Clinical Assessment DSM5 Part 1

Hi, this is Dr. Diane Gehart and this is my
lecture on clinical assessment that goes with my text “Mastering Competencies
in Family Therapy,” the second edition. Well, since the publication of the second
edition, the DSM-5 has come out and so I am updating this lecture to include
DSM-5 diagnosis and you can also find the updated clinical assessment
form on as well as the Cengage website for the textbook,
if you want to start using DSM-5 right away. And this is a lecture in part– in two parts. This is the first
part that goes over the basic introduction to clinical assessment and mental
status and, in part two, we’re going to go over how to actually fill out a
clinical assessment form. So, clinical assessment is something I recommend
doing after doing case conceptualization, which is a much more theoretical
conceptualization and it’s a form of assessment, where clinical assessment is
based more on a medical model, on a psychiatric model, and it is something that
all mental health professionals need to do. And there are some real common
standards across all the mental health professions, whether you’re a family
therapist, a licensed professional counselor, a psychiatrist, a psychologist, a
psychiatric nurse, a social worker. All these different professionals who work
in the mental health– with clients in a mental health practice, have some
basic things that they need to do and these include monitoring for client
safety. And– So, often times, this kind of clinical
assessment is associated with, and some of the importance of why it’s
so standardized, is that it’s considered basic for monitoring client safety. Another big piece of this is
kind of assessing for both medical and, more importantly, psychiatric
conditions and how they relate to the treatment. And so, there’s something
that’s called mental status exam — for short, it’s called MSE — and
basically, this is an exam that can be given in many different ways in which
the clinician identifies major psychiatric symptoms that are related to the
client’s presenting problems. As part of this– Then, you make the mental
health diagnosis using the diagnostic– the DSM manual and in May 2013, a new
edition, the DSM-5, was released and we’re going to go over how that actually
affects the writing up of a diagnosis in this workshop. And then, finally,
associated with all of this is basic case management and that means getting
your clients’– clients connected up with community resources to help them
address whatever that they’re bringing to you. And so, case management can
involve– kind of connecting them with crisis services as well as evaluations
for psychiatric meds or health– health checkups, hooking them up with support
groups, working with their social workers or probation officers. Case
management is a very big thing when it– but it is part of this broader– under
this broader umbrella of clinical assessment and something that you naturally
follow up with if you identify particular sorts of problems. So, these are the
basic common things that happen and there is really a wide variety of ways in
which therapists can choose to carry out these duties and– So, we’ll talk some
about that and a lot of that has to do with the work context that you’re in. If
you’re in a hospital, in patient, versus a private practice versus an agency. And how large the agency is sometimes, these
duties are broken up where there’s one person doing diagnosis, another person
is doing case management, and another team might be working on client safety,
and in another context, the one therapist will be doing it all. And so– And in general, therapists are
expected to have a certain level of ability to do all of these things in order
to function independently, which means qualify for licensure. So we’ll be
covering those in this lecture and of course, you know, this– you’re going to
teach whole classes on each one of these topics individually. And this lecture
and my book is really just giving you more of a basic introduction, assuming
that somewhere along the line, you’re going to have a class on working with
community resources, and a class on how to do a diagnosis, and we’re just kind
of putting that all together, learning how to put that into a clinical form is
really the focus of these two lectures. So to begin, I want to just introduce
you to some contemporary issues in clinical assessment, namely the DSM-5. So
many of those controversial changes were made based on the evidence for one of
the changes that had a bit of controversy behind it was autism spectrum
disorder is a collapsing of– for other former diagnoses including Asperger
syndrome and the former autism disorder and there was some controversy but the
evidence and the research that they had collected over the years and the
general scientific consensus is that this was more of a set of symptoms across
a spectrum from mild, moderate, to severe than two distinct or four distinct
disorders and so they were collapsed. And there really needed to be a solid
research base for any of the proposed changes that we see in the DSM-5. The
other thing to note is that the DSM-5 really is an international– more of an
international document. There was much more of an international effort
in terms of putting it together. The revisions were actually a collaborative
process between the World Health Organizations and
the American Psychiatric Association and there was an international co-chair for
all of the work groups that actually drafted the new criteria. 30% of each task force needed to be
international, not American basically. And so, there was a real intentional
effort to make this document applicable across cultures and towards that end,
the new edition of the ICD — the ICD-11 — will be coming out 2015 and that is
the International Diagnostic Manual that is used for both physical and mental
health in most other countries. They use the ICD for psychiatric diagnosis
and the DSM-5 and the ICD-11 are going to be much
more correlated than any other versions of those two documents. Now, there’s been a lot of talk about the
DSM-5 and pro and con and fears and hopes and all that good stuff. And– But I
