Assessment and Diagnosis “Under the Gun”

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CHAPTER

Diagnosis and 10

Treatment

Planning

CHAPTER OBJECTIVES

From the perspective of the medical model, the primary—and sometimes

only—purpose of a clinical interview is to identify an appropriate diagnosis

and treatment plan. In this chapter, we look at philosophical and practical aspects

of diagnosis; we also review several approaches for developing treatment plans for

counseling or psychotherapy clients.

After reading this chapter, you will understand:

• Basic principles of psychiatric diagnosis, including the definition of

mental disorders according to the Diagnostic and Statistical Manual

of Mental Disorders, 5th Edition (DSM-5; American Psychiatric

Association, 2013).

• Common problems associated with assessment and diagnosis.

• Methods and procedures for diagnostic assessment.

• A balanced approach for conducting diagnostic clinical interviews.

• An integrated or biopsychosocial approach to treatment planning.

• How to identify client problems, associated goals, and establish a

treatment plan to guide the therapy process.

• The importance of matching client resources with specific approaches

to clinical treatment.

PRINCIPLES OF PSYCHIATRIC DIAGNOSIS

In 1993, Frank and Frank wrote: “We propose to group those who receive psychotherapy

into five rough categories: the psychotic, the neurotic or persistently

disturbed, the shaken, the misbehaving, and the discontented” (p. 11). This is

an example of one of many formal and informal diagnostic systems that exist

for grouping individuals with mental health problems. These systems may be as

simple and intuitive as Frank and Frank’s (1991) or as complex as the fifth edition

of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) The DSM-5

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330 Part Three Structuring and Assessment

now includes nearly 300 mental disorders in its 947 pages (American Psychiatric

Association, 2013).

The revision process for the DSM-5 has been nothing short of amazing. We

mean this in at least two ways; the effort has been amazing: “ ... hundreds of people

working toward a common goal over a 12-year process” (American Psychiatric

Association, 2013, p. 5). And the politics have been amazing. Originally planned

for publication in May, 2011 after significant delays related to many factors,

including conflicts of interest among work group members, it was finally released

at the American Psychiatric Association annual meeting in San Francisco on

May 18, 2013. Along the way, there were strong letters of protest from many

constituents, much gnashing of teeth, and wailing of the sort that can only happen

on the Internet. To help capture the controversy, here’s a short excerpt from a

Psychology Today article written by Allen Frances, MD, former chair of the DSM-IV

Task Force and professor emeritus at Duke University.

This is the saddest moment in my 45 year career. ... The ... American

Psychiatric Association has... [approved] ... a deeply flawed DSM-5 containing

many changes that seem clearly unsafe and scientifically unsound.

Despite criticisms the DSM has been and will likely continue to be the

authoritative diagnostic guide for North American mental health professionals.

The first edition was published in 1952; the second, in 1968; the third, in 1980; a

revision of the third edition, in 1987; the fourth edition in 1994; and in 2000, a

text revision of DSM-IV (DSM-IV-TR). Even with so many editions and extensive

review, psychiatric diagnosis remains controversial. As Widiger and Clark (2000)

claimed of the DSM-IV: “There might not in fact be one sentence within DSM-IV

for which well-meaning clinicians, theorists, and researchers could not find some

basis for fault” (p. 946). But, of course, the DSM-5 has outdone the DSM-IV

both in terms of complexity and controversy. This controversy has already led to

extensive discussion, debate, and publication within the mental health professions.

For example, as of February 1, 2013, there were over 300 professional publications

listed on PsycINFO with the word “DSM-5” in the title ... despite the fact that

the 5th edition of the DSM wouldn’t be published for another 3 months.

Disputes surrounding psychiatric diagnosis and the concept of mental disorders

run so deep that the DSM-IV-TR and ICD-10 both include explanations or

disclaimers for why the term “mental disorder” is used. The DSM-IV-TR contained

a brief but articulate section titled “Definition of Mental Disorder.” In this

section, the DSM authors admitted they have produced a manual for diagnosing

a concept that lacks an adequate operational definition:

... although this manual provides a classification of mental disorders, it

must be admitted that no definition adequately specifies precise boundaries

for the concept of “mental disorder.” The concept of mental

disorder, like many other concepts in medicine and science, lacks a

consistent operational definition that covers all situations. (American

Psychiatric Association, 2000, p. xxx)

Interestingly, although the DSM-5 continues to use the term mental disorder (and

not mental illness), this time around the authors refrained from commenting on

the reasoning behind this choice.

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Chapter 10 Diagnosis and Treatment Planning 331

As we discuss diagnostic interviewing strategies in the following pages, be

forewarned that you are venturing into only partially charted waters. Nonetheless,

as scientists and professionals, we believe it’s a fascinating journey, filled with

adventure, intrigue, and more than an occasional unresolved dispute.

Defining Mental Disorders

From your own experiences you probably recognize that it’s often difficult to

draw a clear line between mental disorders and physical illness. When you become

physically ill, sometimes it’s obvious that your stress level, lack of sleep, or

mental state has contributed to your illness. Other times, when you’re distressed

psychologically, your physical condition can contribute to a disturbed emotional

state and thinking processes (Jakovljevic, 2006; Witvliet et al., 2008). The difficulty

distinguishing between mental and physical problems was acknowledged in the

DSM-IV-TR:

A compelling literature documents that there is much “physical” in

“mental” disorders and much “mental” in “physical” disorders. The

problem raised by the term “mental” disorders has been much clearer

than its solution, and, unfortunately, the term persists in the title of

DSM-IV because we have not found an appropriate substitute. (American

Psychiatric Association, 2000, p. xxx)

Despite ongoing quandaries over what to call mental disorders, and whether

mind or body is the primary contributor to such disorders, it’s safe to say that the

DSM-5 contributors have identified numerous important cognitive, emotional,

and behavioral problems or deviances that exist in many people throughout the

world. These mental conditions or mental disorders produce immense suffering,

conflict, and distress in the lives of millions. Without a doubt, and no matter

what we call them, mental disorders are frequently identifiable and have clear and

adverse effects on individuals, couples, families, and communities.

