T
he concept of formulating and completing a diagnostic assessment is richly embedded in the history of mental health practice (Ahn &Kim, 2008; Dziegielewski, 2010). The desire to master this process has been strengthened by its necessity for practice reimbursement (Dziegie- lewski, 2013). Therefore, all mental health prac- titioners need to become familiar with the major formal methods of diagnostic assessment, espe- cially the ones used and accepted in health and mental health service delivery. This chapter out- lines the issues that contribute to the hesitancy and reluctance to determine what constitutes a mental disorder and how the termsdiagnosisand assessmentrelate. If these two terms are seen as a dichotomy, obvious difficulty in practice focus and strategy may result. The purpose of this chapter is to explore the relationship between diagnosis and assessment and to introduce a more comprehensive term, the diagnostic assessment.
The diagnostic assessment describes a combina- tion approach that utilizes the meaning inherent in each term.
Once the terms are clearly defined, the infor- mation gathered during the diagnostic assessment becomes central for identifying and classifying mental health disorders, as well as reporting this information systematically to insurance compa- nies for reimbursement. In completing the diag- nostic assessment, factors such as race, ethnicity, culture, and gender can affect the diagnostic impression derived. With the rapid changes related to globalization, culture has become so embedded in the human experience that
separating it out is almost impossible (Pare, 2013). Recognition of this supporting informa- tion is essential to ensure the comprehensive diagnostic assessment that is vital for high-quality care. The information gathered through a com- prehensive diagnostic assessment can also be uti- lized to understand the client and, in turn, better help the client understand himself or herself. Once completed, the diagnostic assessment becomes the foundation for identifying problem behaviors that will be utilized in establishing treatment plan considerations, as well as the best course of inter- vention for a particular client. Because mostfields of practice utilize the DSM as the basis of the formal diagnostic assessment system, this text focuses on this classification scheme.
UTILIZING THEDSM-5IN THE PRACTICE SETTING
In the United States, most health and mental health practitioners use theDSMto classify men- tal health problems. However, as described in Chapter 1, the DSM, which was originally designed for statistical and assessment purposes, does not suggest treatment approaches. This makes the DSM essential as a starting point for determining the nature of a client’s problem, as well as providing supportive information on prev- alence rates within the larger population to inform policy decisions. Thus, the book is valuable for clinicians, practitioners, and researchers. For researchers, the interest lies in understanding the 23
etiology and pathophysiology of the disorders;
for clinicians, the focus remains on the immediate and pragmatic, such as identifying clinically sig- nificant symptoms that affect human behavior and functioning (Nunes & Rounsaville, 2006).
TheDSMdoes, however, fall short on treatment strategy and options. Therefore, supportive books are required to address this important aspect of comprehensive, efficient, and effective care. In addition to the information provided in theDSM- 5, practitioners need to be familiar with the latest and most effective forms of treatment and practice strategy based on relevant diagnostic criteria.
Professional Use: Who Can Use theDSM-5?
TheDSM-5states clearly that it was designed to be used in a wide variety of settings, including inpatient and outpatient settings and consulta- tion and liaison work. Furthermore, theDSM-5 was designed for use by professionals, not as a self-help book for the lay public. The DSM is very complex and could overwhelm a client unfamiliar with the technical jargon. Therefore, use by the lay public is discouraged. Historically, the role of the professional is to interpret the diagnostic criteria, inform the client, and work with the client on what the best course of action would be.
TheDSM-IV-TR and DSM-5 both clearly state this philosophy, although Paris (2013) ques- tions it. He believes that clients have a right to know their own diagnoses and that the more they know, the more they are empowered to participate in self-help strategies. Also, with the Internet and other forms of information so read- ily accessible, clients often actively gather infor- mation related to their own mental health. This supports the notion that clients should not be kept unaware of their diagnoses and the contri- buting criteria. To do this creates a disservice that forces them to be passive consumers of their own
health and mental health care. Most practitioners would agree wholeheartedly that client partici- pation in their own health care is essential, so why not their own mental health care? Argu- ments that theDSMis very complex and could overwhelm a client unfamiliar with the technical jargon have been questioned, and active client participation has become expected (Paris, 2013).
This active involvement is confirmed by the use of technology. Many clients are savvy in using the Internet to look up information, and it makes sense that they would not hesitate to look up information related to their own health and mental health needs, as well as those of family members. Unfortunately, this opens up the client to information that may or may not be accurate, adequate, or entirely relevant to his or her situation. Or clients may be in a compromised cognitive position that does not allow them to fully integrate this information. To further com- plicate this picture, the Internet is such an open venue that the information gained may not be reputable and may be misleading or confusing to the client or his or her family. Although DSM information is designed for the professional, when questioned about a diagnostic assessment and information is shared with the client, pro- fessional awareness and support are essential for the best treatment outcomes.
