When the Diagnosis Conceals the Story
Sexual Abuse, Symptoms, and Professional Responsibility
Diagnoses can be necessary. They may provide language for suffering, open access to treatment, structure professional assessment, and help ensure that people receive rights and assistance. In mental health care, child welfare, education, and social work, diagnostic categories can serve as important tools for communication and decision-making. Yet diagnoses may also become problematic if they detach symptoms from the history out of which those symptoms arise. When children and adults who have been subjected to sexual abuse are understood primarily through their reactions, the violation itself may disappear from view. The diagnosis may then come to conceal the story.
This is not an argument against diagnosis. It is an argument against diagnostic reductionism. People do not need less professional knowledge, but better professional knowledge. A professional assessment must be able to include both symptoms and experiences, both functional difficulties and life history, both clinical descriptions and moral questions concerning power, responsibility, and violation. If the professional asks only what kind of symptom this is, but not what the symptom may express, the understanding becomes too narrow.
Sexual abuse of children may be expressed in many different ways. Some develop clear trauma reactions. Others show anxiety, depression, sleep disturbances, self-harm, eating disorders, substance use problems, dissociation, learning difficulties, sexual difficulties, somatic complaints, or relational problems. Still others may appear apparently well-functioning for long periods. This variation makes diagnosis difficult. There is no simple symptom profile that directly demonstrates that a person has been subjected to sexual abuse. At the same time, many reactions after abuse may resemble conditions that, in other contexts, are understood in entirely different ways.
This is particularly evident in children. A traumatised child may be restless, inattentive, angry, withdrawn, socially difficult, easily startled, daydreaming, numb, or seemingly absent. The child may have difficulties with learning, sleep, regulation, bodily contact, and trust. Such expressions may be understood as attention difficulties, conduct problems, attachment problems, learning difficulties, depression, anxiety, psychosis, or neurological conditions. In some cases, such diagnoses may be correct. In other cases, they may be partly correct. But if the child’s experiences are not explored, the diagnosis may become a name for the surface.
This makes the question of misdiagnosis serious. A child who dissociates may look like a child who is not paying attention. A child who startles, rages, or withdraws may look like a child with behavioural problems. A child who hears voices or experiences unreality may be understood within a psychosis-like framework. A child who alternates between seeking closeness and rejecting it may be described as manipulative or unstable. Such descriptions may, in some situations, capture something real, but they may also obscure the underlying experience of fear, violation, and lack of protection.
A central professional question is therefore not only: Which diagnosis fits? It is also necessary to ask: What has this child been subjected to? What has the child learned about adults, the body, boundaries, and trust? What strategies has the child developed in order to survive? What function has the behaviour served? What becomes unbearable for the child? Such questions do not replace diagnostic assessment, but they broaden it. They shift attention from classification alone to understanding.
In the field of trauma, this has often been formulated as the difference between asking “What is wrong with you?” and “What has happened to you?” This is a useful contrast, but it must be used with precision. It is not always possible to know what has happened. Nor is it always correct to explain all difficulties by earlier trauma. Yet the contrast reminds us of something essential: symptoms do not arise in a vacuum. They belong to life histories, relationships, bodies, and social contexts. For children who have been subjected to sexual abuse, reactions may be meaningful responses to meaningless and violating experiences.
Diagnoses have a tendency to individualise. They locate suffering in the person. This may be necessary in order to describe treatment needs, but it may also have unintended consequences. When a child receives a diagnosis, attention may shift from the child’s surroundings to the child’s functioning. The child becomes the one who has the problem. The family, the institution, the perpetrator, the silence, and the failure of protection may recede into the background. This is particularly problematic when the child’s symptoms are connected to experiences that are precisely about adults’ failure of responsibility.
This does not mean that diagnoses in themselves blame the child. But if they are used unreflectively, they may contribute to such a displacement. A child described as difficult, impulsive, oppositional, or emotionally unstable may be met with control rather than protection. An adolescent who self-harms or uses substances may be understood as treatment-resistant rather than as a person attempting to regulate unbearable pain. An adult who struggles with intimacy and trust may be described as avoidant or demanding, without anyone asking what intimacy has previously cost.
Judith Herman shows how prolonged and relational trauma may affect self-experience, affect regulation, and the capacity for relationships. This offers a broader understanding than a narrow list of symptoms. In ICD-11, this breadth is expressed in the diagnosis of complex PTSD, where trauma reactions also include negative self-concept, difficulties in emotion regulation, and relational disturbances. This is important because it shows that prolonged violations may leave behind not only isolated symptoms, but may also affect a person’s fundamental way of being in the world.
At the same time, caution is necessary. Complex PTSD must not become a new total explanation. No diagnosis can contain the whole human being. A diagnosis may describe a pattern of suffering, but it cannot fully describe the individual’s history, dignity, resources, or possibilities for agency. Nor can it, by itself, assign moral responsibility. A diagnosis can say something about how a person suffers. It cannot alone say what the person has been subjected to, who failed them, or what must be restored.
This is a practical-philosophical point. To understand a human being is not the same as classifying them. Classification may be part of understanding, but it cannot replace judgement. Professional judgement involves the capacity to move between the general and the concrete. General knowledge says something about symptoms, risk factors, trauma reactions, and principles of treatment. The concrete encounter requires the helper to see this person, this history, this body, this relationship, and this situation.
When the diagnosis conceals the story, it is often because the professional seeks order too quickly. Diagnoses provide order. They may create overview in material that is difficult to grasp. They may reduce uncertainty and make action possible. But human suffering does not always fit into neat categories. This is especially the case in sexual abuse of children, where experiences may be fragmented, shame-laden, silent, and bodily expressed. The story may not appear as a clear narrative, but as restlessness, absence, pain, rage, avoidance, or breaks in memory. If only what fits the language of the diagnostic manual is regarded as relevant, much of the meaning of experience may be lost.
