Diagnosis and Treatment Planning

CHAPTER

Diagnosis and 10

Treatment

Planning

CHAPTER OBJECTIVES

From the perspective of the medical model, the primary—and sometimes

only—purpose of a clinical interview is to identify an appropriate diagnosis

and treatment plan. In this chapter, we look at philosophical and practical aspects

of diagnosis; we also review several approaches for developing treatment plans for

counseling or psychotherapy clients.

After reading this chapter, you will understand:

• Basic principles of psychiatric diagnosis, including the definition of

mental disorders according to the Diagnostic and Statistical Manual

of Mental Disorders, 5th Edition (DSM-5; American Psychiatric

Association, 2013).

• Common problems associated with assessment and diagnosis.

• Methods and procedures for diagnostic assessment.

• A balanced approach for conducting diagnostic clinical interviews.

• An integrated or biopsychosocial approach to treatment planning.

• How to identify client problems, associated goals, and establish a

treatment plan to guide the therapy process.

• The importance of matching client resources with specific approaches

to clinical treatment.

PRINCIPLES OF PSYCHIATRIC DIAGNOSIS

In 1993, Frank and Frank wrote: “We propose to group those who receive psychotherapy

into five rough categories: the psychotic, the neurotic or persistently

disturbed, the shaken, the misbehaving, and the discontented” (p. 11). This is

an example of one of many formal and informal diagnostic systems that exist

for grouping individuals with mental health problems. These systems may be as

simple and intuitive as Frank and Frank’s (1991) or as complex as the fifth edition

of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) The DSM-5

329 Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

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330 Part Three Structuring and Assessment

now includes nearly 300 mental disorders in its 947 pages (American Psychiatric

Association, 2013).

The revision process for the DSM-5 has been nothing short of amazing. We

mean this in at least two ways; the effort has been amazing: “ … hundreds of people

working toward a common goal over a 12-year process” (American Psychiatric

Association, 2013, p. 5). And the politics have been amazing. Originally planned

for publication in May, 2011 after significant delays related to many factors,

including conflicts of interest among work group members, it was finally released

at the American Psychiatric Association annual meeting in San Francisco on

May 18, 2013. Along the way, there were strong letters of protest from many

constituents, much gnashing of teeth, and wailing of the sort that can only happen

on the Internet. To help capture the controversy, here’s a short excerpt from a

Psychology Today article written by Allen Frances, MD, former chair of the DSM-IV

Task Force and professor emeritus at Duke University.

This is the saddest moment in my 45 year career. … The … American

Psychiatric Association has… [approved] … a deeply flawed DSM-5 containing

many changes that seem clearly unsafe and scientifically unsound.

Despite criticisms the DSM has been and will likely continue to be the

authoritative diagnostic guide for North American mental health professionals.

The first edition was published in 1952; the second, in 1968; the third, in 1980; a

revision of the third edition, in 1987; the fourth edition in 1994; and in 2000, a

text revision of DSM-IV (DSM-IV-TR). Even with so many editions and extensive

review, psychiatric diagnosis remains controversial. As Widiger and Clark (2000)

claimed of the DSM-IV: “There might not in fact be one sentence within DSM-IV

for which well-meaning clinicians, theorists, and researchers could not find some

basis for fault” (p. 946). But, of course, the DSM-5 has outdone the DSM-IV

both in terms of complexity and controversy. This controversy has already led to

extensive discussion, debate, and publication within the mental health professions.

For example, as of February 1, 2013, there were over 300 professional publications

listed on PsycINFO with the word “DSM-5” in the title … despite the fact that

the 5th edition of the DSM wouldn’t be published for another 3 months.

Disputes surrounding psychiatric diagnosis and the concept of mental disorders

run so deep that the DSM-IV-TR and ICD-10 both include explanations or

disclaimers for why the term “mental disorder” is used. The DSM-IV-TR contained

a brief but articulate section titled “Definition of Mental Disorder.” In this

section, the DSM authors admitted they have produced a manual for diagnosing

a concept that lacks an adequate operational definition:

… although this manual provides a classification of mental disorders, it

must be admitted that no definition adequately specifies precise boundaries

for the concept of “mental disorder.” The concept of mental

disorder, like many other concepts in medicine and science, lacks a

consistent operational definition that covers all situations. (American

Psychiatric Association, 2000, p. xxx)

Interestingly, although the DSM-5 continues to use the term mental disorder (and

not mental illness), this time around the authors refrained from commenting on

the reasoning behind this choice.