think that one of the main things that’s really important to understand when
you hear any of the discussion about any of the changes is a– really getting a
sense of the big picture in terms of where is mental health diagnosis going. And– I think this helps frame the other change–
the changes in DSM-5 so you understand what’s going on better. There is a move towards what is called
dimensional assessment. So, dimensional assessment is looking at a
particular psychological function like mood or substance
use or mood stability along a spectrum from mild, moderate, to severe and
we are familiar with this in the DSM-4. We had that for mood disorders in particular,
you know, major depressive disorder: mild, moderate, severe. We’re going to see a lot more of that in
the DSM-5 and if you read the foreword of the
DSM-5, they talk about how in general psychiatry– psychiatric diagnosis, the research
seems to be pointing us more in this direction of looking at people across
a spectrum of functioning rather than trying to have very discreet categories
that are clearly distinct. And
there is less evidence to support that– this kind of category– categorization
of mental health and mental functioning and there’s more towards this view of
dimensional assessment. And so, the DSM-5 has been significantly restructured
if you’re familiar with the DSM-4. And that restructuring is largely based on
what the evidence base says about what we understand about the etiologies of
the different disorders so they started grouping together different disorders
based on known causes and also, this is going to allow for and facilitate more
dimensional assessment as the DSM-6 and future versions roll out so this is not
going to be any radical change. I mean, this is going to be moving at glacial
speed. It’s pretty slow. But the idea here is that, you know, right
now, the research is showing us is that as you move
forward in the future, we are more likely to see mental health diagnosis that
looks like you’ve got moderate mood, you know, depressive– depression, mild anxiety,
you know, severe mood stability issues, mild substance abuse issues. But you’re going to be rating
people across several realms of functioning, several dimensions of functioning. And looking at that and even– that may even
allow for changes, you know, you might get worse in one area and better in
another. So, much more flexible
dimensional way of looking at functioning rather than saying you’re bipolar or
you’re schizophrenic or whatever that might be. So for therapists working
routinely with clients in outpatient settings, you’re doing psychotherapy,
family therapy, some of the biggest news in the DSM-5 is that the actual
diagnosis format, how you write up mental health diagnosis, has changed. In the
DSM-4, there was a five axis diagnosis system that was used and basically, with
us using, you know, studies on diagnosis and looking at interrater reliability
and such and also looking at the general evidence base for those different
axes, there was no scientific evidence to really support the use of this
five-axis system. And the new diagnosis format is just what
everyone else in medicine is using to single quote-on-quote
“diagnostic line.” And so, for this,
you would put in any diagnosis one through three, or what was on the former
axes one through three, on a single line and then, what was– used to be on
axis four is actually going to be coded on these same line– diagnostic line as
a V-code or what will soon be a Z-code — we’ll talk about that in a minute too
— as a type of a diagnosis. And for those of you familiar with axis five,
which was a global score from zero to a hundred, there is no current
replacement for this axis five, global assessment of function, the GAF score. It’s very likely that the closest thing
is what’s called the WHODAS. It’s a
disability rating scale published by the World Health Organization is the most
likely future replacement. But the WHODAS really is an assessment for
disability ratings. So there is significant change for those used
to the old diagnostic system. For those of you just learning diagnosis,
this is going to be a lot easier and you don’t even know
what you’re missing. Now, I know some
of you reading or listening to this, potentially reading the book, may not be
familiar with the DSM-4 diagnosis and even though technically, you know, we’re
all supposed to be using DSM-5 here forward, it’ll be, still be a while before,
I think, everyone has switched over to DSM-5 and in addition, you will be
reading potentially the whole files, the whole clinical reports, that include
the five-axis diagnosis system. So I think it’s important, if you’re not
familiar with this, just to briefly touch on it. The first– So in the
beginning, we have here this axis one is where you’re going to put most of your
mental health diagnoses such as major depressive disorder, adjustment disorder,
schizophrenia. Axis two diagnoses were just– it was an axis
just for personality disorders and mental retardation
so this, you know, these were mental health diagnoses but they were pulled
out because they were considered more pervasive and so, this longer exists
anymore. It would just be listed
along with all of the other diagnoses. Axis three were any medical concerns
and/or diagnoses and here you would, if you had an axis to it and you’re in a
medical environment, you’d be using ICD-9 codes. And then axis four, you wrote
out what the psychosocial stressors and/or environmental conditions or concerns
were. And as I mentioned on the former slide, the–
in the new DSM-5, many of these are included in the V-code or soon to
be Z-code section. Then for axis
five, these were where you’d put Global Assessments of Functioning or Global
Assessments of Relational Functioning and this is what they did away with and
just to give you a sense of how it worked, it’s a hundred-point scale and
basically, every ten points, they had a different criteria for that. But
basically, when you’re working in a mental health, in a general outpatient or
inpatient settings, 70 or above were considered high– fully functional, not
really eligible for insurance reimbursement. So these are more like numbers