The DSM-5 remains a primarily descriptive and categorical system. This

means it provides descriptions of symptom sets associated with specific diagnoses

and that individuals are classified as having or as not having psychiatric

diagnoses. Although the DSM-5 has been reorganized to reflect developmental

and dimensional issues in psychopathology it has not moved significantly away

from a categorical approach: “Despite the problem posed by categorical diagnoses

the DSM-5 Task Force recognized that it is premature scientifically to propose

alternative definitons for most disorders” (p. 13).

In its introduction, the DSM-5 offers a general definition of mental disorder:

A mental disorder is a syndrome characterized by clinically significant

disturbance in an individual’s cognition, emotion regulation, or behavior

that reflects a dysfunction in the psychological, biological, or developmental

processes underlying mental functioning. Mental disorders are

usually associated with significant distress or disability in social, occupational,

or other important activities. (American Psychiatric Association,

2013, p. 20)

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332 Part Three Structuring and Assessment

The DSM-5 also includes information about what is not a mental disorder:

An expectable or culturally approved response to a common stressor or

loss, such as the death of a loved one, is not a mental disorder. Socially

deviant behavior (e.g., political, religious, or sexual) and conflicts that

are primarily between the individual and society are not mental disorders

unless the deviance or conflict results from a dysfunction in the individual,

as described above. (p. 20)

Not surprisingly, significant vagueness in the DSM-5 definition of mental

disorder remains. If you go back and read through the DSM-5 definition of mental

disorder several times, you’ll find substantial lack of clarity. For example, there’s

plenty of room for debate regarding what constitutes “a clinically significant

disturbance.” Additionally, how can it be determined if human behavior “reflects a

dysfunction in the psychological, biological, or developmental processes underlying

mental functioning” (p. 20)? Further, the manual recognizes that “an expected

or culturally approved” behavioral response is not a mental disorder, but doesn’t

provide any guidelines for making this judgment (this is an example of a universal

exclusion criterion, as discussed in Chapter 6).

Over the years the DSM system has received much criticism for being vague,

subjective, and political (Eriksen & Kress, 2005; Horwitz, 2002; Horwitz &

Wakefield, 2007). As a historical example, Szasz (1970) wrote:

Which kinds of social deviance are regarded as mental illnesses? The

answer is, those that entail personal conduct not conforming to psychiatrically

defined and enforced rules of mental health. If narcotics-avoidance

is a rule of mental health, narcotics ingestion will be a sign of mental

illness; if even-temperedness is a rule of mental health, depression and

elation will be signs of mental illness; and so forth. (p. xxvi)

Szasz’s point is well taken. After all is said and done, DSM’s general definition

of mental disorder and the criteria for each individual mental disorder consist

of carefully studied, meticulously outlined, and politically influenced subjective

judgments. This is an important perspective to keep in mind as we continue down

the road toward clinical interviewing as a means for psychiatric diagnosis and

treatment planning.

Why Diagnose?

Like Szasz (1970), many of our students want to reject the entire concept of diagnosis.

They’re critical of and cynical about the DSM, or they believe that applying

diagnoses dehumanizes clients by affixing a label to them and then ignoring their

individual qualities, what Morrison (2007) has referred to as pigeonholing. Whatever

their arguments, our position regarding diagnosis remains consistent. We

empathize with our students’ complaints, commiserate about problems associated

with diagnosing unique individuals, criticize the many examples of inappropriate

diagnostic proliferation (e.g., bipolar disorder in youth), but we continue to value

the teaching and learning of diagnostic assessment strategies and procedures,

justifying ourselves with both philosophical and practical arguments.

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Chapter 10 Diagnosis and Treatment Planning 333

Philosophical Support

No matter what we call them, mental disorders exist. As far as we know, emotional

distress, mental suffering, character pathology, and suicidal behavior have existed

from day one. Psychiatric diagnosis is designed to classify or categorize mental

disorders based on specific defining characteristics. Knowledge about mental

disorders, their similarities, differences, usual course and prognosis, and prevalence

helps mental health professionals provide more appropriate and more effective

treatments. Such knowledge is reassuring and empowering to therapists who want

to help clients. Additionally, this knowledge base guides research on preventing

mental disorders.

Practical Support

There are a number of positive practical outcomes of accurate diagnosis. A

diagnosis is a consolidated, organized description of client symptoms. Arriving

at this shorthand description requires careful observation and inquiry. After the

best diagnosis is obtained, clinicians can communicate with other professionals,

insurance or managed care companies, and other interested parties.

At best, a diagnosis is a working hypothesis. It forces clinicians to bring

together disparate pieces of the puzzle and tentatively name a cluster of symptoms.

It then suggests a general course of action that, if pursued, should yield somewhat

predictable responses. It lays the groundwork for planned interventions and

informed use of theory and technique.

In addition to enabling professional communication and hypothesis testing,

a final positive and practical aspect of diagnosing is this: Sometimes, a label is a

huge relief for clients. Clients come for help with a confusing and frightening

symptom set. They may feel alone and uniquely troubled. They may feel no

one else in the world has ever been so dysfunctional, odd, or anxious. It can

be a big relief to be diagnosed, to have your problems named, categorized, and

defined. It can be comforting to realize that others—many others—have reacted to

trauma in similar ways, experienced depression in similar ways, or even developed

similar maladaptive coping strategies (such as irrational thoughts or damaging

compulsions). The wise clinician realizes that diagnosis can imply and instill

hope (Frank & Frank, 1991; Pierce, 2004; Mulligan, MacCulloch, Good, &

Nicholas, 2012).

