All of these things are not like the others...

My son’s kindergarten teacher has the class do an activity in which she shows them a picture such as the one below and asks “Which one doesn’t belong?” (see more examples at wodb.ca)

There’s no right answer, as justification can be made for many different ways in which one doesn’t belong. This exercise builds critical thinking and reasoning skills as well as mathematical understanding (without requiring mathematical language). As one of my son’s classmates exclaimed at the end of a recent, animated “Which one doesn’t belong” discussion – “None of them are the same. Each one doesn’t belong!”

This exercise is quite different from the “Which one doesn’t belong” activities I remember from my childhood. In those, there was always one lonely outlier. One right answer.

But since I’ve shifted my perspective to expect that there are different ways in which one doesn’t belong, I now see more than one answer. (Is it the blue balloon that doesn’t belong because the others are red, or the flower-shaped one that doesn’t belong because the others are more ovoid?)

What’s critical here is which feature I see as salient.

If I show you a picture of 3 women and 1 man, and ask “Which one doesn’t belong?” there’s an obvious answer – apparent gender is the salient feature. But what if I then tell you that the man and women #1 and #2 are all classical musicians, and woman #3 is a tax auditor? Now who doesn’t belong?

Categories and labels help us make sense of the world. Many people, upon receiving a psychiatric diagnosis, experience a huge sense of relief, of finally understanding why some things are harder for them than for other people, of not feeling alone in their struggles. They are able to find purpose and agency to move forward in overcoming their challenges.

But one of the problems with labels is that when you think you have an answer, you stop asking questions.

I once had a clinician say to me, when I raised a concern about something that was happening with a client, “Well, that’s just part of her autism!”

The problem with this claim is that the etiology (cause or mechanism) of the symptoms of Autism Spectrum Disorders is extremely heterogeneous. While a strong genetic component has been demonstrated, it’s not a simple “one gene causes autism” scenario, but rather a huge number of genes, many of which do very different things. Many different mechanisms can give rise to the same symptom presentation. As a simple example, many individuals with autism find eye contact aversive, and abnormally high levels of activity in the amygdala and other subcortical regions during eye contact may be responsible for this. However, there are other possible reasons for someone not to make eye contact, including physical pain. This article by Speech-Language Pathologist Ann Densmore presents a few eye-opening cases in which multiple factors (medical or speech/language conditions) led to symptom presentation that looked like autism, but wasn’t. Thankfully, she didn’t stop her inquiry with that diagnosis and was able to uncover the real reasons behind the symptoms, and the kids showed dramatic improvement.

I remember working with a child with ASD whose extremely aggressive tantrums were thought to be purely due to his resistance to task demands. His school staff was using standard predictability and reinforcement approaches to try to increase his cooperation. Upon beginning our work with him, we discovered that he had an early history of gastro-intestinal issues, and that any slight hunger or GI sensation (such as the feeling of needing to have a bowel movement) would completely dysregulate him. The attempts at structure and reward were, if anything, increasing his discomfort and damaging his relationships with staff, as he was feeling misunderstood and micromanaged.

If we assume what the reason for a symptom is because of a diagnostic label, our attempted support can be not only ineffective, but actually harmful.

It’s important to understand that psychiatric diagnoses were developed to be descriptive, rather than implying a specific mechanism, unlike most medical diagnoses. The boundaries between psychiatric diagnoses are not black and white, with many symptoms overlapping, so diagnostic mislabeling or overdiagnosis is common. (For those interested in this topic, I recommend the book Saving Normal, by Allen Frances, who chaired the task force to develop the DSM-IV).

Even if the diagnosis is a good fit, inquiry should continue. The best way to address a symptom or deficit is going to vary from individual to individual (and based on environment, relationship, and the person’s physiological state at the time). If the deficit is “core” to the diagnosis and we place too much weight on the label, we might incorrectly conclude that the best we can hope for is to accommodate the disorder. If we continue to ask questions, we can work to improve functioning in a way that is meaningful to the individual, not just to make them look "normal."

Another downfall of labels is highlighted by john a. powell in his talk Otherness and Belonging - “Where there is the other, there is fear.” He explains how when we see something as separate from ourselves, the relationship becomes one of power and domination. To “other” someone is to deny their humanity - the impact of this in race relations and war is well-known (it’s much easier to kill, enslave, and marginalise the “other”). While to “other” or stigmatise is not the intent of psychiatric diagnosis, this is unfortunately what sometimes occurs. Many of the strategies that are used with children with psychiatric diagnoses are about control – about dominating that which we cannot understand.

In my work with clients, as well as supporting friends and family, I have found the best starting point to be to reflect on how we are alike, not on how we are different. When I observe a symptom like repetitive behaviour, I think about what state I am experiencing when I show repetitive behaviour (like pen-twirling - for me it’s usually anxiety/worry, high arousal and/or intense concentration), and consider whether the child might be experiencing one of these states. We all experience tactile, auditory or visual over-stimulation at some point - think about the last uncomfortably long hug you received - so when I am considering how to support someone with one of these sensitivities, I try to remember how I feel when I reach my own threshold. Rather than thinking in terms of diagnostic labels, I try to use labels such as “tired,” “afraid,” or “overwhelmed,” which can also apply to me. This is not to say that we’re all the same, just that we’re more alike than different.

When I can cultivate a felt sense of someone else’s experience, I can offer support from a place of real empathy rather than trying to control something in them that scares me.

Ultimately, all of these things are not like the others, but all of these things belong…