BLOG POST – Spring 2018

Posted on March 12th, 2018

DIAGNOSIS… A SHOT IN THE DARK:

All therapists diagnose their patients – even those of us who claim that they never do. We have to. How can we help our clients if we don’t know what their problems are? Some of us label our patients deliberately and use those labels as guides to treatment choices. Others of us, perhaps without realising it, implicitly label our patients if we usually adhere to a particular treatment approach, (usually the one in which we were first trained). After all, every school of psychotherapy has its own unique beliefs about the origins of its patients’ distress – that’s labelling by default. So, it’s not a question of ‘should we diagnose’? Diagnosis is unavoidable. The real question is, ‘how can we minimise any harm that might come about when we do so’?

Strictly speaking, diagnosis is a medical term and should only be used by medical practitioners. What psychotherapists do are assessments, (in practice it’s the same thing). I have written extensively about psychotherapeutic assessment in my book ‘Mental Health in Counselling and Psychotherapy’, (www.amazon.co.uk/Mental-Health-Counselling-Psychotherapy-Practice/dp/0857253778). I’ve even included a ‘How To Assess Guide’. Why not have a look?

Whether we are assessing, (or diagnosing), our clients, it is important to remember that our conclusions are always simply a collection of personal judgements. They are nothing more than our best guesses at the time. There are no objective tests in psychiatric or psychotherapeutic diagnosis. You can’t take a patients ‘psychiatric temperature’ nor can you measure someone’s ‘emotional blood levels’. Not only that, but experience shows that no psychological diagnosis is reliably predictive. You cannot confidently say that ‘Mental Condition A’ will result in ‘Abnormal Behaviour Type 1’. What makes our assessments even more ‘fuzzy edged’ is that mental health diagnosis is carried out on a ‘menu’ basis. For any given condition, an ‘a la carte’ list of symptoms is provided. The more positives scored, the more likely it will be concluded that a patient has that particular condition. Menu-based diagnostic systems generate two major problems. Firstly, deciding on a ‘positive’ is a matter of opinion. Are our opinions soundly based? Secondly, because many of the symptoms on any given list are also found in the lists for other mental health conditions, we have to be sure that we are working with the right list to begin with. The imprecise nature of mental health diagnosis is further highlighted by the option to diagnose ‘Not Otherwise Specified’ for most of the psychological disorders. That diagnosis is best translated as ‘we know you’ve got it but we can’t prove it!’

So, given all the uncertainties, should we assess our patients? My answer is a firm ‘Yes’ because our best guesses, backed up by clinical experience, are very often correct. In any case, what else have we got to work with?  I also say ‘Yes’ because appropriately tailored therapy packages can help our clients and inappropriately tailored ones can harm them. Take for example a patient suffering from one of the trauma-related conditions. In those cases, specific therapy styles such as CBT, EMDR, or DBE are often helpful. Non-directional standard counselling is at best useless, and at worst, a source of re-traumatisation. Assessment helps us to make better choices about our patients’ therapeutic needs.

Psychotherapeutic assessment is not something to be carried out by the untrained or the inexperienced. That’s because the very first thing to do, is to find out whether or not a presented set of symptoms indicates a physiological or a psychological disorder. For example, a patient presenting with what at first sight appears to be severe anxiety might actually have abnormal coronary or thyroid activity. Equally, a patient who has been prescribed beta-blockers by a GP for what seems to be a heart rhythm problem might actually be suffering from a psychosomatic condition. Sensible psychological assessors follow a simple rule – ‘if in doubt, get it checked out’! Sensible psychotherapists and sensible medics co-operate and support each other. It’s not ‘medicine OR psychotherapy’, it’s ‘medicine AND psychotherapy.

The next thing to do is to not let your initial patient labelling put blinkers on you. Over any course of psychological treatments, diagnoses can, (and should), vary as new symptoms emerge and old symptoms fade away. This means your initial diagnosis must be under constant review and so must your treatment strategies. Flexibility is the name of the game!

Next, when treatment planning always consider the pros and cons of any given therapeutic method. Don’t be blinded by the ‘one size fits all’ approaches offered by the traditional psychotherapies. Any of the main schools of psychotherapy, (humanistic, analytical, cognitive-behavioural, and their many sub-divisions), can be helpful or harmful, depending on circumstances. The most important assessment decision of all is deciding which treatment method, (or mixture of treatment methods), is best for which client and at which time during the therapeutic process.

There is a final point to bear in mind when diagnosing or assessing a patient. Labels tend to get fixed. It they get noted in official records then this can affect, distort even, a person’s whole life. The danger is that everybody will stop seeing the person and only see the label. Not only that, although obviously a convenient form of professional shorthand, labels all too often are very much misunderstood, even within the helping professions. So be careful how you use diagnostic labelling and be very careful about letting others know about your diagnostic conclusions. Above all, use assessment as a therapeutic aid; don’t let it take over the show.