Specific Diagnostic Criteria

In contrast to establishing a satisfactory general definition for mental disorders,

identifying a DSM diagnosis for a particular client may seem, on the surface,

rather straightforward. After all, psychiatric diagnosis is based on a process

where clinicians determine the presence or absence of various symptom clusters

(i.e., syndromes). In most cases, the DSM-5 provides specific, more or less

measurable criteria for its diagnoses. Typically, DSM diagnoses are characterized

by a symptom list for defining the condition. For example, to qualify for generalized

anxiety disorder, individuals must meet the criteria in Table 10.1.

The diagnostic criteria for generalized anxiety disorder illustrate challenging

tasks associated with accurate diagnosis. First, based on criterion A, diagnostic

interviewers must establish whether a given client is experiencing “excessive”

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334 Part Three Structuring and Assessment

Table 10.1 Diagnostic Criteria for Generalized Anxiety

Disorder (DSM-5: 300.02)

This table is a summary and adaptation of the DSM-5 diagnostic criteria for

generalized anxiety disorder. For the actual criteria, you should consult the

DSM-5 (American Psychiatric Association, 2013, p. 222).

A. The client has “excessive anxiety and worry” that occurs “more days than not

for at least 6 months”and pertains to “a number of events or activities.”

B. The client has difficulty controlling the anxiety or worry.

C. Three or more of the specific symptoms listed below are present and linked to

the anxiety/worry

A. feeling restlessness or “keyed up or on edge”

B. feelings of fatigue that come on easily

C. blank mind or problems with concentration

D. “irritability”

E. “muscle tension”

F. problems sleeping

D. The preceding symptoms “cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.”

E. The symptoms aren’t caused by a substance or a medical condition.

F. The symptoms aren’t “better explained by another mental disorder.”

anxiety and worry, how frequently the anxiety is occurring, how long the anxiety

has been occurring, and how many events or activities the individual is anxious

or worried about. This information relies on the interviewer’s ability to gather

appropriate symptom-related information and the client’s ability to articulately

report symptom-related information. In addition, obtaining information required

by criterion A involves interviewer and client subjectivity (i.e., the determination

of what constitutes “excessive”).

Second, under criterion B, interviewers must assess how difficult clients find

it to control their worry. This information requires an evaluation of client coping

skills and efforts, which essentially involves asking questions about what clients

have tried to do to quell their anxiety and how well these coping efforts have

worked in the past.

Third, and perhaps the most straightforward diagnostic task, interviewers

must identify whether clients are experiencing specific anxiety-related symptoms

(see Table 10.1). Unfortunately, even this apparently simple task is fraught with

complications, especially in cases where clients are motivated to either overreport

or underreport symptoms. For example, clients seeking disability status for an

anxiety disorder may be motivated to exaggerate their symptoms, and clients

who desperately want to remain in the workplace may minimize symptoms.

Consequently, along with questioning about these specific anxiety symptoms,

the interviewer must stay alert to the validity and reliability of the client’s

self-reported symptoms (Feinn, Gelernter, Cubells, Farrer, & Kranzler, 2009;

Gilboa & Verfaellie, 2010; J. Sommers-Flanagan & Sommers-Flanagan, 1998).

Fourth, to label an individual as having generalized anxiety disorder (GAD),

interviewers need considerable knowledge of other DSM diagnostic criteria.

Eleven other diagnoses that may need to be ruled out are listed in GAD criterion F.

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Chapter 10 Diagnosis and Treatment Planning 335

An interviewer needs to have working knowledge of many other diagnostic criteria

to assign or rule out a GAD diagnosis. Obviously, this is no small task; it requires

lengthy education, training, and supervision.

Fifth, criterion D requires interviewers to determine whether reported anxiety

symptoms cause “clinically significant distress or impairment in social, occupational,

or other important areas of functioning.” Criterion D is the distress and

impairment criterion. Although this criterion is essential for diagnosis, it is also

inherently subjective. Nowhere in DSM-5 is a clinically significant impairment

defined.

Sixth, based on criterion E, before establishing a definitive diagnosis, interviewers

need to determine whether the anxiety symptoms are caused by exposure

to or intake of a substance, or a general medical condition. Substances and medical

conditions need to be ruled out as causal factors in virtually every DSM-5

diagnostic category.

Overall, the GAD example illustrates a range of tasks and issues with which

diagnostic interviewers must grapple. The reality is that, based on the DSM’s

diagnostic paradigm, a psychiatric diagnosis is seated within the context of a

unique individual. Indeed, if it were not for unique individuals and their confusing

variability in reporting their personal experiences and their confounding and

confusing motivational and interpersonal dynamics, psychiatric diagnosis would

be a simpler process.

Assessment and Diagnosis Problems

To determine if a client meets the diagnostic criteria for GAD, interviewers must

determine whether the client has three of six symptoms from criterion C. Given

this fact, it may be sufficient (and justifiable) to directly ask the client a series of

specific DSM-5–generated questions pertaining to generalized anxiety disorder.

For example, the following questions could be asked:

1. Over the past 6 months or more, have you felt restless, keyed up, or on edge

for more days than not?

2. Over the past 6 months, have you felt easily fatigued more often than not?

3. Over the past 6 months, have you noticed, on most days, that you have

difficulty concentrating or that your mind keeps going blank?

4. Over the past 6 months, have you felt irritable at some point on most days?

5. Over the past 6 months, have you found yourself troubled by muscle tension

more often than not?

6. Over the past 6 months, have you had difficulty falling asleep, or have you

found that you regularly experience restless or unsatisfying sleep?