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Chapter 10 Diagnosis and Treatment Planning 331

As we discuss diagnostic interviewing strategies in the following pages, be

forewarned that you are venturing into only partially charted waters. Nonetheless,

as scientists and professionals, we believe it’s a fascinating journey, filled with

adventure, intrigue, and more than an occasional unresolved dispute.

Defining Mental Disorders

From your own experiences you probably recognize that it’s often difficult to

draw a clear line between mental disorders and physical illness. When you become

physically ill, sometimes it’s obvious that your stress level, lack of sleep, or

mental state has contributed to your illness. Other times, when you’re distressed

psychologically, your physical condition can contribute to a disturbed emotional

state and thinking processes (Jakovljevic, 2006; Witvliet et al., 2008). The difficulty

distinguishing between mental and physical problems was acknowledged in the

DSM-IV-TR:

A compelling literature documents that there is much “physical” in

“mental” disorders and much “mental” in “physical” disorders. The

problem raised by the term “mental” disorders has been much clearer

than its solution, and, unfortunately, the term persists in the title of

DSM-IV because we have not found an appropriate substitute. (American

Psychiatric Association, 2000, p. xxx)

Despite ongoing quandaries over what to call mental disorders, and whether

mind or body is the primary contributor to such disorders, it’s safe to say that the

DSM-5 contributors have identified numerous important cognitive, emotional,

and behavioral problems or deviances that exist in many people throughout the

world. These mental conditions or mental disorders produce immense suffering,

conflict, and distress in the lives of millions. Without a doubt, and no matter

what we call them, mental disorders are frequently identifiable and have clear and

adverse effects on individuals, couples, families, and communities.

The DSM-5 remains a primarily descriptive and categorical system. This

means it provides descriptions of symptom sets associated with specific diagnoses

and that individuals are classified as having or as not having psychiatric

diagnoses. Although the DSM-5 has been reorganized to reflect developmental

and dimensional issues in psychopathology it has not moved significantly away

from a categorical approach: “Despite the problem posed by categorical diagnoses

the DSM-5 Task Force recognized that it is premature scientifically to propose

alternative definitons for most disorders” (p. 13).

In its introduction, the DSM-5 offers a general definition of mental disorder:

A mental disorder is a syndrome characterized by clinically significant

disturbance in an individual’s cognition, emotion regulation, or behavior

that reflects a dysfunction in the psychological, biological, or developmental

processes underlying mental functioning. Mental disorders are

usually associated with significant distress or disability in social, occupational,

or other important activities. (American Psychiatric Association,

2013, p. 20)

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332 Part Three Structuring and Assessment

The DSM-5 also includes information about what is not a mental disorder:

An expectable or culturally approved response to a common stressor or

loss, such as the death of a loved one, is not a mental disorder. Socially

deviant behavior (e.g., political, religious, or sexual) and conflicts that

are primarily between the individual and society are not mental disorders

unless the deviance or conflict results from a dysfunction in the individual,

as described above. (p. 20)

Not surprisingly, significant vagueness in the DSM-5 definition of mental

disorder remains. If you go back and read through the DSM-5 definition of mental

disorder several times, you’ll find substantial lack of clarity. For example, there’s

plenty of room for debate regarding what constitutes “a clinically significant

disturbance.” Additionally, how can it be determined if human behavior “reflects a

dysfunction in the psychological, biological, or developmental processes underlying

mental functioning” (p. 20)? Further, the manual recognizes that “an expected

or culturally approved” behavioral response is not a mental disorder, but doesn’t

provide any guidelines for making this judgment (this is an example of a universal

exclusion criterion, as discussed in Chapter 6).

