Category Archives: Diagnosis and Assessment

Concerns About Diagnosis

new2I just started my first practicum placement and I am supposed to give a diagnosis to each client.  I’m worried that I don’t have enough experience to make a diagnosis and that my diagnosis might create problems for my clients later on, if they or someone else sees their records.  

Your concerns are common among students in practicum training.  It often feels daunting to take on the role of assigning a diagnosis to your client.  You may be uncomfortable with the gravity of this professional responsibility, and you may have questions about the validity of diagnostic labels that don’t include consideration of the client’s strengths and capacities.  Many clinicians are aware of the potential use of diagnosis in pathologizing or stigmatizing individuals who are vulnerable to being treated with discrimination and bias.  I will share several steps you can take to maximize the likelihood that your diagnostic process will be beneficial to the client rather than harmful.

The first step is to be thorough and comprehensive in gathering relevant information and considering alternative diagnoses that fit your client’s symptoms and presenting problem.  If you are required to assign a preliminary diagnosis after the first session, make sure to re-evaluate the diagnosis after you have completed a full assessment.  Be careful of the tendency to jump quickly to a diagnosis that you consider to be non stigmatizing, such as an adjustment disorder, that may not be an accurate reflection of the full clinical picture.  I recommend reading the DSM diagnostic criteria for three to five alternative diagnoses as well as the information about differential diagnosis considerations for these diagnoses.  Once you have reached a conclusion about the client’s diagnosis, review this with your supervisor to insure that your final diagnosis is the most accurate and appropriate for the client’s presentation.  With complex clinical presentations, you may have a primary diagnosis and one or more secondary diagnoses.

A second step to take regarding diagnosis is to include a description of the client’s initial symptoms and presenting issues in the client record, in addition to the diagnosis itself.  Usually you will complete an initial assessment which should contain the client’s report and your observations that support the diagnosis.  Your progress notes should track the client’s thoughts, affective states and behavior related to the diagnosis and any changes to the diagnosis resulting from new information or progress.  This insures that anyone viewing the client’s record at a later date will have a more complete picture of the client’s symptoms and functioning than is conveyed by the diagnosis alone.

A third step to maximize the benefit to the diagnostic process is to discuss the diagnosis with the client.  Clinicians are often reluctant to do this because of the worries mentioned in your question.  However, a collaborative discussion often results in relief and clarity for the client who may feel confusion, self-criticism and shame about her condition.  I generally enter these discussions by summarizing what the client has told me and my observations, then sharing the diagnosis that fits the clinical picture.  An example is ” You’ve told me that you don’t enjoy anything, that your sleep and appetite are disrupted and that you feel really down.  I’ve noticed that you are pretty harsh in judging yourself and your energy seems low.  All of these things are signs of depression, and I believe the diagnosis of major depressive disorder fits what you’re experiencing now.”  I then ask the client what her thoughts and reactions are to hearing this and engage in a discussion of any questions or concerns she  may have.  If there is any indication at that time or later in treatment that the client may want her record to be shared with another party, you can remind her that the diagnosis is part of the record and talk about the implications that may have.

I hope you find these suggestions helpful in making diagnoses with more confidence.  Please email me with comments, questions or suggestions for future blog topics.

Cultural Factors in Diagnosis

new1I just had my first session with a 20-year-old woman who meets the DSM criteria for borderline personality disorder.  Her emotions are very labile, her relationship with her boyfriend is unstable and she was fired from her job as a nanny recently because she was often late and had frequent crying spells.  I think DBT would be a good treatment for her, but she immigrated from Thailand three months ago and I don’t know whether DBT has been used with Thai Americans.

It’s important to be aware of the importance of culture in choosing a treatment modality, but before addressing that question let’s look at the issue of culture related to diagnosis.  This young woman’s recent immigration is the context for her symptoms, which makes an initial diagnosis of adjustment disorder more appropriate than borderline personality disorder.  If she came alone to take a job as a nanny, the drastic change in cultures would be exacerbated by a loss of social support and the network of relationships she left behind.  If she came with her boyfriend, that relationship would be under tremendous strain as they both adjust to U.S culture.  In one session, you don’t have time to gather information about her history and background to know whether these symptoms have been longstanding, as required for a personality disorder diagnosis, or whether they developed around the time of her immigration.