that you would see at discharge when you’re– or termination. Then 60 to 69
were mild symptoms, 50-50 were moderate symptoms, and 40-49 were severe
symptoms, and the DSM-4 did have some criteria for trying to determine that,
although there wasn’t a lot of interrater reliability. It’s one of the reasons
they did away with this. And then 39 and below was more– There had
to be pretty significant dysfunctioning or difficulty
meeting basic needs, there were serious safety issues, and often, you were
looking at hospitalization and very close medical monitoring when you’re looking
at anything below forty. So that
was the old DSM-4 and DSM-3 five-axis diagnosis system for those of you who are
not familiar with it. So another thing that’s not necessarily
new to the DSM-5 but let’s say more prolific in the DSM-5
are subtypes and specifiers. So
subtypes are mutually exclusive subgroups within a diagnostic category and
these are going to be diagnose– diagnosis specific. There are going to be
separate numbers for each subtype so the adjustment disorders have subtypes
with different codes for each. In contrast, specifiers are much more general
and some of these new specifiers are used across several or all diagnoses and
some are diagnosis specific and you will find that they DSM-5 seems to employ
many more specifiers and the purpose of the specifier really is to alert the
clinician that there are particular clinical issues that you– to be aware of
and that these may warrant specific or unique forms of treatment. So for
example, the new conduct disorder has a new specifier that is called delimited
pro-social emotions and so what that means is that this is a more severe form
of the disorder that may need some special treatment. It’s a form of conduct
disorder where there is little empathy across relationships in context so it’s
a more severe form in that this will help researcher’s kind of organize their
research around this. It also alerts the clinician. There’s another specifier
for a mood and bipolar type disorders, which is with anxious distress, and this
is my favorite of all specifiers because there’s actually a specifier for the
specifier, which is mild, moderate, to severe, and this is to say you– when
you have someone who has maybe major depressive disorder but there are anxiety
features and you can– instead of giving them either a new anxiety disorder,
it’s kind of indicating this is a– this person has depressive episodes but
there are also pretty significant anxiety disorders going along that may need
separate or distinct or clinical attention. So that’s what specifiers are. Now,
specifiers do not get a new code or special code. They are just written out
after the name of the diagnosis to alert clinicians or members– anyone looking
at the diagnosis that there are unique features and to specify exactly what
version of the disorder that they have. So another real important thing in the
DSM-5 to know about in terms of how to write up a diagnosis is understanding
the ICD- 9 and ICD- 10 codes. So the DSM-4 has what are actually diagnostic
codes in them, that are actually correlated to the ICD-5, that is the
diagnostic manual produced by the World Health Organization for diagnosing both
physical and mental health issues. The ICD-9 codes are basically three numbers,
point, and then you got two numbers, in most all cases. These were in the DSM-4
they were also in the DSM-5 and this five digit all numeric coding system is
related to the ICD-9. Well in October 2014 the United States is
scheduled to adopt ICD-10 codes, which have been out for
quite some time. The old DSM-4
codes, which are the ICD-9 codes are no longer going to be valid for billing in
the United States. Most other countries have actually adopted
ICD-10, the US is very slow in the pickup of this, largely because
of the financial expense. We
were actually scheduled to implement ICD-10 in October 2013, but because
basically large medical systems are saying we can't make this happen, it has
been delayed a year. Now there is an ICD-11 coming out in 2015
and a lot of people are like "oh can't we just switch over
to that?' Apparently the decision
has been that no we will not be switching over to ICD-11, we're going to do the
10 in October 2014 and these codes were all included in the DSM-5, it's in grey
letters in parenthesis after all of the ICD-9 codes. Come October '14, you can
still pull out your DSM-5 and you will have the correct codes, but just know at
that point, you'll be using these alpha-numeric codes that have a letter, then
two digits, a point and usually one digit sometimes you'll get a couple digits
after that. And that's what the new codes are going to
be looking like in October 2014. OK so how you're going to write up this DSM-5
diagnosis. I just
kind of actually given you all the different pieces of information you needed
to know. So now we're going to look at what it's actually
going to look like when you put it into a form. And the form that using is the revised clinical
assessment with DSM-5 changes, that goes with the textbook, and so this is what
the prompt actually looks like. You put the code and then you're going to
write out the diagnosis with the specifier. So here's an example DSM-5 diagnosis with
ICD-9 codes. So this will be good through October 2014
or if you're looking through old files, this is what it's going
to look like. So you'll see you have
your code and then you're going to write out the diagnosis with any specifiers. So here we have major depressive disorder,
recurrent, moderate. And then here
we have the new DSM-5 specifier, the one that has the specifier with mild
anxious distress. So then you move, so you see these five numbers? These are
not access numbers; these are actually just the number for each of the
diagnosis. The second diagnosis is a PTSD so you have
the PTSD code, then it's written out Post Traumatic Stress Disorder
and then you have a specifier with delayed onset. The next two codes are V/Z codes or V codes;
we'll get to the Z codes in a moment. For the equivalent of what used to be on some
of the Gaf Scores. So here we have the V15.41 which is personal