Over the years the DSM system has received much criticism for being vague,

subjective, and political (Eriksen & Kress, 2005; Horwitz, 2002; Horwitz &

Wakefield, 2007). As a historical example, Szasz (1970) wrote:

Which kinds of social deviance are regarded as mental illnesses? The

answer is, those that entail personal conduct not conforming to psychiatrically

defined and enforced rules of mental health. If narcotics-avoidance

is a rule of mental health, narcotics ingestion will be a sign of mental

illness; if even-temperedness is a rule of mental health, depression and

elation will be signs of mental illness; and so forth. (p. xxvi)

Szasz’s point is well taken. After all is said and done, DSM’s general definition

of mental disorder and the criteria for each individual mental disorder consist

of carefully studied, meticulously outlined, and politically influenced subjective

judgments. This is an important perspective to keep in mind as we continue down

the road toward clinical interviewing as a means for psychiatric diagnosis and

treatment planning.

Why Diagnose?

Like Szasz (1970), many of our students want to reject the entire concept of diagnosis.

They’re critical of and cynical about the DSM, or they believe that applying

diagnoses dehumanizes clients by affixing a label to them and then ignoring their

individual qualities, what Morrison (2007) has referred to as pigeonholing. Whatever

their arguments, our position regarding diagnosis remains consistent. We

empathize with our students’ complaints, commiserate about problems associated

with diagnosing unique individuals, criticize the many examples of inappropriate

diagnostic proliferation (e.g., bipolar disorder in youth), but we continue to value

the teaching and learning of diagnostic assessment strategies and procedures,

justifying ourselves with both philosophical and practical arguments.

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Chapter 10 Diagnosis and Treatment Planning 333

Philosophical Support

No matter what we call them, mental disorders exist. As far as we know, emotional

distress, mental suffering, character pathology, and suicidal behavior have existed

from day one. Psychiatric diagnosis is designed to classify or categorize mental

disorders based on specific defining characteristics. Knowledge about mental

disorders, their similarities, differences, usual course and prognosis, and prevalence

helps mental health professionals provide more appropriate and more effective

treatments. Such knowledge is reassuring and empowering to therapists who want

to help clients. Additionally, this knowledge base guides research on preventing

mental disorders.

Practical Support

There are a number of positive practical outcomes of accurate diagnosis. A

diagnosis is a consolidated, organized description of client symptoms. Arriving

at this shorthand description requires careful observation and inquiry. After the

best diagnosis is obtained, clinicians can communicate with other professionals,

insurance or managed care companies, and other interested parties.

At best, a diagnosis is a working hypothesis. It forces clinicians to bring

together disparate pieces of the puzzle and tentatively name a cluster of symptoms.

It then suggests a general course of action that, if pursued, should yield somewhat

predictable responses. It lays the groundwork for planned interventions and

informed use of theory and technique.

In addition to enabling professional communication and hypothesis testing,

a final positive and practical aspect of diagnosing is this: Sometimes, a label is a

huge relief for clients. Clients come for help with a confusing and frightening

symptom set. They may feel alone and uniquely troubled. They may feel no

one else in the world has ever been so dysfunctional, odd, or anxious. It can

be a big relief to be diagnosed, to have your problems named, categorized, and

defined. It can be comforting to realize that others—many others—have reacted to

trauma in similar ways, experienced depression in similar ways, or even developed

similar maladaptive coping strategies (such as irrational thoughts or damaging

compulsions). The wise clinician realizes that diagnosis can imply and instill

hope (Frank & Frank, 1991; Pierce, 2004; Mulligan, MacCulloch, Good, &

Nicholas, 2012).

Specific Diagnostic Criteria

In contrast to establishing a satisfactory general definition for mental disorders,

identifying a DSM diagnosis for a particular client may seem, on the surface,

rather straightforward. After all, psychiatric diagnosis is based on a process

where clinicians determine the presence or absence of various symptom clusters

(i.e., syndromes). In most cases, the DSM-5 provides specific, more or less

measurable criteria for its diagnoses. Typically, DSM diagnoses are characterized

by a symptom list for defining the condition. For example, to qualify for generalized

anxiety disorder, individuals must meet the criteria in Table 10.1.

The diagnostic criteria for generalized anxiety disorder illustrate challenging

tasks associated with accurate diagnosis. First, based on criterion A, diagnostic

interviewers must establish whether a given client is experiencing “excessive”

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334 Part Three Structuring and Assessment

Table 10.1 Diagnostic Criteria for Generalized Anxiety

Disorder (DSM-5: 300.02)

This table is a summary and adaptation of the DSM-5 diagnostic criteria for

generalized anxiety disorder. For the actual criteria, you should consult the

DSM-5 (American Psychiatric Association, 2013, p. 222).