Using this simple and straightforward diagnostic approach may, in some

circumstances, produce an accurate diagnosis. However, in reality, accurate diagnostic

assessment is considerably more complex. As suggested from constructive

critiques of psychiatric diagnosis and differential activation theory, the preceding

practice of asking six consecutive negatively worded questions focusing on anxiety

may adversely affect the patient, the patient’s mood, the working alliance, and

consequently diagnostic reliability and validity (Eriksen & Kress, 2005; Lau, Segal,

& Williams, 2004).

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Further, in DSM-5’s introductory section, it is emphasized that diagnostic

criteria should not be applied in a check-list manner:

The case formulation for any given patient must involve a careful clinical

history and concise summary of the social, psychological, and biological

factors that may have contributed to developing a given mental disorder.

Hence, it is not sufficient to simply check off the symptoms in the diagnostic

criteria to make a mental disorder diagnosis. (American Psychiatric

Association, 2013, p. 19)

Before moving on to a detailed description of diagnostic assessment strategies

and procedures, we identify several specific problems associated with establishing

an accurate diagnostic label for individual clients:

Client deceit or misinformation: Clients may not be straightforward or honest

in their symptom descriptions (Feinn et al., 2009; Jaghab, Skodnek, &

Padder, 2006). Even in cases when they are honest, they may have

difficulty accurately describing their symptoms in ways that match DSM

criteria. In addition, if you gather information from individuals other

than clients (e.g., from teachers, parents, romantic partners), you may

obtain invalid information for many different reasons. In fact, research

indicates that when children, parents, teachers, and others rate the same

individual, their interrater agreement is generally low (Rothen et al.,

2009). Despite this fact, obtaining diagnostic-related information from

parents and other available informants remains essential.

Interviewer countertransference: When using a diagnostic interview, you may

lose your objectivity and/or distort client information. This may occur

partly because of countertransference (Aboraya, 2007). For example, if

a client triggers a negative reaction in you, you may feel an impulse to

“punish” the client by giving a more severe diagnostic label. Similarly,

you may minimize psychopathology and associated diagnoses if you like

your client.

Diagnostic comorbidity: In many cases, clients qualify for more than one

DSM diagnosis. In fact, with regard to children, diagnostic comorbidity

occurs more often than not (Samet & Hasin, 2008; Watson, Swan, &

Nathan, 2011). This comorbidity problem makes sorting out appropriate

diagnostic labels even more difficult.

Differential diagnosis: Although some clients report symptoms consistent with

more than one diagnostic entity and are appropriately assigned two or

more diagnostic labels, other clients report confusing symptom clusters

requiring extensive questioning for diagnostic clarity. For example,

it’s notoriously difficult, albeit important, to discriminate some diagnoses

from others (e.g., mood disorder with psychotic features versus

schizoaffective disorder versus schizophrenia versus delusional disorder).

Despite difficulties sorting out these various disorders, diagnostic speci-

ficity is important because of treatment implications (i.e., medication

type, treatment approach, hospitalization, prognosis).

Confounding cultural or situational factors: in the DSM-5 it is acknowledged

that culture and context will influence diagnosis: “ ... The boundaries

between normality and pathology vary across cultures for specific types

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Chapter 10 Diagnosis and Treatment Planning 337

of behaviors.” (p. 14). Consequently, your diagnostic task includes a

consideration of your clients’ individual social, cultural, and situational

contexts when providing diagnoses, which is not always an easy task

(Hays, 2008).

Given these problems, many therapists and researchers advise using what has

been referred to as “multimethod, multirater, multisetting assessment procedures”

(J. Sommers-Flanagan & Sommers-Flanagan, 1998, p. 191). This means that,

under ideal circumstances, diagnosticians gather a broad spectrum of diagnosticrelated

information from (a) various assessment methods (e.g., clinical interview,

behavior rating scales, projective assessments); (b) various raters (e.g., parents,

teachers, clinicians, and/or romantic partners); and (c) various settings (e.g., school,

home, clinician’s office, work).

DIAGNOSTIC ASSESSMENT: METHODS AND PROCEDURES

After this brief taste of diagnostic interviewing problems and tasks, you may

feel overwhelmed. Learning diagnostic interviewing assessment procedures is a

formidable challenge. However, amazingly, many mental health professionals

have learned to use the DSM system with sensitivity, precision, and grace. Doing

so requires tenacity, rote learning, patience, and balance.

A number of methods are available for gathering diagnostic-relevant information,

including diagnostic interviewing, social/developmental history, questionnaires

and rating scales, physical examinations, behavioral observations, projective

techniques, and performance-based testing. Because this book is on interviewingbased

approaches, our discussion focuses on diagnostic interviewing.

Diagnostic Interviewing

There are two basic forms of diagnostic interviews: semistructured and structured.

They’re defined as:

[A] semistructured interview typically includes a predetermined set of

questions followed by either unplanned questioning or a free response or

exploration period. (Sommers-Flanagan et al., 2014, in press)

[A] structured clinical interview is a tightly managed protocol or process

wherein clinicians ask a systematic series of predetermined questions,

including follow-up questions. In this approach there is little or no

opportunity for unplanned or spontaneous questioning by clinicians

and little or no spontaneous exploration of diverse topics by patients.

(Sommers-Flanagan et al., 2014, in press)

Many published diagnostic interviewing procedures exist, most of which are

based on the DSM-III-R or DSM-IV diagnostic criteria. Determining an appropriate

diagnostic label is the primary or exclusive goal of these procedures. Diagnostic

interviews can be administered by counselors, social workers, psychologists, physicians,

or technicians with specific training in administering a particular diagnostic

interview (Segal & Hersen, 2010). In some cases, the training required for an

individual to administer a particular diagnostic interview is extensive.

