On Being a Student Therapist: Making a DiagnosisWe’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.

19 Comments to
On Being a Student Therapist: Making a Diagnosis

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  1. It is interesting to read that non-medical professionals, including those in training, are allowed to diagnose mental illnesses there. Here in the UK, only fully qualified medical doctors can do so; GPs are allowed, but for anything beyond mild depression or anxiety, they prefer to leave it to consultant psychiatrists.

    In my view therapists / psychologists are actually much better placed than physicians to make diagnoses. At least here, they spend much, much more time with clients than doctors do and tend to be at least as informed about the range of disorders. I wish therefore that the NHS would adopt a similar policy to parts of the US!

    Interesting article – thank you. Best wishes.

  2. I am a longtime therapy patient with a variety of issues.

    I will tell you that I doubt there is any need to inform your client of a possible diagnosis.

    -you’re not sure that it’s true
    -it definitely affects the way a person sees themselves
    -various issues and diagnostic criteria are hardly written in stone (look at the massive recent changes in this area.

    It’s probably enough for you to keep this diagnosis AS A POSSIBILITY in your own mind, and use it as a possible way to understand your client and his/her sensitivities, and as a way to reach out to this person.

    For example, there is no need to tell a person that you think they might have BPD, but you might use that possible diagnosis to say something like “It does feel really awful when people go away, doesn’t it?”

    Do you see what I mean? Talk to your supervisor about this of course, but really– what would you be trying to accomplish by telling this person your idea of their possible diagnosis? And is there another, gentler and more constructive way to do this?


  3. Kate,

    I work with the general population though I have worked with specific types such as the dual diagnosed and also folks with somatoform disorders. At least with my current clients, I have found that I best help them by not giving them a diagnosis that will slot them for life and therefore hurt them. I do not accept insurance so I don’t have to produce a DSM Coded designation. I’m glad about that. Why? Because I’ve seen how giving an incorrect or simply a stigmatic label creates big problems for the client/patient in the future. I’ve seen how a young man was thrown out of becoming a US Naval Academy Cadet despite having formal acceptance and the backing of his Congressman. The Feds found an obscure insurance claim where the clinician had diagnosed the person as having Attention Deficit Disorder when he was a small child.

    These days, if I have to, I use the Generalized Anxiety Disorder category as a typical catch-all for most issues folks in the general population go through. Some of my colleagues have criticized the DSM as simply a device that is designed for insurance companies. I wonder sometimes.

    I wish you success in your journey.

    Samuel Lopez De Victoria, Ph.D.
    http://www.DrSam.tv

  4. Please avoid saddling this person with a diagnosis. In itself, the diagnosis can only hurt her. If there are particular techniques that are useful for the diagnosis you’re considering, and having that diagnosis in your head helps YOU, there’s no reason not to go ahead and use those techniques. Thank you for recognizing the responsibility of your position here and its capacity for causing serious life-long damage. In my case, I feel that the harm of a diagnosis (based on the fact that my long-time therapist has confirmed that I’ve since exhibited no signs of this or any other disorder, likely a mis-diagnosis)I was given several years ago has far outweighed any “help” I’ve received from mental health professionals.

  5. As a psychologist, I am well-learned in the dangers of making a diagnosis (i.e., stigma, being wrong, are diagnoses real? etc.) However, this is the client’s treatment, not the therapist’s. The client is coming with trust and is expecting an open and honest relationship. It is paternalistic to suggest that the client should not know about the opinion of the individual she is seeing for professional help. If the therapist can deliver the information to the client about the diagnosis, as well as communicate the dangers of a diagnosis, this can greatly aid in treatment planning, self-understanding, and would enrich the relationship. The therapist must simply present the diagnosis as a hypothesis. Therapists do not have a right to keep relevant information from their clients. It’s unethical.

