I work at an agency that requires us to give a diagnosis to each of our clients. I’ve gotten comfortable with this requirement and the diagnoses I give to my clients, but I’m concerned that someone will ask me about their diagnosis. I think the clients will feel upset about knowing that I have diagnosed them, so I dread the possibility of someone asking me about it.
One section of Chapter 5 of my book specifically reviews how to discuss diagnosis with your client, and the case example at the end of that chapter includes an illustration of a therapeutic conversation about diagnosis. I’ll summarize some of the important points here.
Your concern is common among clinicians, who associate diagnosis with the medical model and a lack of subjective understanding and empathy for the client. Agencies whose clients rely on third party funding generally require that all clients receive a diagnosis because of funder requirements. Your clients might not be able to get the treatment they need without third party payment and your documentation of a diagnosis that meets medical necessity guidelines, but it does raise a clinical dilemma.
A place to start with this dilemma is to review your diagnoses and confirm that they are accurate based on the clients’ report of symptoms and your observation of them in session. It sounds like you’ve done this with your clients, but your level of concern may decrease if you go through this review systematically. If any of your diagnoses don’t fit the client’s report or if symptoms have changed during the course of treatment, you can modify the original diagnosis to fit the current symptom picture.
In anticipating a conversation with your client, there are several things to keep in mind. One issue is to think about the meaning of diagnosis at this particular time in treatment. A client who raises a question about diagnosis in the second session probably has different reasons for wanting to discuss it than a client who raises the question after six months. When a client asks about diagnosis, you can explore the meaning by saying something like “I’m happy to talk with you about this, but I’m also curious about what goes into your question.” Starting with reassurance that you will answer the question makes it more likely that the client will be open in sharing her/his motivation. You can then discuss the diagnosis in a way that addresses the client’s concern. For example, if the client expresses worry that she/he is “crazy” you will answer differently than if the client wonders what the number means on the statement she/he received from the insurance provider.
A second issue to consider is the emotional response your client is likely to have to the specific diagnosis you have assigned. Approach this conversation in the same way you approach any topic in the therapy. It is best to say a few sentences initially, then ask the client for her/his reaction and be alert for nonverbal cues that provide additional information. If the client’s diagnosis is something that may be negatively charged for your client, consider prefacing disclosure of the diagnosis by a statement like “You may have some preconceptions about what this particular diagnosis means, so if it’s all right, I’d like to tell you why I have used this diagnosis for you.” Then summarize the aspects of the client’s report of symptoms and your observations that support the diagnosis. You can then ask the client if your summary seems accurate. After you and the client have agreed on the symptoms and issues, you can then say “In the field of psychotherapy, that combination of difficulties is described with the diagnosis of (the name of the disorder)” and pause for the client’s response. If the client is concerned about whether this diagnosis means she/he will be unable to improve or to achieve life goals, you can discuss the treatment approaches that you are using and express realistic optimism that the client’s symptoms can be managed effectively.
Probably the most important way to insure a productive and therapeutic conversation about diagnosis is to continue to reflect on your views of diagnosis and the stigma you may hold about diagnosis in general or about specific disorders. If you develop the skill to speak openly about diagnosis, your clients’ shame, self-judgment and suspicion will be minimized. My personal definition of diagnosis is that it is a standard, professional way of summarizing a broad range of information about the client’s present and past symptoms and experiences. For me, a diagnosis doesn’t reflect a feeling or judgment about the client and it doesn’t imply a prediction about the client’s overall capacity to lead a fulfilling life. Holding the meaning of diagnosis in this way enables me to respond to my clients’ questions with confidence that the conversation will not have a negative impact on our therapeutic relationship.
I hope these suggestions are helpful in having conversations about diagnosis with your therapy clients. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.