Regarding the question of treatment modality, it is possible she would benefit from learning some of the skills that are part of Dialectical Behavior Therapy (DBT).  However, if you begin with a diagnosis of adjustment disorder, the initial focus of treatment will be on learning more about the circumstances of her immigration and her life in Thailand as well as her three months in the U.S.  You will also want to learn more about her previous strategies for coping with distress, her interpersonal relationships including the boyfriend, and her educational and work achievements.  It would also be advisable to learn more about resources appropriate for recent Thai immigrants as well as to research available mental health providers who are fluent in her native language.  It will be important to take a collaborative approach with the client, asking what she feels would be helpful and what steps she wants to take, as you talk with  her about different treatment options with you or other providers and social supports that are relevant to her circumstances.  Consulting with your supervisor, teachers and colleagues who have knowledge and expertise in clinical issues related to immigration and Thai-American culture will also be valuable.

If the client decides to continue in treatment with you, you can then move to the question of specific treatment goals and interventions.  Your consultation and supervision may give you information about interventions shown to be effective with Thai American immigrants, but your client’s responses and preferences about treatment are the best source of guidance.  You should be prepared to adapt interventions, like DBT, that were developed for a different cultural group and to pay close attention to the subtleties of the therapeutic relationship to gauge the impact of your interactions.

I hope you find these suggestions helpful in working with an individual or family who has recently immigrated from another country and culture.  Please email me with comments, questions or suggestions for future blog topics.

Contacting Other Professionals

therapyI’m concerned that my client’s psychiatrist is prescribing the wrong medication.  She’s taking an anti-depressant instead of an anti-anxiety medication, and she says her anxiety hasn’t improved.  She signed a release giving me permission to contact the psychiatrist, so I plan to call him.

It’s often useful to talk with other professionals who are involved in your client’s health care, and preparing in advance makes the conversation more productive and collaborative.  In this instance, you have formed an impression of the psychiatrist’s professional judgment based on your client’s report which you should reflect on before contacting him.  I recommend approaching all conversations with other care providers with an assumption of competence and professionalism on their part.  There are many reasons your client may be telling you her anxiety hasn’t improved on her current medication regimen.  Before concluding that the psychiatrist has made a mistake, consider whether your client has been taking her medication as prescribed and for a sufficient length of time to be effective, whether she has tracked her anxiety symptoms on a regular basis to verify her subjective impression, and whether she has any history of addiction that could be related to her desire for and advisability of benzodiazepines for anxiety.  In addition, reflect on the interpersonal meaning of the client’s report to you and the triangle she has created between you, the psychiatrist and herself.  This may repeat an early family pattern related to conflict and loyalty that you want to handle differently than the client has experienced in the past.

Once you have checked your biases and can approach the conversation with an open, collaborative attitude, it’s good to take some time to prepare by writing down the questions you want to ask and a summary of information you want to share.  Make sure your questions are neutral and will not put him in a defensive position.  For example, it’s better to say “can you tell me how you made the decision to prescribe Zoloft?” than to say “do you think another medication would be more effective?”.  An open-ended question like “what information can you share that will help in my treatment of her anxiety?” is a good way to foster collaboration and may broaden your perspective.  When you write your summary or make notes about what you plan to share, remember to keep it brief, concise and relevant to the psychiatrist’s relationship with the client.  The client’s authorization gives you permission to exchange information, but HIPAA still obligates you to share only the minimum necessary information. When you talk with the psychiatrist by phone, start by asking questions and giving him a chance to share his ideas.  This will show you areas of agreement and consistency in your views of the client, and highlight what you may want to emphasize in your summary.  In your first conversation, I recommend that your agenda be only to establish a collaborative working relationship.  If you have areas of concern or disagreement, it is better to address those in a later conversation after some time has passed and you have had an opportunity to talk with a supervisor or colleague.