  6. Coming from the perspective of a patient:

    Diagnoses serve a purpose. They lead to correct treatment. I’ve often heard that “if the treatment works, the diagnosis doesn’t matter.” It does to a point. Treatments can vary depending on diagnoses, and when the patient needs to change providers (which is inevitable), the diagnosis will serve as a guide for treating that individual.

    That said, diagnoses should not be an identity. There is a chance that your patient will use the diagnosis as such. We all go through that. It’s a phase, and we outgrow it.

    As for what other people will do with the diagnosis – it’s unfortunate that there is still a stigma behind mental illnesses. For most people, it doesn’t destroy their lives. There are a lot of successful people that have been diagnosed with something. It’s not the end of the world.

  7. While I see Dr. Sam’s point, I think it’s not a luxury a student therapist has (to *not* make diagnoses). Student therapists are expected to learn the modern diagnostic system and diagnose their patients appropriately.

    I’m more in agreement with Anna — diagnoses serve an important, but sometimes over-emphasized, need. They allow professionals to talk about a specific disorder and all be “on the same page” about what that disorder looks like, symptom-wise.

    The problem comes in, as Anna noted, when patients (or therapists, or both) decide that the diagnosis is the end of therapy. “Oh, you’re depressed, well, let’s just get you on an antidepressant and that’ll be it.” Diagnoses are not identities, yet too many people use them as such.

    They are simply labels meant to help therapists and patients better understand the concern that is being addresses in psychotherapy. They say nothing about causes or specific treatments, all of which must still be tailored to the individual.

  8. Providing the correct diagnosis to clients can arouse a great deal of anxiety, especially for students who are being exposed to a particular symptom pattern for the first time. This is exactly why we are required to have licensed supervisors and why we are not allowed to provide a diagnosis without their approval.

    There are several relevant issues here such as whether diagnosis even matters as well as whether clients should be informed about their diagnosis. While I agree with Dr. Sam about the dangers of mislabeling an individual, a correct diagnosis can be very useful in helping a multidisciplinary team to conceptualize the struggles that an individual copes with in addition to deciding how best to approach treatment.

    There is also the problem that Dr. Sam appears to be knowingly providing people with a misdiagnosis of Generalized Anxiety Disorder regardless of their presenting problem. Not only is this ethically questionable, but it can have negative implications as well. Imagine the confusion this would cause for anyone who works with the client after Dr. Sam and sees a chart with only GAD on Axis I. Even if you assess that the client’s anxiety appear to revolve around fantasies of persecution and delusions of grandeur, you might be more inclined to second-guess your clinical opinion and make an error in formulating a treatment plan.

    As for how clients react to learning of their diagnosis, the results are not surprisingly mixed. Imagine telling a client that you are diagnosing them with Antisocial Personality Disorder. The attitudes and behaviors associated with the diagnosis are usually ego-syntonic, so the client might not even bat an eye. But imagine having to tell an older adult that they have dementia that will progressively worsen. One study found that most of these individuals welcomed the information while 25% felt upset after receiving the news (Jha, Tabet, & Orrell, 2001).

    The main thing to remember is that the diagnostic label is not the center of the conversation with your client. Instead, talking about the maladaptive patterns of behavior and cognition associated with the disorder and how it is impacting the individual’s functioning in the world can be very beneficial. Concrete examples can help to illustrate your point. Perhaps most important is that diagnosis affects how you approach treatment, and talking about these issues with the client can help in formulating a plan and setting mutual goals for treatment.

    Reference:
    Jha, A., Tabet, N., & Orrell, M. (2001). To tell or not to tell: Comparison of older patients’ reaction to their diagnosis of dementia and depression. International Journal of Geriatric Psychiatry, 16, 879-885.

