Assessment, Diagnosis & Treatment

(As published in the October 2006 Honor Cord (non-working link); as published by Phi Theta Kappa; contact the publisher for information on how to locate the archives )

By: Kurt D. LaRose

People pursue the assistance of mental health practitioners hoping that therapy will offer relief in difficult life circumstances.  Divorce, drugs, sexual dysfunctions, abuse, depression, and legal and employment problems are common issues that lead people to seek professional therapy.  A topic that is often overlooked between therapists and clients is treatment effectiveness, even as the evaluation of treatment (counseling) is hardly a new phenomenon.(1)  Nevertheless, positive outcomes for clients who seek therapy, depend heavily on good assessments, reliable diagnosis, and written treatment plans.

For as many years as professionals have been providing therapy, its effectiveness has been debated.(2)  That mental health counseling works is supported in the literature and in the research.(3)  And research supports the client/therapist relationship as central in treatment success.  But how do you know if it works?

Experts in the use of assessment tools argue that historians “will write that well into the 1990’s few practitioners or clinicians evaluated the effects of their new treatments in any systematic way…they [counselors] would simply ask clients from time to time how they were feeling or how they were doing.”(4)  And this method is still used today – known in part as ‘client centered practice.’(5)  The argument (in its simplest form) suggests that if you’re the client, and you say, “I’m all better,” it must be true.  (For some examples of evaluations completed by LaRose please see:  School Counseling Programs and Rural Mental Health Service Programs).

But most people know of examples where such proclamations are hardly evident.  In the case of substance dependency disorders, it is not uncommon for the drug or alcohol dependent person to espouse that their life is great, even as family, friends, and co-workers can point to multiple factors that suggest otherwise.  Denial patterns are not limited to substance dependency however, as there is usually some degree of resistance in all kinds of disorders. (6)  What differentiates the client centered argument that says, “all is well,” versus the mental health professional statement that says “Houston, we have a problem?”

One of the key components to getting good therapy with good results, is to find a professional who produces a comprehensive assessment – and who recommends the use of assessment instruments to identify and diagnose (and/or rule out) mental health problems.  Note that, a “good assessment” attempts to simultaneously do both: diagnose disorders and rule them out.

A mental health provider usually interviews clients to discuss presenting problems (and some professionals assess client strengths).  Based upon certain variables a diagnosis can be made.  One word of caution is that if the diagnosis is determined based solely upon the content of the interview, it is possible that the resulting mental illness diagnosis will be largely subjective – and potentially erroneous.

What the mental health services consumer may want to consider, when they are given a diagnosis by a doctor, counselor, or therapist, is whether or not the professional used an established measurement tool to confirm or rule out the diagnosis – in addition to the initial interview content and in addition to the expertise of the mental health provider.  From a purely biological perspective, if you reported to the family physician that you had a swollen elbow – sore and bruised as it might be, would you want an operation to treat a bone injury without a supporting x-ray?

Experts in the field of mental health are professionals in determining whether or not a set of variables suggest a mental illness.  Most mental health professionals also have access to a wealth of assessment tools that independently measure the intensity or severity of various problems – and those instruments have a history of trials that support them as valid tools (similar, and not exactly like the validity that is realized in the use of x-ray technology).  And you have a right to ask the mental health provider to (who should have completed a written assessment, with a comprehensive report that identifies a diagnosis) include in their assessment a previously published instrument to support whatever conclusions they’ve reached.

The truth is, that all mental illness diagnoses are influenced by the subjective insights of the providers who complete the assessments.  And sometimes the use of known and reliable instruments to measure the existence of a mental illness diagnosis is cost prohibitive – but – if you want an accurate diagnosis, the cost may well be worth it.  Why?  Without supporting indicators of a mental illness diagnosis, consumers can assume that the diagnosis is largely (if not entirely) based upon what is commonly known as “practice wisdom.” (7)

While practice wisdom is a necessary component in diagnosing and treating mental illness, by itself, it leaves much to be questioned.  Would you want a mental illness diagnosis to be pronounced for you or a loved one, based solely upon opinion?  It would be better to ask the mental health provider to support their clinical opinion with reputable and documented resources, so that you can be sure the diagnosis is accurate.  Without it, why should you undergo any kind of treatment, if there’s nothing but opinion to suggest a mental illness – even if the opinion is from an expert?