I hope you find these suggestions helpful in talking with a psychiatrist or other health care professional.  Please email me with comments, questions or suggestions for future blog topics.

Cross-Cultural Mental Health Treatment

I have just been assigned to see a client who is from a culture that is completely unfamiliar to me.  She immigrated to the U.S. three years ago and speaks English, but I’m concerned about being able to do psychotherapy with her.  How can I make sure I don’t over diagnose symptoms that may have a different cultural meaning for her than for my other clients?

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It’s good that you’re aware of the importance of your client’s culture in your diagnosis and psychotherapy.  When working with a client whose culture is unfamiliar to you, I recommend doing some research into the culture to learn some basic facts about her country of origin.  If you haven’t worked with other individuals who are recent immigrants, doing research into this area will also be valuable.  However, also remember that your client is the best person to educate you about herself.  She is presenting for behavioral health treatment because she is in distress and wants help with some issues that are troubling her.  The skills you use in the first session with any client will serve you well in this situation.  In addition, you may want to ask her how her family members or friends in her country of origin would understand or interpret her symptoms to provide some cultural context for her concerns.

One way to keep the cultural context in mind when using the DSM for diagnostic purposes is to ask about events leading up to the client’s immigration and conditions since she arrived in the U.S.  It is possible that an adjustment disorder or posttraumatic stress disorder diagnosis may be appropriate.  If her symptoms don’t fit either of these diagnoses, you can use an initial “not otherwise specified” or provisional diagnosis, which will note your lack of sufficient information to make a full diagnosis.  This can be changed as you learn more about her history and current life circumstances.

Another way to use the DSM as a resource for assessment is to incorporate the cultural formulation found in Appendix I of the DSM-IV and in Section III of the DSM-5.  The outline for cultural formulation includes cultural identity, cultural conceptualization of distress, psychosocial stressors and supports, and cross-cultural features of the treatment relationship.  The DSM-5 also includes a set of interview questions that can be used in assessing the cultural context of the client’s clinical presentation.

A final issue to consider in your initial assessment and ongoing psychotherapy is the cultural context of your role as a professional in the therapeutic relationship.  If you are still in training, you may not think of yourself as an expert, and many of your U.S. born clients may treat you as a peer or make comments about your status as an intern or trainee.  Many other cultures hold a value of deference to authority, however, and this may make your client reluctant to disagree with you or to express her preferences about the treatment.  In addition, recent immigrants and other cultural groups often have experiences of discrimination and misunderstanding by officials, administrators and service providers.  It can be helpful to directly express your interest in the client’s ideas, to ask open-ended rather than closed questions, and to acknowledge the extent and limitations of your knowledge.  Even so, it may take more time to develop a therapeutic alliance with this client than with clients who are from cultural backgrounds similar to yours.

I hope you find this blog helpful in working cross-culturally.  Please email me with comments, questions or suggestions for future blog topics.

Working With Depression

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I’m worried about one of my clients who was very depressed and overwhelmed in our last session. How should I decide whether to call her before our next session?

This is a common and distressing situation for students in psychotherapy training. You may find yourself preoccupied with worry and uncertainty about your client’s wellbeing, especially if you are personally vulnerable to anxiety. Part of the developmental process in clinical psychology training is expanding your focus from alleviating your own distress to evaluating the impact on your client of different interventions. As behavioral health professionals, our primary responsibility is client welfare so all of our clinical interactions should be centered on that consideration.

Regarding a depressed, overwhelmed client, your first step should be consulting with your supervisor. This is especially important if you are in your first practicum or field placement setting and you should continue to consult with your supervisor throughout your training whenever you are concerned about a client’s safety. These situations bring up intense feelings for clinicians and it is hard to be objective in evaluating the most appropriate response when you are caught in the emotional intensity. Some of us respond to intense emotions by shutting down and minimizing the client’s risk and others of us become agitated and overestimate the risk.

