Introduction to the Counseling Profession

Chapter 12

Diagnosis and Treatment Planning

Chapter Topics

The Process and Produce of Diagnosis

“Diagnosis is the act of identifying and naming the nature of a problem, with the expectation that this naming will lead to a more informed and effective means of solving the problem. Diagnosis, then, is both the process of identifying and naming phenomena and the product of the name itself.”

Diagnosis

Relies on the use of a common language to identify the presence of an agreed-upon phenomenon, syndrome, or disorder.

A diagnosis is made based on client signs and symptoms, as well as other sources of data such as structured or non-structured interviews and psychological tests.

The Process and Produce of Diagnosis

Diagnosis

A sign is a behavior or characteristic that can be seen, heard, or otherwise detected by others.

A symptom is something that can be seen, heard, or felt only by the person experiencing it, such as anxiety, sadness, or hallucinations.

The most well-known and widely used system of diagnosis is the American Psychiatric Association (APA) publication, the Diagnostic and Statistical Manual of Mental Disorders.

The Process and Produce of Diagnosis

Diagnosis

The essence of the process of diagnosis is first to identify a client’s experiences as belonging to a group or cluster based on similarities.

The next step in the process is to determine, as the assessment process continues, important differences among these experiences of distress.

This assessment should include not only individual factors, but family, cultural, and other contextual factors as well.

The Process and Produce of Diagnosis

Diagnosis

The processes of clustering client problems (that is, they all are suffering from anxiety), and then differentiating them from each other by their salient characteristics (triggering events, intensity, and other factors) allows us to make a differential diagnosis.

Arriving at an accurate diagnosis, or in some cases a group of diagnoses, allows us to set appropriate counseling goals, develop treatment plans based in research and well-established theory, and measure the client’s movement toward those goals more effectively.

The Process and Produce of Diagnosis

Definition of a Mental Disorder

In order for a diagnosis of mental disorder to be applied to a person, at least one of the following three features must be present. Either the person:

Is currently experiencing distress.

Demonstrates impairment or disability in daily functioning.

Is at “a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”

“A mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual. Behaviors that are considered to be expected responses to an event or behaviors that are sanctioned within the client’s culture are not considered to be mental disorders.”

The Expanding Role of Diagnosis in Counseling

The ability of professional counselors to accurately and appropriately diagnose mental disorders (as well as to recognize the absence of diagnosable disorders) is important for several reasons:

The development and use of a common diagnostic language enhances our ability to generate and share research and ideas.

“While counseling’s professional identity emphasizes a strengths-based, wellness-oriented perspective, counselors must be able to recognize and appropriately work with people with mental illnesses, advocate for the proper use of diagnoses, and collaborate with other professionals.”

The Expanding Role of Diagnosis in Counseling

An accurate diagnosis is the foundation of appropriate treatment planning and using research-supported practices.

Professional counselors are increasingly being recognized as primary providers of mental health care.

Diagnosis permits the counselor to identify clients who would be better served by another practitioner or by a team approach, for example, in coordination with a psychiatrist who can prescribe and monitor medications.

The Expanding Role of Diagnosis in Counseling

Benefits of Diagnosis

Diagnosis gives a name to the client’s distress, and acknowledges that the client is not alone in his or her misery.

Having a legitimate diagnosis might also facilitate the client’s engagement in the counseling process.

The accurate diagnosis of certain mental disorders may prompt the counselor to refer a client to another professional.

Having a diagnosis often allows the client to receive insurance coverage for the cost of counseling and other mental health services.

The Expanding Role of Diagnosis in Counseling

Risks of Diagnosis

Having a diagnosis of a mental disorder may, in some people, lead to a sense of hopelessness or futility.

A client might use the diagnosis as a rationalization for irresponsible or destructive behaviors.

Diagnosis may carry a stigma that accompanies many psychiatric diagnoses if that diagnosis becomes known to others.

Another risk of having a diagnosis of mental disorder is that it may, in effect, become the person’s identity.

Some diagnoses might divert the attention of the counselor away from recognizing and addressing cultural and systemic factors that contribute to, or even cause, individual distress.

The Expanding Role of Diagnosis in Counseling

Ethical Considerations

Informed Consent

Client Choice

Client Collaboration

Attention to Client Strengths

History and Overview of the DSM

The DSM provide information on:

The incidence of disorders, the usual age at onset, and expected course of the disorders.