A. The client has “excessive anxiety and worry” that occurs “more days than not

for at least 6 months”and pertains to “a number of events or activities.”

B. The client has difficulty controlling the anxiety or worry.

C. Three or more of the specific symptoms listed below are present and linked to

the anxiety/worry

A. feeling restlessness or “keyed up or on edge”

B. feelings of fatigue that come on easily

C. blank mind or problems with concentration

D. “irritability”

E. “muscle tension”

F. problems sleeping

D. The preceding symptoms “cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.”

E. The symptoms aren’t caused by a substance or a medical condition.

F. The symptoms aren’t “better explained by another mental disorder.”

anxiety and worry, how frequently the anxiety is occurring, how long the anxiety

has been occurring, and how many events or activities the individual is anxious

or worried about. This information relies on the interviewer’s ability to gather

appropriate symptom-related information and the client’s ability to articulately

report symptom-related information. In addition, obtaining information required

by criterion A involves interviewer and client subjectivity (i.e., the determination

of what constitutes “excessive”).

Second, under criterion B, interviewers must assess how difficult clients find

it to control their worry. This information requires an evaluation of client coping

skills and efforts, which essentially involves asking questions about what clients

have tried to do to quell their anxiety and how well these coping efforts have

worked in the past.

Third, and perhaps the most straightforward diagnostic task, interviewers

must identify whether clients are experiencing specific anxiety-related symptoms

(see Table 10.1). Unfortunately, even this apparently simple task is fraught with

complications, especially in cases where clients are motivated to either overreport

or underreport symptoms. For example, clients seeking disability status for an

anxiety disorder may be motivated to exaggerate their symptoms, and clients

who desperately want to remain in the workplace may minimize symptoms.

Consequently, along with questioning about these specific anxiety symptoms,

the interviewer must stay alert to the validity and reliability of the client’s

self-reported symptoms (Feinn, Gelernter, Cubells, Farrer, & Kranzler, 2009;

Gilboa & Verfaellie, 2010; J. Sommers-Flanagan & Sommers-Flanagan, 1998).

Fourth, to label an individual as having generalized anxiety disorder (GAD),

interviewers need considerable knowledge of other DSM diagnostic criteria.

Eleven other diagnoses that may need to be ruled out are listed in GAD criterion F.

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Chapter 10 Diagnosis and Treatment Planning 335

An interviewer needs to have working knowledge of many other diagnostic criteria

to assign or rule out a GAD diagnosis. Obviously, this is no small task; it requires

lengthy education, training, and supervision.

Fifth, criterion D requires interviewers to determine whether reported anxiety

symptoms cause “clinically significant distress or impairment in social, occupational,

or other important areas of functioning.” Criterion D is the distress and

impairment criterion. Although this criterion is essential for diagnosis, it is also

inherently subjective. Nowhere in DSM-5 is a clinically significant impairment

defined.

Sixth, based on criterion E, before establishing a definitive diagnosis, interviewers

need to determine whether the anxiety symptoms are caused by exposure

to or intake of a substance, or a general medical condition. Substances and medical

conditions need to be ruled out as causal factors in virtually every DSM-5

diagnostic category.

Overall, the GAD example illustrates a range of tasks and issues with which

diagnostic interviewers must grapple. The reality is that, based on the DSM’s

diagnostic paradigm, a psychiatric diagnosis is seated within the context of a

unique individual. Indeed, if it were not for unique individuals and their confusing

variability in reporting their personal experiences and their confounding and

confusing motivational and interpersonal dynamics, psychiatric diagnosis would

be a simpler process.

Assessment and Diagnosis Problems

To determine if a client meets the diagnostic criteria for GAD, interviewers must

determine whether the client has three of six symptoms from criterion C. Given

this fact, it may be sufficient (and justifiable) to directly ask the client a series of

specific DSM-5–generated questions pertaining to generalized anxiety disorder.

For example, the following questions could be asked:

1. Over the past 6 months or more, have you felt restless, keyed up, or on edge

for more days than not?