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Adult Diagnostic Interviewing

Numerous adult diagnostic interviewing schedules exist. Some schedules are broad

spectrum; they assess for a wide range of DSM disorders (First, Spitzer, Gibbon, &

Williams, 1995; Lobbestael, Leurgans, & Arntz, 2011; Spitzer, Williams, Gibbon,

& First, 1992). Other schedules are more specific and circumscribed; for example,

some structured and semistructured interview schedules such as the Alcohol Use

Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV) or

the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) evaluate only

for the presence or absence of specific conditions (Grisham, Brown, & Campbell,

2004; Ruan et al., 2008).

Child Diagnostic Interviewing

There are also numerous child-diagnostic interviewing schedules. Again, these

can be classified as either broad spectrum (e.g., The Child Assessment Schedule;

Hodges, 1985) or circumscribed (e.g., Anxiety Disorders Interview Schedule for

Children; Silverman, 1987).

Advantages Associated With Structured Diagnostic Interviewing

Advantages associated with structured diagnostic interviewing include:

1. Structured diagnostic interview schedules are standardized and straightforward

to administer. Therapists can ask clients specific diagnostic-relevant

questions.

2. Diagnostic interview schedules generally produce a DSM diagnosis, consequently

relieving clinicians of subjectively weighing many alternative

diagnoses.

3. Diagnostic interview schedules generally exhibit greater interrater reliability

than therapists functioning without such schedules.

4. Diagnostic interviews are well suited for scientific research. It’s imperative

that researchers obtain valid and reliable diagnoses to effectively study

the nature, course, prognosis, and treatment responsiveness of particular

disorders.

Disadvantages Associated With Diagnostic Interviewing

There are also numerous disadvantages associated with diagnostic interviewing:

1. Many diagnostic interviews require considerable time for administration.

For example, the Schedule for Affective Disorders and Schizophrenia for

School-Age Children (Puig-Antich, Chambers, & Tabrizi, 1983) may take

1 to 4 hours to administer, depending on whether both parent and child are

interviewed.

2. Diagnostic interviews don’t allow experienced diagnosticians to take shortcuts.

This is cumbersome because experts in psychiatric diagnosis might

require less information to accurately diagnose clients than beginning

therapists.

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Chapter 10 Diagnosis and Treatment Planning 339

3. Some clinicians complain that diagnostic interviews are too structured and

rigid, de-emphasizing rapport-building and basic interpersonal communication

between client and therapist. Extensive structure may not be acceptable

for practitioners who prefer using intuition and who emphasize relationship

development.

4. Although structured diagnostic interviews have demonstrated reliability,

some clinicians question their validity. All diagnostic interviews are limited

and leave out important information about client personal history, personality

style, and more. Critics contend that two different therapists may

administer the same interview schedule and consistently come up with the

same incorrect diagnosis.

Given their time-intensive requirements in combination with mental health

provider needs for time-efficient evaluation and treatment, it’s not surprising that

diagnostic interviewing procedures are underutilized and sometimes unutilized in

clinical practice. In fact, critics contend that even the diagnostic criteria themselves

are more oriented toward researchers than clinicians (Phillips et al., 2012):

It is difficult to avoid the conclusion that the diagnostic criteria are mainly

useful for researchers, who are obligated to insure a uniform research

population. (p. 2)

The reality is that researchers and academics are—far and away—the primary

users of structured diagnostic interviewing procedures.

THE SCIENCE OF CLINICAL INTERVIEWING:

DIAGNOSTIC RELIABILITY AND VALIDITY

The clinical interview is the cornerstone of diagnostic assessment (SommersFlanagan

et al., 2014, in press). No self-respecting (or ethical) mental health

professional would consider diagnosing a client without conducting a clinical

interview. Nevertheless, the scientific question remains: Do diagnostic interviews

provide reliable and valid diagnostic data and thereby conclusions?

Reliability refers to replicability and stability. If a procedure, such as a diagnostic

interview, is reliable, it consistently produces the same result; two therapists,

interviewing the same client, would come up with the same diagnosis. Statistically

speaking, it’s a commonly agreed on fact that an instrument or procedure must

be reliable (it must produce consistent results) to be valid (producing a correct

or truthful result). However, it’s also possible for an interview procedure to be

highly reliable but invalid—when two or more interviewers consistently agree on

diagnoses, but the diagnoses are incorrect.

In 1980, along with the publication of the DSM-III, many mental health

professionals, especially psychiatrists, breathed a collective sigh of relief. Finally,

after nearly 30 years of rampant diagnostic subjectivity, there was a comprehensive

and atheoretical system for objectively determining whether an individual suffered

from a mental disorder. More importantly, there was now a system, complete

with measurable diagnostic criteria, for determining identifying specific mental

disorders. The DSM-III was showered with praise. The reliability problem (the

problem articulated by the fact that two different psychiatrists, seeing the same

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patient in a brief period of time, often disagreed about the proper diagnosis) was

finally addressed; in the minds of some mental health professionals, the reliability

problem was solved (Sommers-Flanagan et al., 2014, in press).

However, other professionals believed that DSM’s diagnostic reliability problem

was far from solved. In their scathing critique of contemporary diagnosis,

Kutchins and Kirk (1997) wrote:

Twenty years after the reliability problem became the central scientific

focus of DSM, there is still not a single major study showing that DSM

(any version) is routinely used with high reliability by regular mental

health clinicians. Nor is there any credible evidence that any version

of the manual has greatly increased its reliability beyond the previous

version. The DSM revolution in reliability has been a revolution in

rhetoric, not in reality. (p. 53)

Although Kutchins and Kirk’s (1997) position is sometimes considered radical,

mainstream and conservative researchers also consistently question the DSM system’s

reliability and validity (Craig, 2005; Hersen & Turner, 2003). For example,

in a study of how clinicians make judgments about mental disorders in youth, it

was determined that diagnostic decisions vary—perhaps appropriately—based on

social context and race. However, perhaps less appropriately, clinician theoretical

orientation, age, and occupation were also significantly associated with final

diagnostic decisions (Pottick, Kirk, Hsieh, & Tian, 2007).

