On Being a Student Therapist: Making a Diagnosis
We’re back from spring break, and the push to the end of the semester is on. Depending on who you ask, we either have seven weeks left (the university calendar), or approximately 35 more drives to campus (my personal calculation). Now that I’ve gotten over the hump of juggling six clients who needed to be seen four times each in five weeks’ time, seeing eight clients who need to be seen at least four times each in seven weeks’ time sounds like a piece of cake!
During my supervision session prior to break, I expressed frustration to my supervisor about a client who had asked to continue counseling beyond her class requirement. I questioned this client’s commitment to counseling and whether her problems were significant enough to warrant additional sessions, especially since I had been assigned six new clients, and therefore, continuing counseling with this client would mean extra work for me. My supervisor reminded me that I had been very excited to work with this client initially, and gently encouraged me to keep working with her for a few more sessions.
Then my supervisor did her job: she suggested that my client might have a serious disorder, one I hadn’t even considered, or honestly, would have even occurred to me on my own. Since I knew basically nothing about this particular disorder, I decided to take my supervisor’s suggestion under consideration and do more research while on break.
So I did. I looked online for information, read the DSM-IV-TR criteria, talked with my mentor, emailed a fellow Psych Central blogger about her articles on this topic, and ordered, received and read an entire book about the disorder. I now feel much more educated, enough so that I feel like I would be able to have an informed discussion with my client about a potential diagnosis.
Diagnosis is a tricky, controversial subject. I have several reservations about it, including my lack of experience in making diagnoses (I’m in the diagnosis class currently, and we have not covered this disorder yet) and whether having a diagnosis helps or hurts a client, especially since once a diagnosis is in a medical file, it’s there permanently and can have profound effects for a client’s future. Even though we’re a training clinic, our clinic director told us a story about a former client applying for an FBI position, and having to turn over the client file for a background check. At this stage of the game, given my level of experience, I don’t want that responsibility on my shoulders.
Of course, once I have a discussion with my client about my thoughts, she may tell me I’m full of it, and that will be the end of the discussion. (Maybe. Client denial is a topic for another post.) But what if she says, “Yes, that’s me!”? I can’t anticipate what comes next: “I’m so glad to know I’m not alone and what can we do about it?” or “And so you’re telling me I’m defective?”
So here I am at a crossroads. Now that I think I have a name for my client’s expressed feelings and behaviors, I want to share them with her and formulate a plan to help relieve her distress, based on the empirical treatments for her problem. On the other hand, I fear making the problem worse by subscribing to the medical model for addressing her issues and “labeling” her. Also, I only have four sessions left with her, and if she indeed does have this disorder, it won’t be resolved by then. She would need to see someone in the community to continue treatment, therefore carrying this diagnosis beyond a month’s time and outside of a training clinic.
Thinking ahead to being in professional practice in the real world, I had only briefly thought about what I would do if a client seemed to clearly fit a diagnosis. There are some behavioral disorders that seem to be fairly clear-cut, although that’s probably an inaccurate statement in itself. In this case, diagnosing a disorder that is more about cognitive functioning feels much more subjective. In addition, this particular client also seems to have a very mild form of the disorder I have in mind, which makes diagnosing it feel even more precarious. I fear damaging the relationship if the client tells me I’m wrong.
However, I wonder if, after I present my hypothesis and share what the usual symptoms of this disorder are, she will disclose further symptoms that she either hasn’t thought to share or was too embarrassed to share previously. Will this be a breakthrough in our relationship and work together, giving us direction and purpose that was starting to elude us?
Despite my reservations, this is my time to experiment. I think by prefacing the conversation with “I am new to making diagnoses, but after talking with my supervisors and doing research, I think you might have [this disorder]. I’d like to share what I’ve learned with you and see what you think,” would help soften any potential blow. I very much want to make this a dialogue between the two of us. That way, not only will I get feedback about whether my clinical judgment was correct, I can learn about the effect of having a diagnosis.
I realize every client will react differently to receiving a potential diagnosis, but I can’t learn what happens if I don’t try. I feel comforted by having the backing of my supervisor, the safety net of still being a student, and knowing that I have done research, so this is not just me taking a risk for the sake of having the experience. My intentions are pure and good, and my desire is to help this client to the best of my ability. If having a diagnosis to help shape our time together is the way to do that, then that’s the direction we’ll go.
Thieda, K. (2010). On Being a Student Therapist: Making a Diagnosis. Psych Central. Retrieved on April 19, 2015, from http://psychcentral.com/blog/archives/2010/03/19/on-being-a-student-therapist-making-a-diagnosis/