In certain types of therapy, it is not uncommon to share diagnostic information with the client. For example, in some cognitive behavioral approaches, a client may be presented with a list of criteria reflecting the symptoms of a diagnosis and asked which ones he or she has.
Once self-identified, how to behaviorally address the symptoms may be the next step. From this, a treatment plan with a clear practice strategy related to how to either control the symptoms or avoid them may be implemented. Therefore, regardless of whether the DSM is designed for professionals, client-initiated interactions related to this information may occur. Knowing how to
best handle this situation for the client and his or her family members is an important part of the therapeutic process.
This book is designed for professional prac- titioners who use theDSM-5,including psychi- atrists and other physicians, psychologists, social workers, occupational and rehabilitation thera- pists, and other health and mental health pro- fessionals. Although they may all have different training and expertise, they still are expected to use this categorical and dimensional approach by applying clinical skill and judgment to achieve similar determinations. These professionals need to be trained in how to use this categorical and dimensional approach and be aware of its poten- tial for misuse before putting it into practice.
Special care and consideration are necessary to protect the rights of clients while identifying issues to be addressed to ensure client benefit and progress.
WORKING AS PART OF A TEAM:
CONNECTIONS AND COLLABORATIONS
Serving as part of a team, social workers and other mental health professionals have a unique role in the assessment and diagnostic process. Most pro- fessionals agree that a comprehensive diagnostic assessment starts with taking into account the complexity of the human condition and situa- tional factors that affect behavioral health (Pear- son, 2008). As part of a collaborative team, the mental health professional gathers a wealth of information regarding the client’s environment and family considerations. The practitioner also needs to remain aware that whether taking a leadership or supportive role, all efforts must resonate with the culture of the team (Conyne, 2014). Therefore, the practitioner can serve as the professional bridge that links the client to the multidisciplinary, interdisciplinary, and
transdisciplinary teams and the environment (Dziegielewski, 2013).
The term multidisciplinary can best be explained by dividing it into its two roots,multi anddiscipline. Multimeans“many”or“multiple”; disciplinemeans“the field of study a professional engages in.”When combined, professionals from multiple disciplines work together to address a common problem. In health care settings, multi- disciplinary teams were part of a cost-effective practice response to the shifts from institutional care to community and home care through the delivery of specialized services (Rosen & Callaly, 2005). This type of team collaboration may also improve patient care outcomes (Burns & Lloyd, 2004). The multidisciplinary team is often recog- nized as a preferred form of service delivery, especially in complex health and mental health service delivery systems (Orovwuje, 2008). Multi- disciplinary teams include health and social welfare professionals from various disciplines: psychiatrists, physicians, nurses, social workers, physical thera- pists, occupational therapists, and so on.
When serving on a multidisciplinary team, each member has a distinct professional role and refers to other professionals in the same or other agencies in a loose yet semistructured manner.
Each professional generally works indepen- dently, sometimes in isolation, to solve the problems and related needs of the individual.
At the same time, the professionals share what is learned about the client to improve treatment progress and overall team concerns. A key fea- ture of multidisciplinary teams is participants’ network-style group interaction (Rosen &
Callaly, 2005), in which the boundaries within professional disciplines are maintained, with each providing a perspective of the client’s problem to address key features in the delivery of care. This process of patient care planning provides a com- prehensive method of service delivery for the client. In multidisciplinary teamwork, “a team manages its resources collectively according to
client needs or along professional discipline boundaries” (Whyte & Brooker, 2001, p. 27).
Communication and goals are consistent across disciplines, with each contributing to the overall welfare of the client. (See Quick Reference 2.1.) In the current mental health care system, which stresses evidence-based practices and out- comes to measure quality, multidisciplinary approaches are limited in meeting the current standards of care secondary to their structural makeup and style of approach to service delivery.
Measurement is difficult when the interpretation of the stated goals and how to best achieve them differs among varied professionals. These profes- sionals are all committed to working together to help the client, but in this type of teamwork, there may be different approaches and expect- ations for what is considered high-quality care and how to best achieve it. And while commu- nication is evident, cohesion in multidisciplinary teams is not always feasible in service delivery, especially with normal differences in world- views, professional identities, salaries, status, atti- tudes, and educational backgrounds (Carpenter, Schneider, Brandon, & Wooff, 2003; Lankshear, 2003). The multidisciplinary team is still often used to provide services from a team perspective in mental health care, yet a more collaborative and integrative approach, known as the inter- disciplinary team approach, is gaining in popu- larity (Dziegielewski, 2013; Molodynski &
Burns, 2008; Rosen & Callaly, 2005).