A summary of diagnostic interviewing reliability published in the Encyclopedia

of Clinical Psychology described the reliability and validity problem this way:

The scientific consensus is that psychiatric diagnostic reliability greatly

improved with the 1980 publication of DSM-III and subsequent development

of structured or semi-structured clinical interviewing protocols like

the SCID-I. Despite this progress, problems with inter-rater reliability

and questions about validity persist. Typically researchers have reported

kappa coefficients (a measure of reliability) for the SCID-I ranging from

−0.03 to 1.00 (with a recent study using DSM-IV criteria ranging from

0.61 to 0.83; Lobbestael, Leurgans, and Arntz 2011). For the SCID-II

kappa coefficients have ranged from 0.43 to 1.00 (and 0.77 to 0.94 in a

more recent study using DSM-IV; Lobbestael et al., 2011). It should be

noted that these research studies have used highly trained interviewers

and that there is little scientific evidence demonstrating that independent

clinicians would obtain similar reliability using the SCID or other structured

diagnostic assessment interviews. (Sommers-Flanagan et al., 2014,

in press)

As it turns out, obtaining diagnostic validity for specific cultural and agebased

subgroups is an additional diagnostic challenge. For example, in a study of

adolescent alcohol users, the researchers were surprised to discover that youth

participants didn’t drink in ways that matched the diagnostic criteria. Specifically,

the youths puzzled over the diagnostic criterion “drinking more or longer than

intended” because their behavioral goal had been to drink until intoxication; they

hadn’t considered setting pre-drinking limits on consumption (Chung & Martin,

2005). Consequently, that diagnostic criterion made little sense to them.

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Although controversy over the reliability and validity of the DSM system still

persists, a number of scientifically supported conclusions can be drawn from the

literature on clinical interviewing for psychiatric diagnoses thus far:

• Generally, the diagnostic criteria for DSM-IV had more potential and, in many

cases, higher reliability than previous diagnostic nomenclatures; it remains

unclear whether the DSM-5 will further improve reliability.

• The more closely you stick to the DSM diagnostic criteria, the more likely you

can produce reliable diagnoses. Even so, reliability among clinical practitioners

is likely to be only moderate at best.

• The more formal training you receive in a diagnostic interviewing procedure,

the more likely you are to produce reliable diagnoses.

• More structured interviewing procedures that de-emphasize contextual factors

are more likely to produce reliable diagnoses; however, de-emphasizing

contextual factors de-emphasizes individual uniqueness, which can result in

cookbook approaches to diagnostic assessment.

Some diagnostic criteria aren’t a good fit for culturally diverse clients, youth, the

elderly, and others; consequently, although emphasizing individual uniqueness

complicates the diagnostic process, it’s often essential.

A BALANCED APPROACH TO CONDUCTING

DIAGNOSTIC CLINICAL INTERVIEWS

We advocate a middle ground position on diagnostic interviewing. We recognize

that some clinicians prefer to ignore or minimize diagnostic interviewing, whereas

others promote it as essential (Horwitz & Wakefield, 2007). Although developing

diagnostic skills is standard for many counselors, social workers, psychologists,

and psychiatrists, if too much attention is paid to diagnosis, clients’ unique, human

qualities can be overlooked. Consequently, consistent with professional ethical

codes and principles, we believe a diagnostic interview is a collaborative process

between therapist and client that leads logically to a theoretically or empirically

supported treatment plan (see Chapter 5). As such, a diagnostic interview should,

at a minimum, contain the following components:

1. An introduction characterized by culturally sensitive warmth, role induction,

and active listening. During this introduction, culturally appropriate

standardized questionnaires and intake/referral information may be used.

2. An extensive review of client problems, associated goals, and a detailed

analysis of the client’s primary problem and goal. This should include

questions about the client’s symptoms using the DSM-5 as a guide—but not

as a cookbook.

3. A brief discussion of experiences (personal history) relevant to the client’s

primary problem. This should include a history of the presenting problem

if such a history hasn’t already been conducted.

4. A brief mental status examination.

5. A review of the client’s current situation, including his or her social support

network, coping skills, physical health, and personal strengths.

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Introduction and Role Induction

All clients should be greeted with warmth and compassion. The goal of developing

a diagnosis and treatment plan shouldn’t change the therapist’s interest in the

client as a unique individual.

After reviewing confidentiality limits, skillful clinicians introduce diagnostic

interviews to clients using a statement similar to the following:

Today, we’ll be working together to try to understand what has been

troubling you. This means I want you to talk freely with me, but also, I’ll

be asking lots of questions to clarify as precisely as possible what you’ve

been experiencing. The better we can identify your main concerns, the

better we’ll be able to come up with a plan for resolving them. Does that

sound okay to you?

This statement emphasizes collaboration and deemphasizes pathology. The

language “try to understand” and “main concerns” are client-friendly ways of

talking about diagnostic issues. This statement is a role induction designed to

educate clients about the interview process. When clients understand what to

expect, they’ll be more responsive to questions. Additionally, clients usually

become engaged in the interview when asked “Does that sound okay to you?”

Rarely do clients respond to this collaborative invitation with “No! It’s not okay!”

If they do, you’ve instantly obtained important diagnostic information.

Throughout the interview, don’t forget to use active listening skills. Beginning

therapists often become too structured, excluding client spontaneity, or too

unstructured, allowing clients to ramble. Remember to integrate active listening

and diagnostic questioning throughout your diagnostic interview.

