I 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.