Similar to the multidisciplinary team, the interdisciplinary team includes a variety of health care professionals. An interdisciplinary approach takes a much more holistic approach to health care practice.“An interdisciplinary team in a modern mental health service brings specialist assessments and individualized care together in an integrated manner and is the underlying mechanism for case allocation, clinical decision-making, teaching, training and supervision and the application of the necessary skills mix for the best outcomes for service users” (Rosen & Callaly, 2005, p. 235).
Interdisciplinary professionals work together throughout the process of service provision. Gen- erally, the entire team develops a plan of action.
This type of teamwork involves a collaborative coordination of care; team-related activities, such as treatment planning; and shared leadership and power (Zeiss & Gallagher-Thompson, 2003).
In service provision, the skills and techniques that each professional provides often overlap.
Interdependence is stressed throughout the referral, assessment, treatment, and planning pro- cess rather than through networking. This is different from the multidisciplinary team, where assessments and evaluations are often completed in isolation and later shared with the team.
Boundaries in the formation of interdisciplinary teams are often blurred. In the interdisciplinary team process, each professional team member is encouraged to contribute, design, and imple- ment the group goals for the health care service QUICK REFERENCE 2.1
Multidisciplinary Teams
A group of professionals working together for a common purpose, working independently while sharing information through formal lines of communication to better assist the patient/client/consumer.
Definition fromThe Changing Face of Health Care Social Work: Opportunities and Challenges for Professional Practice (3rd edition), by S. F. Dziegielewski, 2013, New York, NY: Springer (p. 35).
to be provided (Dziegielewski, 2013; Mezzich &
Salloum, 2007).
Within the interdisciplinary team, each mem- ber may also supervise each other’s work—a key difference from multidisciplinary teams, in which each member is measured and supervised inde- pendent of each discipline and agency (Rosen &
Callaly, 2005). Interdisciplinary teams can facili- tate high-quality care by gathering participatory information related to the analysis of the client’s problem. A variety of multidisciplinary skills are available that work in a mutual and reciprocal educational fashion and produce viable and demonstrable results. This allows implementation and problem-solving capabilities that encourage collaboration among providers to decrease and avoid isolation and to generate new ideas.
(See Quick Reference 2.2.)
The transdisciplinary team is similar to the interdisciplinary team in that it also has a variety of health care professionals. The primary differ- ence is the degree of openness between the team members, with all openly sharing information and participating in the client-helping strategy.
With this holistic approach to practice, all of a client’s health and mental health needs are treated together, and case allocation and clinical decision making, teaching, training, and super- vision are done collaboratively as a team. This is more common in health care but may continue to gain in importance as the need for more collaborative teamwork grows. (See Quick Reference 2.3.)
Regardless of the type of team utilized, multidisciplinary, interdisciplinary, or trans- disciplinary mental health professionals should QUICK REFERENCE 2.2
Interdisciplinary Teams
A group of health care professionals who work together for a common purpose, working interdependently where some degree of sharing roles, tasks, and duties can overlap with both formal and informal lines of communication to better assist the patient/client/consumer.
Definition fromThe Changing Face of Health Care Social Work: Opportunities and Challenges for Professional Practice (3rd edition), by S. F. Dziegielewski, 2013, New York, NY: Springer (p. 35).
QUICK REFERENCE 2.3 Transdisciplinary
Teams
A group of health care professionals and the patient/client/
consumer and identified members of his/her support system freely share ideas and work together as a synergistic whole where ideas and sharing of responsibilities are commonplace in routine care.
Definition fromThe Changing Face of Health Care Social Work: Opportunities and Challenges for Professional Practice (3rd edition), by S. F. Dziegielewski, 2013, New York, NY: Springer (p. 35).
always emphasize client skill building and strength enhancement. A team approach helps to build satisfaction among members and pro- vides leadership enhancing satisfaction among all team members (Baran, Shanock, Rogelberg, &
Scott, 2012). If client needs are addressed from this perspective, each team member will be well equipped to contribute accordingly to the diag- nostic assessment, supporting the development of the treatment plan, which will guide and determine future service delivery. Attending to the dynamics of the team collaboration as well as the contributions each team member makes can only lead to enhanced service delivery (Packard, Jones, & Nahrstedt, 2006). These types of col- laborative teams can be utilized in service deliv- ery and provide fertile ground for understanding how service delivery can be unsuccessful when fragmentation occurs (Bunger, 2010).
DIAGNOSIS AND ASSESSMENT:
IS THERE A DIFFERENCE?