Some of the factors to consider in evaluating your client’s risk, in consultation with your supervisor, are the length of your relationship with the client, whether the client’s emotional state is a change in response to a recent stressor or is more longstanding, how the client has coped or reacted to similar feelings in the past, and what internal strengths and external supports are available to the client. Clients who are new to you, who are reacting to a recent precipitating event, who use self-destructive or impulsive coping strategies, and have few strengths and supports are at greater risk. If you are concerned about suicidality, use a risk assessment tool such as the Suicide Assessment Five-step Evaluation and Triage.

If you and your supervisor agree that the client’s risk is high, you should contact the client to make a further assessment. If the client’s risk is low, you can wait until your next session to do further assessment. If there is a moderate level of risk, your decision will be based on your understanding of the meaning your intervention will have to your client. You may contact the client as a way to communicate your care and concern, but the client may experience your call as intrusive and undermining. You can develop an understanding of your client’s likely interpretation of your interventions based on your knowledge of her/his early experiences with parents and other caregivers and your observations of her/his relational patterns. A client who experienced neglect and has an expectation that others will be absent and uncaring will respond more positively to an unexpected call from you than a client who experienced abuse and intrusion. However, because psychotherapy always has the overriding goal of supporting client autonomy and self-determination, it is safer to refrain from initiating contact with a client unless there is a clear reason to do so.

After consultation and consideration of your client’s welfare, you may determine that contact with the client isn’t appropriate but still feel worried. This is the time to refocus your attention on your own coping strategies and self-care. Learning psychotherapy involves strengthening your ability to manage intense emotions and placing the client’s welfare above your personal needs. It also involves differentiating between your relationships with family and friends and your professional relationships with clients.

I hope this has been helpful to you. Please email me with feedback or suggestions for future blog topics.

Evaluating First Session of Behavioral Health Treatment

therapy1I just completed a first session with a new client. I feel like it went pretty well, but I’m not sure how to tell. What should I think about before I see the client again next week?

Generally, we end a client session with a general feeling about how it went, as you did. It seemed like a good session, a great session, a terrible session or just okay. That general feeling is the combination of a number of factors which can be helpful to separate out. It is also important to integrate your feeling about the session with your thoughts about the clinical work and what you will do next.

Often our feeling about a client session, especially the first session, comes primarily from our experience of the therapeutic alliance. The therapeutic alliance refers to a shared feeling of working together toward the same goal. After the first session, we have a sense of whether the tone was collaborative, distant or adversarial and how easy or difficult it was to feel empathic and warm toward the client. We also get a sense of whether there were obstacles to the alliance which mean it will be more difficult to establish a sense of collaboration. When you feel the session went well, it can be helpful to think about the nature of the therapeutic alliance and how that contributes to your general feeling.

During the first session you probably got an idea of why the client is coming for treatment and learned some information about his or her life and history. You may find it useful to write down your client’s primary concerns, any safety issues that are present, and questions you want to follow up. This will help to organize your thoughts and identify areas to explore in subsequent sessions. Many clinicians feel a conflict between a desire to build rapport and an agency requirement to do an assessment and/or develop a treatment plan. However, one of the best ways to build rapport is to express your desire to understand the client’s life and goals, and this understanding is the basis for your assessment and treatment plan. You can provide focus and structure by combining empathic listening with sensitive questioning and summarizing comments. This is useful to clients whose lives are somewhat chaotic and unpredictable.

Identifying issues to discuss with your supervisor is also part of beginning treatment with a new client. You may have questions about the client’s symptoms and diagnosis, the appropriate unit or modality of treatment (seeing the client individually or as part of a family unit, referring for medication), safety concerns, or feelings that have arisen for you about or with the client. Even when you feel good about your first session and don’t have any pressing concerns, it is wise to mention the client to your supervisor so she/he is updated on your case load.

I hope some of these suggestions help you in preparing for early sessions when you are getting to know a new client. Please email me with comments, questions or suggestions for future blog topics.