  9. When I was eleven years old, the DSM-IV defined Asperger’s for the first time, opening the autism diagnosis for people who learned speech on time. My mother, an occupational therapist who worked with autistic people, knew I should have been diagnosed, but refused to have me evaluated and would not tell me about her suspicions. Instead, she took me out of school and tried to “cure” me through diet and discipline. I was told over and over that I wasn’t trying hard enough, that I was being lazy and irresponsible and a badly-behaved little brat. I tried my best. At nineteen, I burned out and ended up having to stay in a hospital psych ward twice. Not long afterward, a psychiatrist finally clued me in to the diagnosis that should’ve been made years ago.

    A diagnosis is a tool. You use it because it’s a set of traits that generally follow a certain pattern and develop in a certain way and respond to certain treatments. You also use it to tell people, “Hey, this is not a moral failing. You are not alone. There are people who have the same thing, and there are known solutions to these problems.”

    Thanks to my much-delayed diagnosis, I was able to do a lot of research and talk to people who had found solutions to the same problems that I was dealing with. I was able to get away from the idea that my disability was something I could get rid of if I “tried harder”. I am now living on my own and in college. If I had known earlier, I might have spent my teen years learning these things and made it at 18; but it is better late than never.

    Not knowing about a diagnosis is almost universally harmful. If you don’t know about it, you can’t deal with it. Sure, you might escape thinking you’re defective (stupid mental illness stereotypes); but it’s just as damaging to think you’re a moral failure who doesn’t try hard enough.

    I learned this in physics class, oddly enough: You cannot solve a problem unless you define all your terms first. Know exactly what you are dealing with, and gather all the equations involved. A diagnosis is the same way. You need to define the problem before you can learn to work with whatever weird brain you’ve got and go about your life successfully.

  10. I’ve never minded receiving a diagnosis myself or talking one over with a therapist.

    The only thing that bugged me was my very initial contact with the psychiatric profession, where, upon seeing cuts on my arms, the doctor said “Well, I’d say BPD, hm?”, gave me a prescription for olanzapine and out of the office I was. No answers, just a smug: “You’re not stupid, are you, just read up on it.”

    Every therapist I’ve seen since (and it took me a long, long time to gather the courage) agrees that it is bull***t, yet the dogged BPD diagnosis keeps following me in my file and I usually spend the first time seeing a doctor, any doctor, with convincing him/her that I am not there because I didn’t get along with the previous one but have, indeed, moved cities, etc. (And no, I am not trying to get any prescriptions and no, I am not lying to you, and no, I don’t come to manipulate you, I come because I am sick.) It feels a little disheartening at times.

    So, Kate, by all means, please discuss the diagnosis. With your patient. Talk it over. I for one would have appreciated someone like you, someone I could have asked, someone who would listen before I get stuck with a label that pretty much I don’t care for but that keeps following me all the same.

    I don’t mind diagnoses, I don’t even mind the BPD diagnosis, inapplicable as it is. I do mind how it makes others behave towards me. And some diagnoses, to my experience, are worse than others.

  11. I hope some of your reservations come from informing yourself on just how poor inter-rater reliability and validity is for the disorders described in the DSM.

  12. Oh also, I seriously question the practice of writing psychiatric diagnoses in a patient’s medical file and/or transferring said diagnosis without the expressed written permission of the patient. For insurance purposes, the doctor should consult the patient on what code they think would be appropriate and provide as little info as possible (only one disorder, even if they have several). Excluding cases of psychosis maybe. Most diagnoses change over time anyway and some of great stigma attached to them.

  13. I’ve seen harm come from both NOT diagnosing and diagnosing a client. First, I agree that you as a student therapist should NOT be diagnosing a client, certianly not formally. Your best course of action I think would to be say to the client “you have symptoms of x or xyz behavior” and refer them to a specialist or at least a more experienced mental health professional for treatment of that problem. And of course educate them as much as you can and see what their thoughts are on it. Depending on what it is, you may want to have them fill out a simple questionnaire. My therapist did that with me and it helped tremendously.