2. Over the past 6 months, have you felt easily fatigued more often than not?

3. Over the past 6 months, have you noticed, on most days, that you have

difficulty concentrating or that your mind keeps going blank?

4. Over the past 6 months, have you felt irritable at some point on most days?

5. Over the past 6 months, have you found yourself troubled by muscle tension

more often than not?

6. Over the past 6 months, have you had difficulty falling asleep, or have you

found that you regularly experience restless or unsatisfying sleep?

Using this simple and straightforward diagnostic approach may, in some

circumstances, produce an accurate diagnosis. However, in reality, accurate diagnostic

assessment is considerably more complex. As suggested from constructive

critiques of psychiatric diagnosis and differential activation theory, the preceding

practice of asking six consecutive negatively worded questions focusing on anxiety

may adversely affect the patient, the patient’s mood, the working alliance, and

consequently diagnostic reliability and validity (Eriksen & Kress, 2005; Lau, Segal,

& Williams, 2004).

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336 Part Three Structuring and Assessment

Further, in DSM-5’s introductory section, it is emphasized that diagnostic

criteria should not be applied in a check-list manner:

The case formulation for any given patient must involve a careful clinical

history and concise summary of the social, psychological, and biological

factors that may have contributed to developing a given mental disorder.

Hence, it is not sufficient to simply check off the symptoms in the diagnostic

criteria to make a mental disorder diagnosis. (American Psychiatric

Association, 2013, p. 19)

Before moving on to a detailed description of diagnostic assessment strategies

and procedures, we identify several specific problems associated with establishing

an accurate diagnostic label for individual clients:

Client deceit or misinformation: Clients may not be straightforward or honest

in their symptom descriptions (Feinn et al., 2009; Jaghab, Skodnek, &

Padder, 2006). Even in cases when they are honest, they may have

difficulty accurately describing their symptoms in ways that match DSM

criteria. In addition, if you gather information from individuals other

than clients (e.g., from teachers, parents, romantic partners), you may

obtain invalid information for many different reasons. In fact, research

indicates that when children, parents, teachers, and others rate the same

individual, their interrater agreement is generally low (Rothen et al.,

2009). Despite this fact, obtaining diagnostic-related information from

parents and other available informants remains essential.

Interviewer countertransference: When using a diagnostic interview, you may

lose your objectivity and/or distort client information. This may occur

partly because of countertransference (Aboraya, 2007). For example, if

a client triggers a negative reaction in you, you may feel an impulse to

“punish” the client by giving a more severe diagnostic label. Similarly,

you may minimize psychopathology and associated diagnoses if you like

your client.

Diagnostic comorbidity: In many cases, clients qualify for more than one

DSM diagnosis. In fact, with regard to children, diagnostic comorbidity

occurs more often than not (Samet & Hasin, 2008; Watson, Swan, &

Nathan, 2011). This comorbidity problem makes sorting out appropriate

diagnostic labels even more difficult.

Differential diagnosis: Although some clients report symptoms consistent with

more than one diagnostic entity and are appropriately assigned two or

more diagnostic labels, other clients report confusing symptom clusters

requiring extensive questioning for diagnostic clarity. For example,

it’s notoriously difficult, albeit important, to discriminate some diagnoses

from others (e.g., mood disorder with psychotic features versus

schizoaffective disorder versus schizophrenia versus delusional disorder).

Despite difficulties sorting out these various disorders, diagnostic speci-

ficity is important because of treatment implications (i.e., medication

type, treatment approach, hospitalization, prognosis).

Confounding cultural or situational factors: in the DSM-5 it is acknowledged

that culture and context will influence diagnosis: “ … The boundaries

between normality and pathology vary across cultures for specific types

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Chapter 10 Diagnosis and Treatment Planning 337

of behaviors.” (p. 14). Consequently, your diagnostic task includes a

consideration of your clients’ individual social, cultural, and situational

contexts when providing diagnoses, which is not always an easy task

(Hays, 2008).

Given these problems, many therapists and researchers advise using what has

been referred to as “multimethod, multirater, multisetting assessment procedures”

(J. Sommers-Flanagan & Sommers-Flanagan, 1998, p. 191). This means that,

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