past history of sexual abuse in childhood, and then we have this
fourth diagnosis the V50.1 is inadequate housing and that was something
that would have been on Access 4 in the past. So this is what the DSM-5 and the ICD-9 code
looks like written out. Ok so here we are, with the fabled DMS-5 with
ICD-10 codes. Ok everyone's been
waiting to see it, so this is what it's going to look like starting October
2014. Basically you'll see again here there is a
code the F33.1 major depressive disorder, recurrent, moderate with
mild anxious distress; exact same diagnosis. And the you have F43.10 is the post- traumatic
stress, and you can see there, there are some extra digits after
the point there. And then we're
going to move into Z codes. So there's a Z code for the past history of
sexual abuse and then there's a Z code for inadequate
housing. So this is the exact
same diagnosis, written out with the new ICD-10 codes. So now I also want to
touch on some other contemporary issues related to diagnoses and clinical
assessment. The DSM-5 is not the only major change in
the last few years. I
also want to talk a little bit about recovery oriented mental health and parity
diagnoses. So the Recovery Model is a relatively new
model for use in mental health, and it is parallel, many people have
heard of recovery related to substance abuse and it is a parallel movement,
it is a consumer based movement. Meaning it's led by consumers and families
with persons being diagnosed with severe mental illness, and it's an alternative
model that really focuses on facilitating and promoting the client’s
psycho-social functioning more than just treating a mental illness and reducing
symptoms. So it's very much focuses
on the functioning of the person, so whether or not they can hold a job,
maintain their relationships and live a satisfying life; rather than focusing
on whether or not we've reduced their hallucinations or bipolar mood swings. So
it is a consumer led movement that really focuses on psycho-social functioning,
more than reducing psychiatric symptoms. It is an international movement, in
fact Europe, Australia, and New Zealand are ahead of the US in the implementing
it. Officially the US Department of Health and
Human Services adopted a paradigm of recovery for all publicly funded
treatment of severe mental illness in the US in 2004 and the Recovery Model is
being implemented slowly across the US, things move slow here, glacial speed kind
of like our diagnostic codes and the metric system, it's very slow this is
slow and that just has to do with the financial funding in states like California
where there has been significant funding put behind the Recovery Model, there
is much more developed and in other states where there's much less funding,
it is still being talked about because the US Department of Health and Human
Services talks about it, but it may not be as widely implemented. So the Us Department of Health and Human
Services in 2004 actually did issue an official US definition of recovery which
is ' A journey of healing and transformation enabling a person with a mental
health problem to live a meaningful life in a community of his or her choice
while striving to achieve his or her full potential." As you can see here the
de-emphasis is on diagnostic labeling and the real focus is on promoting
psycho- social functioning, and how this may look and where this may be
different, is in the past there was kind of an assumption, well until all the
symptoms are under, you know manageable that a person should not be out looking
for a job, or you know there was also a period of time where we did a lot of
institutionalizing someone with severe mental illness and moving them away from
their communities of support and their families. And in doing so also some
would say disrupting their life unnecessarily and so the focus is instead
trying to help people diagnose with mental health problems determine how best
to live their lives, support them in achieving their goals, rather than
basically the medical mental health community defining those goals, you know
and saying things like "if you aren't taking your anti-psychotic medication, I
won't work with you.' That has been considered, at least through
this movement based on consumer reports, I mean the consumers
who led this movement were feeling very abused and that is the term that
they did use. There are
organizations about being a survivor of the mental psychiatric treatment
systems. There are some definitely strong feelings
from different perspectives. The focus here is really supporting the client
on their journey of healing, rather than us dictating what they have to
do, in order to get services. Now as
part of the official adoption of a recovery oriented approach to mental health
in the US, there were ten fundamental components of recovery that were
identified. The first is, recovery oriented mental health
treatment should promote self-direction. Meaning the clients or consumers should be
empowered to be the primary decision makers, in terms of
how they're going to approach their recovery, rather than it being dictated by
professionals and institutional policies. The treatments should be individualized and
person- centered and here they're not referring to psych person centered
therapy. They're talking about,
that the road to recovery in approach should be focusing on the whole person,
not just the illness focuses, it's person- centered versus illness-centered. These journeys should be very individualized
and focused on this person as a whole. Empowerment is very important, empowering
people diagnosed with severe mental illness to make decisions, to make
choices, to make changes in their lives and to support them in becoming independent. Another principal is
holistic view of the person, so we're looking at the whole person in terms of
their physical, emotional, spiritual, relational, whole self you know looking
at their work life and their contributions to society; meaning the whole
enchilada. Non- linear is another principal as understanding
that the road to recovery is two steps forward, one step back,
three steps to the side, and that's about how it goes and if you work with
