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Diagnosis vs Definition
by Rabbi Yitzchak Shmuel Ackerman, LMHC
This article orignally appeared in Flatbush Jewish Journal

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1/1/14

Diagnosis vs Definition

Rabbi Yitzchak Shmuel Ackerman, LMHC

FaiveI wasn’t sure if his wife would ever stop crying. He didn’t know what to say to her, wasn’t even sure what to say to himself. He had agreed with her that it was a good idea to take their 13-year-old son for an evaluation. Yitzy had repeatedly refused to go to the psychiatrist and it was only when they decided that they really were going to make him miss the school overnight trip unless he had been to the doctor by then that he agreed to go. Maybe “agreed” is not quite accurate. Faivel said he can’t even think about the words Yitzy said to his mother as he got into the car. He would not have thought that Yitzy would ever have heard such language, would not have dreamed that he would ever say those words to anyone, certainly not to his mother. He remembered just standing there, shocked by what he was hearing, especially shaken by the stunning discrepancy with what he was seeing, Yitzy standing there in his dovening jacket and hat, dressed like the yeshiva boy that he is.

He and Goldie are no longer stunned by the discrepancies between Yitzy and their four younger children. They’ve often wondered why every one of them was so much easier then Yitzy from the day they were born. It seems like he cried 20 hours a day the first two years, and has been yelling at them from the day he learned how to talk. Faivel said not one of their other children has ever looked them in the eye and said, “no I won’t and you can’t make me!”

“We’ve had relatives, from Goldie’s side and from mine, tell us that we have to control him, we have to spend more time with him, we have to be more tolerant of him. Someone actually said to us, ‘well, you always ruin the first one.’ So over the years, we’ve been softer and firmer, stricter and more lenient, and tried never to despair that we had ruined our firstborn child. But Yitzy never improved.”

He said he’d tried to be patient with Goldie, that since she came home with Yitzy from the psychiatrist, she’d been inconsolable. As he continued to describe what had happened, I began understand why.

What is the purpose of diagnosing someone? What do we gain by attaching a label to them? Why would we want to define a child as “oppositional,” or “bipolar”?

Let’s answer the first question in detail and we’ll discover the answers to the second two.

The purpose of diagnosis is to inform treatment. Only once we know what problems we are trying to overcome can we determine how to overcome them. To use a medical example, if someone had discomfort in her arm, the purpose of diagnosis would be to tell us if the pain is coming from inflammation or if it’s coming from a pinched nerve, because the treatment will differ according to the source of the difficulty. In neither case will our patient be labeled or defined as “inflamed,” or “pinched-nerved.” Have you ever heard someone say that his grandparent is arthritis? We all realize that there is much more to Bubby than the arthritis with which she struggles, and that it does not always get in her way. We encourage her to get whatever help she can. When the physical therapy is painful, we first listen respectfully as she describes her frustration, and only then gently urge her on.

Goldie said that the doctor diagnosed Yitzy as oppositional defiant. She then told Goldie that medication and therapy are helpful for some children, and that she recommended both for Yitzy. Goldie said she had explained that to Yitzy in the car on the way home from the doctor’s office. She refused to repeat what he had said to her in response. But she was able to infer from his invective that he had no intention of taking medication or cooperating with therapy. Even if a threat of punishment or a desired incentive led him into the therapist’s office, he intended to make sure that his visit there would accomplish nothing. Goldie is inconsolable because Yitzy is oppositional defiant.

I don’t really know if that’s the way the psychiatrist expressed it to Goldie, or if she just heard it that way. I hope the psychiatrist explained to Goldie that Yitzy is sometimes oppositional and defiant because he has Oppositional Defiant Disorder (ODD). That’s his diagnosis, not his definition. ODD causes him to sometimes think about things differently from most children his age, and to make decisions that lead to poor outcomes for himself and those around him. And sometimes he does very nicely, because there is more to Yitzy than ODD.

It was during my sixth conversation with Faivel and Goldie that I asked them how Yitzy reacts to the bracha when his father bentches him on Friday night. Faivel said he had never bentched his children because no one ever bentched the children when he was growing up. I said that when the gemara says al t’hi birckas hedyot kallah b’aneicha [don’t take lightly the bracha given to you by an ordinary person] it could be understood to mean, “the way to make your bracha more meaningful is b’aneicha, with your eyes.” By making eye contact with each child, you share a special, intimate moment. I asked Faivel and Goldie what they thought about Faivel announcing before Kiddush on Friday night that he and Goldie had decided to take on the minhag of bentching their children, and that the children should please line up for their brachos. Goldie said she was afraid that if Faivel were to say that, Yitzy would make a mocking comment, refuse to leave his seat, and make his siblings reluctant to comply. I asked Goldie what would happen next, and she said she imagined that Faivel would either go over to the other children and bentch them, or coax them into coming to him. Faivel agreed that it might play out that way. I asked them if they could tolerate that outcome, and they said they could. They agreed to give it a try.

One week later, Goldie told me how it actually played out.

Faivel finished pouring the wine and we all stood up for Kiddush. But instead of picking up the kos, Faivel made the announcement and asked the children to come to him for their brachos. Yitzy’s face lit up with a smile like I haven’t seen in a very long time, and he ran to his father. The younger ones followed close behind. And that’s when I knew that he’s not ODD, he’s still Yitzy who suffers sometimes from ODD. Sadly, it often describes him; it does not define him.

Rabbi Yitzchak Shmuel Ackerman, LMHC has a private practice specializing in family, couples, parenting, and pre-marital counseling, and can be reached at 718-344-6575.



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