Once a valid assessment is completed, a diagnosis can be supported.  Mental health providers in the United States use the findings from an assessment to compare reported problem areas by clients with published mental illness criteria.  The criteria for known disorders appear in the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders. (8)

You can ask to see the criteria (right out of the DSM text) as soon as you learn that you are being diagnosed with a disorder (and you are, if insurance is being billed) and question the details of the written assessment that highlights the disorder.  If your set of symptoms is consistent with what these written assessment contains, and with what was supported via valid measurement tools, AND if those symptoms generally match the DSM criteria – you can be pretty certain that the diagnosis is accurate.  And if not?  A second opinion may be a good idea.

When a comprehensive and supported assessment leads to a diagnosis, the next step for consumers to be aware of, is that the mental health provider will likely recommend a treatment plan that will hopefully produce positive results.  Treatment plans vary based upon the disorder, and they vary based upon the type of professional you see (for more information see Choosing a Therapist previously published by Honor Cord).  A rule of thumb about treatment plans is that the best treatment plan is a written one.  And, just as in other areas of the mental health process, you can ask to see and talk about the treatment plan before agreeing to begin counseling.

Some disorders are best treated with counseling, whereas others may require medications – and yet others will require a combination of counseling and medications. (9)  If you are diagnosed with a mental illness disorder, you may want to ask to see the written treatment plan so that you have an idea of how the provider intends to treat you, how long treatment is expected to take, and to ask questions before beginning the treatment — and to agree with the treatment plan (which is also a component of the client centered practice).

Assessment, diagnosis and treatment are not simple processes – at least they shouldn’t be.  Consumers of mental health services, that is you, can expect better outcomes in care, when a standard of care exists; the kind of care that supports and/or refutes diagnosis and treatment in the first place.

NOTE:  This article does not intend to substitute for mental health counseling.  For additional counseling information, contact a licensed mental health professional.   

References

1.  Tripodi, T., & Epstein, I. (1980).  Treatment evaluation.  In T. Tripodi & I. Epstein (Eds.), Research techniques for clinical social workers (pp. 75-94).  New York:  Columbia University.

2. Rubin, A. & Babbie, E. (2001).  Research methods for social work (4^th ed.).  Belmont, CA: Wadsworth.

3.  American Psychological Association, (n.d.). The efficacy of psychotherapy. APA Online. Retrieved April 15, 2006 from the APA website: http://www.apa.org/practice/peff.html

4.  Corcoran, K. J., & Fischer, J.  (2000).  Measures for clinical practice:  A sourcebook.  New York:  The Free Press.

5.  Wickman, S. A. & Campbell, C. (2003).  An analysis of how Carl Rogers enacted client-centered conversation with Gloria.  Journal of Counseling and Development, 81(2), 178-185.

6. Ortega, A. N., & Alegria, M. (2005).  Denial and its association with mental health care use: a study of Island Puerto Ricans.  Journal of Behavioral Health Services & Research, 32, 320-332.

7.  Allen-Meares, P., DeRoos, Y. S., & Siegel, D. H.  (1994).  Are practitioner intuition and empirical evidence equally valid sources of professional knowledge?  In W. W. Hudson & P. S. Nurius (Eds.), Controversial issues in social work research (pp. 37-49).  Boston: Allyn & Bacon.

8.  American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Text revision (4^th ed.). Washington, DC: Author.

9.  Jarosewich, T. & Stocking, V. B. (2003).  Medication and counseling histories of gifted students in a summer residential program.  Journal of Secondary Gifted Education, 14, 91-102.

The references used for this article come from peer-reviewed academic and professional literature.