Reviewing Client Problems

Although we covered client problem conceptualization systems in Chapter 7,

we’d like to reiterate a few basic issues in the diagnostic interviewing context. At

a minimum, a diagnostic interview should include an extensive review of client

problems (and questioning about symptoms based on DSM diagnostic criteria),

associated goals, and a detailed analysis of the client’s primary problem and goal.

While reviewing these areas, consider the following issues.

Respect Your Client’s Perspective, but Don’t Automatically Accept

Your Client’s Self-Diagnosis as Valid

Diagnostic information is available to the general public. Consequently, many

clients will begin diagnostic interviews with professional diagnostic language. For

example:

• Over the past 3 months, I’ve been so depressed. It’s really getting to me.

• I think my child has ADHD.

• I’ve figured out that I’m bipolar.

• I just get these compulsive behaviors that I can’t stop. I have no control over

them.

• My main problem is panic. Whenever I’m out in public, I just freeze.

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Some diagnostic terminology has been so popularized that its specificity has

been lost. This is especially true with the term depression. Many people now

use the word depression to describe feelings of sadness. The astute diagnostician

recognizes that depression is a syndrome and not a mood state. In the first example

on the preceding list, further questioning about sleep dysfunction, appetite or

weight changes, and concentration problems are necessary before concluding that

clinical depression is present. Research has shown that using the single question

“Are you depressed?” isn’t an adequate substitute for an appropriate diagnostic

interview (Kawase et al., 2006; Vahter, Kreegipuu, Talvik, & Gross-Paju, 2007).

Similarly, the lay public overuses the terms compulsive, panic, hyperactive,

and bipolar. In diagnostic circles, compulsive behavior generally alerts the

clinician to symptoms associated with either obsessive-compulsive disorder or

obsessive-compulsive personality disorder. In contrast, many individuals with eating

disorders and substance abuse disorders refer to their behaviors as compulsive.

Similarly, panic disorder is a very specific syndrome in DSM-5. However, many

individuals with social phobias, agoraphobia, or public speaking anxiety talk about

panic. Therefore, when clients describe themselves as having panic, additional

information is needed before assigning a panic disorder diagnosis. Finally, diagnostic

rates of bipolar disorder in both youth and adults have skyrocketed (Blader

& Carlson, 2007; Moreno et al., 2007). As a result, the public (and, unfortunately

some mental health professionals), are inclined to quickly attribute irritability or

mood swings to bipolar disorder. In contrast, we still recommend using established

diagnostic criteria and hope that DSM-5 will help resolve this problem.

Keep Diagnostic Checklists Available

When questioning clients about problems, it’s crucial to keep DSM-5 diagnostic

criteria in mind, but few of us have perfect memories for the DSM diagnostic

conditions. To cope with this challenge, we recommend using checklists to aid

in recalling specific DSM-5 diagnostic criteria. Homemade diagnostic checklists

can help you become familiar with key diagnostic criteria, without necessarily

committing them to memory.

Accept the Fact That You May Not Be Able to Accurately

Diagnose After a Single Interview

It’s good to have high expectations and lofty goals. However, as cognitive

theory and therapy has shown, unreasonably high expectations can set us up for

frustration and disappointment (Leahy, 2004). It’s important to recognize that,

in many cases, you won’t be able to assign an accurate diagnosis to a client after

a single interview. In fact, you may leave the first interview more confused than

when you began. Fear not. The DSM-5 provides practitioners with procedures

for handling diagnostic uncertainty (see American Psychiatric Association, 2013).

These procedures include:

V codes: DSM-5 includes V codes for indicating that treatment is focusing

on a problem that doesn’t meet diagnostic criteria for a mental disorder.

Examples include V61.20 (parent-child relational problem) and V62.82

(bereavement).

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Code 300.9: This code refers to Unspecified Mental Disorder. It’s used when the

clinician determines symptoms are present, but full criteria for a specific

mental disorder are not met. Also, the clinician doesn’t specify why the

criteria aren’t met.

Provisional diagnosis: When a specific diagnosis is followed by the word

provisional in parentheses, it communicates a degree of uncertainty. A

provisional diagnosis is a working diagnosis, indicating that additional

information may modify the diagnosis.

Client Personal History

Even when time is very limited, a minimal social or developmental history helps

ensure accurate diagnosis. For example, DSM-5 lists numerous disorders that

have depressive symptoms as one of their primary features, including (a) persistent

depressive disorder, (b) major depressive disorder, (c) adjustment disorder

with mixed anxiety and depressed mood, (d) adjustment disorder with depressed

mood, (e) bipolar I disorder, (f ) bipolar II disorder, and (g) cyclothymic disorder.

Additionally, many other disorders include depressive-like symptoms or symptoms

that are commonly comorbid with one of the previously listed depressive

disorders. These include, but are not limited to: (a) posttraumatic stress disorder,

(b) generalized anxiety disorder, (c) anorexia nervosa, (d) bulimia nervosa, and (e)

conduct disorder. The question is not necessarily whether depressive symptoms

exist in a particular client, but rather, which depressive symptoms exist, in what

context, and for how long? Without adequate historical information, you can’t

discriminate between various depressive disorders and comorbid conditions.

In some cases, accurate diagnosis is directly linked to client history. For

example, a panic disorder diagnosis requires information about previous panic

attacks (Sanfelippo, 2006). Similarly, post-traumatic stress disorder, by default,

requires a trauma history, and AD/HD can’t be diagnosed unless there was

evidence that symptoms existed prior to age 12. With regard to conduct disorder,

if the youth is or has been living in a neighborhood with a strong culture of

violence, drug use, and theft, it may be an inappropriate diagnosis.