This also applies in encounters with dissociation. Dissociative reactions can be difficult to understand because they break with the expectation of coherence. A child may seem absent, shift in manner, forget episodes, or react strongly to apparently minor triggers. An adult may describe loss of time, numbness, inner distance, or the experience that the world becomes unreal. Without trauma understanding, such expressions are easily misunderstood. With trauma understanding, they may be understood as possible traces of overwhelming experiences, without drawing premature conclusions.
Here, balance is crucial. Professionals must neither overlook trauma nor see trauma everywhere. Both mistakes can cause harm. If trauma is overlooked, the person may be met with the wrong treatment, the wrong expectations, and the wrong attribution of responsibility. If trauma is assumed too quickly, the helper may impose a story on the person that has not been sufficiently examined. A professionally responsible approach therefore requires openness, patience, and methodological humility. It must tolerate uncertainty without becoming passive.
For children, this means that assessment of the care situation, relational interaction, safety, and possible burdens is essential. If a child develops difficulties with regulation, learning, attention, or relationships, the question of the child’s life situation should always be part of the assessment. This does not mean that all children with such difficulties are traumatised. But it does mean that the child cannot be understood apart from their environment. A child does not develop in a vacuum. The child’s symptoms must be seen in light of the child’s relationships.
The same applies to adults. An adult patient with long-standing psychological difficulties may have passed through many diagnoses, treatments, and institutional encounters. If the trauma history is not asked about, treatment may become a series of attempts to regulate symptoms without understanding their origin. This may lead to frustration for both patient and therapist. The patient may be experienced as difficult to help, while the treatment may never have reached the central question: which experiences have shaped this person’s relationship to body, boundaries, trust, shame, and intimacy?
A trauma-informed practice must therefore be historical without being speculative. It must ask about experiences, but not force answers. It must make room for narrative, but not demand a finished story. It must be attentive to signs, but not turn signs into proof. It must understand symptoms as possible expressions of earlier burdens, while at the same time broadly examining medical, neurological, social, and psychological conditions. Professional competence lies in this double movement: seeing more than the diagnosis without abandoning diagnostic responsibility.
Language plays an important role. When a child or an adult is described as “unstable,” “manipulative,” “attention-seeking,” or “difficult,” these are not neutral words. They shape how the person is met. They may make the helper less curious and more controlling. They may also intensify the shame of the person subjected to abuse. A more precise and ethically responsible language asks what the behaviour may express, what function it may once have had, and what conditions must be present for the person to be able to act differently.
This does not mean that responsibility for one’s own actions is abolished. Adults must, in many contexts, be held responsible for how they act toward others. But responsibility must be understood within realistic limits. Traumatisation may impair regulation, trust, impulse control, and self-understanding. Help must therefore be able to combine accountability with understanding. Without accountability, the person may be reduced to a passive victim. Without understanding, accountability may become a new form of condemnation.
When the diagnosis conceals the story, treatment also becomes narrower. The aim may become symptom reduction alone. But after sexual abuse, help may also concern the restoration of dignity, safety, bodily ownership, boundaries, language, and trust. This does not mean that treatment should become moral philosophy instead of therapy. It means that therapy, social work, child welfare, and education always have an ethical dimension. They encounter people who not only have symptoms, but who have been subjected to actions that violated their right to be subjects.
In this context, the diagnosis finds its proper place. It should not be the endpoint of understanding, but a possible tool within a broader professional assessment. It may help us see patterns, but it must not prevent us from seeing the person. It may provide direction for treatment, but it must not replace the question of what the person has experienced. It may be useful, but it must remain open to the story.
The professional responsibility is therefore to allow diagnosis and story to correct one another. Without diagnosis, help may become unstructured and arbitrary. Without story, diagnosis may become cold and reductionist. What is needed is a form of professional knowledge that can both classify and understand, both act and listen, both treat symptoms and acknowledge violations. Sexual abuse demands precisely this kind of professional knowledge, because the abuse affects body, self, relationship, and moral order.
To see beyond the diagnosis is not to reject the diagnosis. It is to insist that the human being is always more than the category used to describe them. The restless child may also be the frightened child. The adolescent who self-harms may also be the adolescent carrying shame. The adult with relational difficulties may also be the adult who once learned that closeness was dangerous. When this story becomes visible, help also changes. It may become less condemning, more precise, and more dignified.
When the diagnosis conceals the story, the profession loses something essential: the connection between suffering and life. When the diagnosis is placed within a broader understanding of experience, body, relationship, and responsibility, however, it can become a useful tool. The diagnosis is then not a label that closes the case, but a provisional language that opens further understanding. It is in this opening that professional judgement begins.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association Publishing.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. Routledge.
Courtois, C. A., & Ford, J. D. (Eds.). (2013). Treating complex traumatic stress disorders in children and adolescents: Scientific foundations and therapeutic models. Guilford Press.
Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55(4), 530–541. https://doi.org/10.1111/j.1939-0025.1985.tb02703.x
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. Basic Books.
Pettersen, K. T.. Consequences of sexual abuse [PowerPoint lectures between 2002 - 2024].
Putnam, F. W. (1997). Dissociation in children and adolescents: A developmental perspective. Guilford Press.
Silberg, J. L. (1996). The dissociative child: Diagnosis, treatment, and management. Sidran Press.
van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
World Health Organization. (2022). ICD-11: International classification of diseases (11th rev.). https://icd.who.int/
No comments:
Post a Comment