pain. But it should never leave a person simply holding a label and wondering what happens next. Nor should it become the final explanation for their behaviour, identity or possibilities. We need a mental health system that does more than identify difficulties: one that responds earlier, sees beyond diagnostic categories, supports those providing care and connects people with the relationships, services and opportunities that make meaningful change possible.

The goal should never be simply to get someone diagnosed, assessed or placed on another waiting list. It should be to help them understand themselves, find appropriate support and build a life that is not entirely organised around their difficulties. For some, that will involve specialist treatment; for others, a combination of therapy, practical help, community connection and opportunities that restore a sense of agency and hope. Whatever the pathway, the person must remain at its centre.

A diagnosis is not a destination. It should be one possible starting point on a wider path towards understanding, support and healing.

About the author

Allen Scott MA MBACP is an integrative psychotherapist in private practice and the creator of TaM. His work explores the intersection of therapeutic relationships, complex emotional distress, diagnostic stigma and access to appropriate mental health support. His MA research at the University of Roehampton explored the lived experiences of four experienced DBT therapists working with clients diagnosed with EUPD/BPD in a specialist NHS service.