Issues that might interfere with the formulation of a correct differential diagnosis.

A small amount of information regarding cultural considerations to be included in the diagnostic process.

“The DSM-IV-TR is a compilation of all mental disorders recognized by the American Psychiatric Association, grouped according to shared characteristics, along with descriptions of the signs and symptoms that must be present in order for each diagnosis to be confirmed. These signs and symptoms are known as diagnostic criteria.”

History and Overview of the DSM It intentionally does not offer information regarding the presumed

causes of disorders or their most effective treatments.

Theoretical neutrality was adopted in order to make the manual more accessible and relevant to practitioners from various theoretical schools.

The DSM approach to mental and emotional distress follows what is commonly referred to as the medical model.

The DSM also provides numerical coding for each distinct disorder and subtypes of disorders. These codes are the consistent with those used in the International Classification of Diseases (ICD), a product of the World Health Organization.

Overview of the DSM-IV-TR

Five Axes Diagnosis

Axis I: Clinical Disorders and Other Conditions That May Be a

Focus of Clinical Attention

Axis II: Personality Disorders and both Mental Retardation and

Borderline Intellectual Functioning

Axis III: General Medical Conditions

Axis IV: Psychosocial and Environmental Stressors

Axis V: Global Assessment of Functioning

Overview of the DSM-IV-TR

Criticisms of the DSM-IV-TR

Yes/No Criterion-Based Approach: All-or-none nature of diagnostic criteria

Recognition of “Culture-Bound” Syndromes Minor Attention to Cultural Variations in Symptom Presentations and Meanings: While the DSM-IV-TR includes some attention to cultural variation in its descriptions of some diagnoses and their diagnostic criteria, it falls far short of what many people would consider appropriate.

Overview of the DSM-IV-TR

DSM-IV-TR Categories of Mental Disorders

The mental disorders and conditions described in the DSM-IV-TR are divided into 17 diagnostic categories, based upon similarities among the diagnoses in each category or by common etiologies (causes) of the disorders.

V Codes: V Codes are used to note psychosocial or environmental circumstances that may be contributing to the client’s distress. V Codes are not mental illness or disorders but fall into the category of “Other Conditions That May be a Focus of Clinical Attention.”

Criticisms of DSM Diagnostic Approach in Counseling

The categorical (as opposed to dimensional) approach to listing and defining diagnostic criteria increases psychiatric diagnoses’ similarity to physical diagnosis.

The increasing number of diagnosable conditions. The number of diagnoses has increased from 106 in DSM-I to 297 in DSM-IV-TR.

Lack of a systemic perspective.

Diagnosis as a requirement for reimbursement or access to services.

There is a risk that diagnostic nomenclature can create an artificially narrow worldview for mental health professionals.

Generating a Diagnosis and Developing a Treatment Plan

Generating an Appropriate Diagnosis

Diagnosis begins with gathering relevant information.

Based on the information obtained, the counselor can generate a broad list of potential diagnoses, then begin systematically begin narrowing the list.

Finally, social and cultural factors, whether or not they fit into the DSM paradigm, should be brought into the diagnostic picture.

“All problem-solving, as well as other endeavors in human development, should begin with a clear conceptualization of the nature of the problem to be solved or the goal to be reached.”

Generating a Diagnosis and Developing a Treatment Plan

Developing a Counseling Treatment Plan

Prioritizing Problems: Prioritize problems based on their degree of threat to the client and the extent to which the problem can be readily resolved.

Considering Individual Strengths and Resources: The client’s strengths, talents, and resources should be actively integrated into the counseling plan. Another facet of a strengths-based approach is in how we interpret the client’s current symptoms as, perhaps, once-effective means of coping with challenges.

“The ACA Code of Ethics (2005) requires that counselors and their clients work collaboratively in the development of counseling plans that “offer reasonable promise of success and are consistent with abilities and circumstances of clients.”

Generating a Diagnosis and Developing a Treatment Plan

Developing a Counseling Treatment Plan

Re-Evaluation, Modification and Ongoing Evaluation of the Counseling Plan: A counseling treatment plan, however well-designed, must be re-evaluated periodically in order to evaluate its effectiveness and make modifications as indicated.

Consultation and Referral: It is incumbent upon the counselor to recognize when a client’s needs and problems fall outside of the counselor’s scope of practice, qualifications, and experience.