this population that will make more sense in terms of it is not linear understanding
and for the professionals to be aware of that and working with clients
through this non-linear journey. An emphasis is really strength- based in terms
of focusing on client resources, strengths and abilities, much in the way solution
focused therapists use and base therapies would be working with clients. There is a whole component of
what's called peer support, and what this means is that people who are well on
their way to, in the recovery of mental health, so this is someone who had been
diagnosed with may schizophrenia, maybe still is, but is out holding a job, has
meaningful relationships, well connected to society. That's a peer who is but
can become a peer mentor to others starting the journey. This is something that
is used quite frequently in substance abuse, and it's also used in recovery
oriented work for mental health. There's also real emphasis and respect of
the whole person and respecting the client’s
perspective and voice desires, wishes and needs, as well as that of the families. Responsibility and there's a real
emphasis on holding a person’s diagnosis with mental illness. They are still
responsible for making good decisions in their lives for taking the lead in
their recovery. And then hope, finally there is hope and that
is in many ways, this is something also solution focused therapists
talk quite a bit about, in recovery they talk a lot about it to. In some ways it is on one of the jobs a
professional does do when they're not making all the other decisions, is
fostering hope in the client, that recovery is possible, that they do have
strengths, they do have resources and they can do it. So a lot of what the
professional ends up doing is helping the client develop a rationally based
sense of hope. You don't want to give them; you know kind
of hope that's not grounded in anything. But there is hope for people with severe mental
illness and it's important that therapists working
with this population educate themselves about outcomes and which are more
hopeful than many of us think and foster that hope in our clients. And another important development in the area
of diagnosis in clinical assessment is parity diagnosis and it's important to
understand the difference between parity and non-parity diagnosis. Parity
diagnosis refers to any mental health diagnosis that has been identified as one
that insurance companies are required to reimburse in a way that is similar to
physical diagnoses. So this is very important when you're actually
billing third party payers, in terms of whether or
not your client get diagnosed with a parity or non-parity diagnosis, because for
certain insurance companies and certain states, it's going to make a bigger
difference than others, but these diagnoses are going to be reimbursed differently
and to understand how you know what the politics around these are. Often these, and so most of the parity
diagnosis there is sufficient research to show that if these are not treated,
there are serious health implications and so that it why they've been deemed
parity diagnoses. So these typically include and each state
can work on its own specific list; anorexia and bulimia, bipolar
disorder, major depressive disorder, obsessive compulsive disorder, panic,
pervasive- developmental disorders, schizoaffective disorders and schizophrenia,
and any disorder with a child. So these are just important to be aware of
as you start doing diagnosis with third party payers. So now that you've gotten an actual introduction
to actual diagnosis, I want to take a step back
and before we go any further to also look at some of the identified, both
the benefits and potential dangers of diagnosis and clinical assessment. Family Therapists, postmodern therapists,
humanist therapists, these are three of the major schools, many of which are
talked about in this textbook that have concerns about how the diagnosis
process actually impacts the change process in the client’s identity and how
there is actually the identified dangers in the process of diagnosis that is,
it is generally required in the larger medical community so it's worth taking
some time to discuss and consider some of the pros and cons. In terms of the
benefits of clinical assessments and diagnosis, some of these are quite
apparent, which we sort of touched on earlier in this lecture, but first of
all, you know diagnosis can be helpful in identifying potential courses of
treatment especially as we have more evidence based treatments for specific
problems or specific populations. Diagnosis can be very helpful in considering
whether one of these may be appropriate. Diagnosis is also can be helpful in
understanding you know and just kind of learning clinicians, how best to keep
clients safe and or the public safe. So knowing when you have someone who’s
going to you know qualify for a major depressive disorder, that there is a
potential for self-harm and suicidal idealizations and so to consider that and
sometimes having that diagnosis kind of clues someone in ''Ah yes I should ask
these questions too.'' And then of course also diagnosis can be helpful
in determining whether or not referrals might
be needed with certain diagnoses, you might want to send them in or as part
of that process you may refer a client out for either a medical or psychiatric
assessment to help in that process and or referring out support group
services for certain disorders, it's known that you know certain types of group
work is particularly beneficial. Diagnosis can be very helpful in terms of
helping you figure out where to go and what to do, especially in terms of keeping
clients safe and connecting them with community resources. In terms of some of the potential dangers
of clinical assessments and diagnosis, there are many
critiques of the whole diagnostic labeling process and part of the problem with
the process as it is now, there isn't like a medical test that you can just
go and take to determine whether your child has ADHD or you've got major depressive
disorder. Mental health