    She eventually diagnosed me with OCD (and a slew of other things). She is an anxiety specialist. I am grateful that someone finally realized that I had OCD, but it certainly added more complexities to my life. I mean, I had just found out that I had had OCD for 8 years and didn’t know it! I began to realize what effect it had on my life and see myself differently. What’s more is that I had learned to cope so effectively, we hardly needed to treat it at all. But still I am glad to have that sorted out. However, in my particular case, I meet criteria for a slew of other things and I don’t think 5+ “diagnoses” helps the client, even if no one else finds out.

    Both as a client and a potential future therapist, I think diagnoses can be important in some situtions and should not be avoided entirely. I think some of these situations are:

    -In the case of Bipolar Disorder, OCD, (severe) Autism, Schizophrenia and other serious, chronic disorders that need to be treated in a specific way. In fact, I think it’s unethical not to tell them. Even If it just means telling them they have signs of the disorder, if you think the client or the client’s family will react very badly to the diagnosis. (BTW, I think personality disorders are bunk and probably shouldn’t be diagnosed. Borderline also has a VERY bad stigma associated with it)

    -When the client has Major Depression, substance abuse, Panic disorder, other anxiety disorders, and doesn’t realize they have a “serious” problem.

    -When the client asks for a diagnosis.

    (I am still angry at the therapist who told me my recurrent severe Major depression was “some seasonal depression” leading me to believe I should be able to handle in on my own and that I didn’t have a serious problem. This led to another 18 months of depression and some poor treatment choices, until my current therapist was finally “real” with me.)

    I hope my perspective helps. Of course the individual client’s beliefs and knowledge need to be taken into account as well.

  14. Not sure what happened to my other comment…Hope this isn’t a double post.

    I’ve seen harm come from both NOT diagnosing and diagnosing a client. First, I agree that you as a student therapist should NOT be diagnosing a client, certianly not formally. Your best course of action I think would to be say to the client “you have symptoms of x or xyz behavior” and refer them to a specialist or at least a more experienced mental health professional for treatment of that problem. And of course educate them as much as you can and see what their thoughts are on it. Depending on what it is, you may want to have them fill out a simple questionnaire. My therapist did that with me and it helped tremendously.

    She eventually diagnosed me with OCD (and a slew of other things). She is an anxiety specialist. I am grateful that someone finally realized that I had OCD, but it certainly added more complexities to my life. I mean, I had just found out that I had had OCD for 8 years and didn’t know it! I began to realize what effect it had on my life and see myself differently. What’s more is that I had learned to cope so effectively, we hardly needed to treat it at all. But still I am glad to have that sorted out. However, in my particular case, I meet criteria for a slew of other things and I don’t think 5+ “diagnoses” helps the client, even if no one else finds out.

    Both as a client and a potential future therapist, I think diagnoses can be important in some situtions and should not be avoided entirely. I think some of these situations are:

    -In the case of Bipolar Disorder, OCD, (severe) Autism, Schizophrenia and other serious, chronic disorders that need to be treated in a specific way. In fact, I think it’s unethical not to tell them. Even If it just means telling them they have signs of the disorder, if you think the client or the client’s family will react very badly to the diagnosis. (BTW, I think personality disorders are bunk and probably shouldn’t be diagnosed. Borderline also has a VERY bad stigma associated with it)

    -When the client has Major Depression, substance abuse, Panic disorder, other anxiety disorders, and doesn’t realize they have a “serious” problem.

    -When the client asks for a diagnosis.

    (I am still angry at the therapist who told me my recurrent severe Major depression was “some seasonal depression” leading me to believe I should be able to handle in on my own and that I didn’t have a serious problem. This led to another 18 months of depression and some poor treatment choices, until my current therapist was finally “real” with me.)

    I hope my perspective helps. Of course the individual client’s beliefs and knowledge need to be taken into account as well.