Identifying a Mental Disorder
Diagnostic assessment starts with defining what constitutes a mental disorder. The terms consist- ent with problematic behaviors within a mental disorder include distress and disability leading to a harmful dysfunction, abnormality, or aberra- tion (Cooper, 2004; Kraemer, Shrout, & Rubic- Stipec, 2007). From a biological perspective, a medical disorder is generally defined as a biolog- ical or evolutionary disadvantage to an organism that interferes or reduces the quality of the life span orfitness (Lilienfeld & Landfield, 2008). Few would disagree that a clear definition can help to guide decisions that determine the boundary between normality and pathology (American Psychiatric Association [APA], 2013). Clearly defining the criteria for a mental disorder is no simple task while taking a strengths perspective
that respects the worth and dignity of each client (Corcoran & Walsh, 2010). Similar to the prob- lems that occur in trying to identify a medical disorder, the actual criteria can be subject to individual interpretation by the client as well as by the provider. For the client, self-reporting of symptoms can be confused by what the client thinks he or she is experiencing and what is actually happening. From the perspective of the practitioner, using a categorical approach to defin- ing symptoms indicative of a mental disorder can also lead to differences. Experienced practitioners can have very different interpretations on how symptoms are identified and what they believe meets the criteria for the diagnosis (Rashidian, Eccles, & Russell, 2008).
When starting with the definition of what constitutes a mental disorder, it is important to note the distinction between disorder and disease (Kraemer, Shrout, & Rubio-Stipec, 2007). Mak- ing this distinction plays a fundamental part in determining whether a disease or a disorder is present in the individual. According to Cooper (2004), making a distinction between these two terms is not easy because related disciplines continue to challenge what constitutes a mental disorder. Furthermore, there is disagreement about how using the taxonomy of categoriza- tions within theDSMinfluences the subsequent diagnostic process. As early as the DSM-II, a condition was considered a disorder when the condition influenced role formulation and appli- cation of the diagnostic impression. Factors iden- tified focused on distress or disability. Starting with the publication of the DSM-III, the term disorder was used interchangeably with the term disease. Regardless of the term used, disease or disorder, it relates directly to harmful, dys- functional behavior from an evolutionary psy- chology perspective (Cooper, 2004). To simplify the definition most often used today, it appears that disease indicates a known pathological pro- cess; a disorder may be two or more separate
diseases, but generally there is a pathological process that is either known or unknown.
For medical professionals, especially those working in primary care, the difficulty in identi- fying a mental disorder rests within the diagnos- tic impression and the variability among professionals in identifying characteristics, traits, and behaviors relative to the disorder (Mitchell, Vaze, & Rao, 2009). Because identification and recognition rates can vary, the actual presence of a mental disorder can be difficult to ascertain, leading to incidents where professionals either over-report or under-report these symptoms. In addition, the flexibility within formulating the diagnostic impression leads to the question of what exactly is the diagnostic impression? And is the formulation of the evaluation completed by the mental health professional more accurately termeddiagnosis orassessment?
When we look specifically at terms like disease and disorder in mental health practice, confusion results when the two terms are not considered distinct. In such cases, the concepts inherent in each tend to blur and overlap in application. This is complicated further by the multiplicity of meanings of the terms used to describe each aspect of what a client is experi- encing and whether it is related to a disease or a disorder. The imprecision of definitions can result in applied social, personal, and professional interpretations in health and mental health prac- tice that are varied rather than uniform. Like problems with defining disease and disorder, the debate on what to call the outlining of a client’s mental health problems, such as diagnosis or assessment, continues. In today’s practice envi- ronment, it is not uncommon to use these words interchangeably (Dziegielewski, 2013; Dziegie- lewski & Holliman, 2001).
Concrete definitions for all these terms and for their relationship to each other facilitate the diagnostic process. Practitioners must be careful not to be too quick in categorizing an individual’s
problems, which may result in diagnostic bias and an inaccurate diagnostic label. The symptoms with which an individual may present for treat- ment may differ, based on numerous variables, including psychological, social, cultural, and envi- ronmental circumstances.
Diagnosis and the Diagnostic Process It is easy to see how the actual definition, criteria, and subsequent tasks of assessment and diagnosis are viewed as similar and overlapping, thereby creating a shared definition. Rankin (1996) believed that in most cases, if viewed separately, the assessment has been considered to come before the diagnosis. Most would agree that completing a psychological assessment provides a process by which the client’s functioning is catalogued. From this perspective, the practi- tioner examines important aspects of individual functioning, such as cognitive, emotional, and psychological strengths and weaknesses (Wright, 2011). The psychological assessment is then the initial building block on which the diagnosis is established. In other cases, the diagnosis is his- torically thought to include both an assessment and a diagnosis. Regardless of whether health or mental health practitioners truly subscribe to or support the distinction between the termsassess- ment anddiagnosis,awareness of the difficulty in trying to separate these two terms and define their uniqueness continues. One commonly accepted definition of diagnosis in the field of social work is in The Social Work Dictionary (Barker, 2003):
Diagnosis: The process of identifying a problem (social and mental, as well as medical) and its underlying causes and formulating a solution. In early social work delineation, it is one of the three processes, along with social study and treatment. Currently, many social workers prefer to call this process