diagnosis is almost always at least at this point, they're working on finding
bio markers for all this for as many of these as possible, but at this point
and for a while, for most mental health diagnoses require a therapist to look
at another person, to look at another human being to determine whether or not
they are normal or they are not normal. As you can imagine when you frame it
that way, there's a lot of potential ways that this can go wrong. Because every
therapist who is doing a clinical assessment is looking through their own lens
of what is normal and what is not normal. This is very much colored by our
culture, our values, our gender, our history, our beliefs, you know what part
of town we live in, who are friends were when we grew up, you know all of these
things actually come into play and there's no way for a therapist to actually
remove that lens because everything we see is actually a reflection, the words
that we use to describe another person reflect our vocabulary not that other
person's internal world, you know or even their external world. And so every,
our descriptions of people always reveal more about how we construct the world
and how that other person constructs the world. It's important for a therapist
to be aware of their biases and to continually cultivate and understanding of
their own biases so that you can hopefully minimize this and this is a very
difficult thing to do and it takes a lot of discipline. Most people are like
"well you know I'm not judgmental, I'm an open person, so I'm not you know I'm
not biased and I'll be a fair judge.'' I think the more honest you are about
this, the more subtle the more you look at the subtleties of human interaction,
this is difficult. For example, I come from an immigrant European
family my Mother is Greek and Dad is Austrian and because
of that though, we certainly have much more I would say Mediterranean type
boundaries. So that looks and
feels normal to me, that sense of people being connected and involved. So we're
looking at in terms of like structural boundaries here from structural therapy. To me, my family I think we're more fairly
healthy range, I hope. But still
more on the enmeshed side, and when I look at other families that might be
more, have a lot more distance, value a lot more independence of its members,
like they can just go have different holidays in different places. For me that
looks and feels kind of weird, you know because that's so different, you know
from my family where we get twenty people around a big table and have dinner
together. It's not a holiday unless everyone's there
and it's loud and there are people and there's food and that just,
you know, what it looks like to me. And so there can be, there's just a wide spectrum
in terms of especially how families can function and how boundaries can
be. Based on your personal
background and the other types of people you've been exposed to in your life. Another way of being healthy in the world
can look very dysfunctional to you just because of your own background. So it's very important that you
continually monitor, this is an unending process, you never get to a point, I
don't care if you're from a diverse marginalized group or not, that it is an
unending process no matter where you come from to become more and more aware of
your own biases and to reduce their effect on how you view other people. So
because of this you start looking at what you know what's normal or not normal
in terms of the diagnostic process, you're always bringing your lenses, your
experience, your values, your culture, your gender, your sexual orientation
norms to the table and it takes a lot of discipline to not have that effect
what you're seeing. Now in terms of the theories described in
this book on family therapy, systems therapists have historically
had a very distant relationship with the DSM and diagnosis and
they have actually seen that or had a lot of concerns about how diagnosing one
person that they would call the identified patient can have a negative effect
on actually the change process, especially from a systems prospective. When you diagnose someone as the problem
person has a mental health disorder, then that person's family kind of feels
like "oh we're off the hook, I don't have to do any changing because this
person, you know, my son has ADHD or my husband has depression, so it's not me,
they're the two people that need to change. I don't need to do anything." Obviously you can imagine in family therapy
sessions that's not really going to help the change process and in fact a system
family therapist would say that a person’s ''mental health disorder'' or set
of symptoms actually plays a role in maintaining the family homeostasis. Which we'll go more into detail, if you
haven't hit that chapter in the book yet. That there's a role, there's a reason
that these particular symptoms are in this particular family. And so they try
not to pathologize the person or the family, but look at how those behaviors
make sense in this system and how can we reorganize this system, restructure
this system so that those symptoms are no longer necessary. So that is how the
systemic person sees diagnosis, so their concern is you start going around
labeling people; A you make it seem more real than it is and B you make it
harder for the change process to actually happen. So the postmodern family
therapist, solution focused narrative collaborative, they also have a lot of
concerns about diagnosis and how it effects therapy, the change process and
even the identity of clients. From a postmodern perspective the problem
with using diagnostic labels is that many clients
will take this on and it actually makes the problem bigger, rather than smaller. So rather than just kind of
feeling blue or out ''oh I have major depressive disorder, oh my goodness all
the commercials on TV tell me I need to be on medicine, oh my goodness this is
a big problem, I'm going to have to work on this for a long time.'' Often it
gets people into a place where they don't connect with their resources,
strengths and abilities. They feel that the burdens actually become
heavier and that the problems even bigger and harder to