  15. I’ve seen harm come from both NOT diagnosing and diagnosing a client. First, I agree that you as a student therapist should NOT be diagnosing a client, certianly not formally. Your best course of action I think would to be say to the client “you have symptoms of x or xyz behavior” and refer them to a specialist or at least a more experienced mental health professional for treatment of that problem. And of course educate them as much as you can and see what their thoughts are on it. Depending on what it is, you may want to have them fill out a simple questionnaire. My therapist did that with me and it helped tremendously.

    She eventually diagnosed me with OCD (and a slew of other things). She is an anxiety specialist. I am grateful that someone finally realized that I had OCD, but it certainly added more complexities to my life. I mean, I had just found out that I had had OCD for 8 years and didn’t know it! I began to realize what effect it had on my life and see myself differently. What’s more is that I had learned to cope so effectively, we hardly needed to treat it at all. But still I am glad to have that sorted out. However, in my particular case, I meet criteria for a slew of other things and I don’t think 5+ “diagnoses” helps the client, even if no one else finds out.

  16. Both as a client and a potential future therapist, I think diagnoses can be important in some situtions and should not be avoided entirely. I think some of these situations are:

    -In the case of Bipolar Disorder, OCD, (severe) Autism, Schizophrenia and other serious, chronic disorders that need to be treated in a specific way. In fact, I think it’s unethical not to tell them. Even If it just means telling them they have signs of the disorder, if you think the client or the client’s family will react very badly to the diagnosis. (BTW, I think personality disorders are bunk and probably shouldn’t be diagnosed. Borderline also has a VERY bad stigma associated with it)

    -When the client has Major Depression, substance abuse, Panic disorder, other anxiety disorders, and doesn’t realize they have a “serious” problem.

    -When the client asks for a diagnosis.

    (I am still angry at the therapist who told me my recurrent severe Major depression was “some seasonal depression” leading me to believe I should be able to handle in on my own and that I didn’t have a serious problem. This led to another 18 months of depression and some poor treatment choices, until my current therapist was finally “real” with me.)

    I hope my perspective helps. Of course the individual client’s beliefs and knowledge need to be taken into account as well.

  17. I think that you has a student therapist have a obligation to tell the client your suspicions and refer them to a place that they can get a proper diagnosis and treatment for their possible condition. However, I don’t think you should “diagnosis them officially” without more experience. Also, I think a better way of saying: I am new at diagnosing, but I think you might have x disorder” is to say “I think you might be showing signs/having symptoms of x disorder. This is why…”. and then start the discussion from there. From the prespective of a patient or client, starting off by saying “I’m new at this, but I believe you have x disorder etc,” sounds like you are just guessing and that there is little chance that I actually have the disorder. This could create treatment problems. However if the client agrees with you, then that’s great.

    For another perspective and example:
    I am happy that my current therapist finally recognized and diagnosed me with OCD. Which I had had for 8 or 9 years and didn’t know it! It added a new level of complexity and was certainly a shocking piece of new to deal with, but I think I would have figured it out eventually, and better now than later. Plus, it definitely aided in treatment decisions and I joined an online community for people with OCD. It was great to hear people with similar experiences. In order to make this diagnosis, I was interviewed by 2 psychologists with expertise in Anxiety disorders (my therapist and the director of the clinic) and filled out a long questionnaire that detailed what symptoms I had. This was at the beginning of treatment at this clinic. Now, I don’t doubt the diagnosis at all (except now it went into remission). I only wish it was made earlier.

    How did this work out? I am curious for an update.

  18. The diagnostic approach to understanding people has profound implications for treatment. Most broadly, it does not involve the therapist in really getting to know the patient. It interferes with understanding one as a whole person, ignoring the larger context of their life and experience. When someone focuses exclusively on diagnostic criteria – the ‘symptoms’ – they become nothing more than a pathological entity. They are not merely a bundle of ‘symptoms.’ These diagnostic categories serve the pharmaceutical industry and the insurance industry more than patients.

  19. don’t call your patients clients plz

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