work through. So instead from a
post-modern perspective there's really a preference for client generated
descriptions of both the problem and the identity because those can be
developed in ways that they're actually is easier to solve the problem and or
to inform the more preferred identity. From a post-modern prospective,
diagnosis is a problem, because the descriptions are not coming from the
client, they're not framed in a way that they're facilitating change. In fact,
narrative therapists often use externalizing of the problem to facilitate a
problem resolution and or they use descriptions that make the problem easy to
solve. So instead of saying I'm blue and depressed,
you know I'm not doing the things that I used to do that were fun. Which ones easier to solve? Let's think
about that, so obviously the you know "I'm not doing what I used to do that
made me happy" becomes a much more solvable problem. Postmodernist are very
skeptical and can have concerns about using diagnosis in terms of the effect
that it's going to have on the client and or his or her identity and or
actually the change process itself. So where does this leave us? For trying to
think about from a general prospective as a family therapist whose most likely
working in a work context where diagnosis is used, how can you approach this
sense of competency while also being sensitive to how diagnosis might affect
the therapeutic process and client’s identities? One way to look at this is
that diagnosis becomes one of the many possible truths out there that may or
may not be useful in terms of the counseling process or the therapy process. For example, major depression might be one
way to describe what’s going on with the client and they also, being sad or blue
might be another descriptor and or the client you know might find that saying
" you know I'm not doing what I used to do and that's the problem." Using diagnosis but seeing it not as you know
I must construct all my therapy and interventions
around this diagnosis. That is
one of many possible ways to describe what’s going on and to explore whether or
not that description is useful. Because there are times where I've worked
with clients most notably with post-traumatic stress
disorder, a lot of clients find that a liberating diagnosis to know that "oh
I'm not totally insane and crazy" and that this is, you know and you talk about
and look at the prognosis for PTSD it's actually much better than most people
would think, given how severe the symptoms can be. So often times some people do find diagnosis
liberating. And so to see diagnosis as a voice in a conversation
rather than a dictator of the therapy process. Looking at how these truths and understood
how contextualized by the webs of relationships
and social discourse around what clients are talking about. What does depression mean or anxiety mean
in a particular family or culture? How are they understanding those symptoms
from their cultural background, from their family
traditions or whatever that might mean? And to look at what is the most useful way
of understanding what's going on. This can allow for a range of possible in-session
uses and possible ways to describe the problem and finding one that
fits with the particular client and from how they're seeing things that the family
is seeing things from a cultural prospective as well as looking from the theoretical
prospective, how best to conceptualization what’s going on. And so for a general to kind sum up as a
family therapist, diagnosis is one of many descriptions rather than the driving
force behind the treatment. So next I want to talk a little bit about
formal and informal clinical assessment. So ways to go about conducting your clinical
assessment. So in terms of looking at written clinical
assessments, there are some, these are pen and paper tests that are
standardized, they're generally considered to be more accurate and they can
be especially useful when you have more severe, multiple symptoms, you're trying
to make a differential diagnosis. And or if clients haven't been responding
to treatment. You can use these
written assessments to help you with these sorts of circumstances and there are
many formal assessments such as the MMPI which is typically not used in
outpatient treatment. Something more like a Beck Depression Inventory
or the MAST for your alcohol screening. There's several different types of these
written assessments. However, there's actually no clear link necessarily
to improved outcomes by using some of these measures. But many therapists non the
less find them helpful in terms of helping them make differential diagnosis,
making their you know, doing their clinical assessment. I think you also want
to consider whether or not these forms are kind of facilitating you when you
work. If you're working from an approach where you,
you know want to avoid the labeling of one person as the identified patient,
then these may not be helpful. That's something to also consider. Another thing to consider is
whether or not the instrument you're using is actually normed for the
population you're using it on. So if you work with very diverse clients,
you may need to consider whether or not you need
to research whether or not those particular instruments you hoped to use are
actually appropriate. Now in terms
of pen and paper measures that are available there is a brand new set, and
there are quite a few of them that come with the DSM-5, this is something
that's totally new that with the DSM-5 the American Psychiatric Association has
made available on their website and also on the
website, these several assessment instruments. The most important which for our
diagnosis process is the cross cutting assessments. Cross cutting symptoms are
symptoms that are relevant to most psychiatric disorders such as insomnia,
mood, anxiety, irritability. These sorts of things and there are also adult
measures and child measures. These cross cutting symptoms measures are
broken into a level one measure, which is the first
level and then there's level two measures. In the level one measure is basically assesses
adults in 13 domains and children for 12. It's relatively brief there's only 1-3 questions
and I think it's 36 questions in all, symptoms for
each domain and these just give the clinicians a broad view as to what are
the areas that the client and what domains of functioning is the client having
some problems. This allows the
clinician to get a good sense of where to ask more questions and follow up. The
level one measures is something that you would give to your clients you know
before they walk in for their first session with their big stack of intake
paperwork and you can give them this level one measure and use it in your
initial assessment sessions to get a sense of what might be going on clinically
with them. Although these are certainly not required,
they are optional measures that are published through the APA,
it's likely that many insurance companies or other agencies will be using
these more widely in the future. We've never had anything quite like it, but
the expectation is that these will become more widely used. In terms of the actual domains, here you can
see the adult level one cross cutting symptom domains. Depression, anger, mania,
anxiety, somatic symptoms, suicidal ideation, psychosis, sleep, memory which is
not on the children's list, repetitive thoughts and behaviors that would go
with OCD, dissociation which is not on the children's, personality functioning
which is not on the children's and substance abuse. For the child level cross
cutting symptom domains, you have somatic symptoms, sleep, inattention which is
not on the adult, depression, anger, irritability which is not on the adult,
mania, anxiety, psychosis, repetitive thoughts and behaviors, substance use,
and suicidal ideation and attempts. These are the general domains of
functioning and of course there are different instruments for children versus
adults. Now in addition to pen and paper measures,
a lot of clinicians or I guess virtually all clinicians also rely on
what is a more informal clinical assessment. These are going to be more self-reported and
these can be both either and or verbal where the therapist is
kind of adapting these written, if they're written to kind of collect things
in a language that fits more with your theoretical approach, yet covers some
of the clinical issues. These more
informal assessments can be more appropriate with diverse clients because you
can adapt them. They are obviously less expensive, there is
less time required, but the cons of these types of more informal
instruments and or interviews is that you may not capture more subtle clinical
issues. In a large measure their
effectiveness is determined by therapist’s skill. And of course the self-report
of client may not be as accurate and so that's also something to be
considering. I just want to mention here because the book
cover this in more detail, that when you're going to verbally
be talking to clients about clinical assessment or doing a clinical assessment
verbally, is really helpful if you can try to integrate it with whatever theoretical
orientation you plan to be using primarily in working with the client. In the book I have identified
specific questions whether you're working from a systemic or postmodern
approach that actually uses you know techniques within those theories to help
gather clinical information. So if you're working from a systemic approach
you can use the techniques for mapping out the
interactional sequence around the problem to identify clinical symptoms. So typically, when you're doing mapping out and assessing interactional sequence you know for person A says or does this, then person B does this, A responds, B responds and then we check into see how C D and F respond. So as you map out whose doing what you can ask about so what are the thoughts and feelings, what are the moods, what are the behaviors. And to also ask about the clinical types of symptoms that are involved around the sequence of behaviors around the problem. Also using circular questions can be very helpful. Circular questions are used by systemic therapists. These can be comparative questions in terms of you can be comparing moods or behaviors, rank ordering moods and behaviors, thoughts, those sorts of things. So this is detailed in the book, but I just wanted to draw your attention to it. Similarly if you're working from a postmodern approach there are certain interventions that can be used to also get a clinical assessment while still working within identifiable techniques and the kind of spirit of your theoretical mo del. In narrative therapy there's something called mapping the influence of persons versus problems and this is a great way to get a ton of clinically relevant information for making a diagnosis while still moving forward and working as a narrative therapist. So when you map the influence of the problem and look at all the ways the problem has effected the person’s life and relationships and so in asking these questions you can ask about mood, thoughts, behaviors, relationships and how their functioning in all the different realms and then you can map the influence of the person, so how does the person influence the symptoms and the problems and so to ask about you know, and then you get a sense of the severity of the problems in terms of how the person is able to actually manage their symptoms. This is, these ways are like I said are described in more detail in the book and it's a way to do a clinical assessment that's going to resonate and be more true to the, some of the theoretical models described in the book. This is the end of the part one and I will be going into part two which will show you how to step by step fill out a generic clinical assessment form.


  1. This information was broken up nicely. I'm preparing for my licensure exam which as you know us now including DSM-V. Thank you so much for posting this video!

  2. you have helped me to understand the dsm 5 .. with its limitations and strengths.  You have helped me to know when to use them as well as, what specifiers are.  I am more confident now that I have watched.  Thank you so much, will be watching more of your videos.  Thanks again

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