Mental Status Examination

As emphasized in Chapter 8, mental status examinations aren’t the same as diagnostic

interviews and shouldn’t be considered diagnostic procedures. However,

current mental state is often linked to diagnostic conditions. In particular, mental

status information can help determine whether substance use is an immediate

factor affecting client consciousness and functioning. Mental status examinations

also inform you of client thinking and perceptual processes that may be associated

with particular diagnostic conditions.

Current Situation

Obtaining information about a client’s current functioning is a standard part of

the intake interview. With regard to diagnostic interviewing, a few significant

issues should be reviewed and emphasized.

A detailed review of your client’s current situation includes an evaluation of

his or her typical day, social support network, coping skills, physical health (if this

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Chapter 10 Diagnosis and Treatment Planning 345

area hasn’t been covered during a medical history), and personal strengths. Each

of these areas can provide information crucial to the diagnostic process.

The Usual or Typical Day

Yalom (2002) has written that he believes an inquiry in to the “patient’s daily

schedule” is especially revealing. He wrote:

... in recent initial interviews this inquiry allowed me to learn of activities

I might not otherwise have known for months: two hours a day of

computer solitaire; three hours a night in Internet sex chat rooms under

a different identity; massive procrastination at work and ensuing shame;

a daily schedule so demanding that I was exhausted listening to it; a

middle-aged woman’s extended daily (sometimes hourly) phone calls

with her father; a gay woman’s long daily phone conversations with an

ex-lover whom she disliked but from whom she felt unable to separate.

(pp. 208–209)

Asking about the client’s typical day can seem boring and tedious, but can open up

a cache of diagnostically rich data that moves you toward identifying appropriate

treatment goals and an associated treatment plan.

Client Social Support Network

Sometimes, it’s critical to obtain diagnostic information from people other than

the client, especially when interviewing children and adolescents. In such cases,

parents are often interviewed as part of the diagnostic work-up (see Chapter 13 for

more detailed information on strategies for interviewing young clients and their

parents). However, even when interviewing adults, outside information may be

necessary. To rely exclusively on a single clinical interview to establish a diagnosis

may be inappropriate and unprofessional. As Morrison (2007) wrote:

Adults can also be unaware of their family histories or details about

their own development. Patients with psychosis or personality disorder

may not have enough perspective to judge accurately many of their

own symptoms. In any of these situations, the history you obtain from

people who know your patient well may strongly influence your diagnosis.

(p. 203)

People other than your client who provide you with information are often

referred to as collateral informants. To collect information from collateral informants

you’ll need to have your client sign the requisite releases.

Client Coping Skills Assessment

Client coping skills may be related to diagnosis and can facilitate treatment

planning. For example, clients with anxiety disorders frequently use avoidance

strategies to reduce anxiety (e.g., agoraphobics don’t leave their homes; individuals

with claustrophobia stay away from stuffy rooms or enclosed spaces). It’s important

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to examine whether clients are coping with their problems and moving toward

mastery or simply reacting to problems and thereby exacerbating symptoms

and/or restricting themselves from social or vocational activities.

Coping skills also may be assessed by using projective techniques or behavior

observation. Projective techniques include having clients imagine a particular

stressful scenario (sometimes referred to as a simulation), and behavioral observations

may be collected either in an office or in outside setting (e.g., school, home,

workplace). As noted previously, collateral informants may provide information

regarding how clients cope when outside your office.

Physical Examination

Often, a conclusive psychiatric diagnosis can’t be achieved without at least a cursory

medical examination. Therapists should inquire about most recent physical

examination results when interviewing new clients. Some therapists ask for this

information on their intake form and discuss it with clients.

As noted at the beginning of this chapter, physical and mental states can have

powerful and reciprocal influences on each other. For instance, a long-term illness

or serious injury can contribute to anxiety and depression. Consider the following

options when completing a diagnostic assessment:

1. Gather information about physical examination results.

2. Consult with the client’s primary care physician.

3. Refer clients for a physical examination.

It’s a professional obligation to make sure potential medical or physical causes

or contributors to mental disorders are considered and noted.

Client Strengths

Clients who come for professional assistance may have lost sight of their personal

strengths and positive qualities. Further, after experiencing an hour-long diagnostic

interview, clients may feel even more sad or demoralized. As we’ve mentioned

before—especially within the context of suicide assessment interviewing—it’s

important to ask clients to identify and elaborate on positive personal qualities

throughout the interview, but especially toward the end of an assessment/

diagnostic process. For example:

I appreciate you telling me about your problems and symptoms. But I’d

also like to hear more about your positive qualities. Like, how you’ve

managed to be a single parent and go to school and fight off those

depressive feelings you’ve been talking about?

Exploring client strengths provides important diagnostic information. Clients

who are more depressed and demoralized have trouble with these questions and

may not be able to identify strengths. Nonetheless, be sure to provide support,

reassurance, and positive feedback. In addition, as solution-oriented theorists

emphasize, don’t forget that diagnosis and assessment procedures can—and

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should—include a consistent orientation toward the positive. For example,

Bertolino and O’Hanlon (2002) stated:

Formal assessment procedures are often viewed solely as a means of

uncovering and discovering deficiencies and deviances with clients and

their lives. However, as we’ve learned, they can assist with learning about

clients’ abilities, strength, and resources, and in searching for exceptions

and differences. (p. 79)

Effective diagnostic interviewing isn’t an exclusively fact-finding, impersonal

process. Throughout the interview, skilled diagnosticians express compassion

and support for a fellow human being in distress (Jobes, 2006; O’Donohue,

Cummings, & Cummings, 2006). The purpose of diagnostic interviewing goes

beyond establishing a diagnosis or “pigeonhole” for clients. Instead, it’s an initial

step in developing an individualized treatment plan.

TREATMENT PLANNING

The initial clinical interview is designed to obtain assessment information. In turn,

this information is used to aid in the diagnostic process and diagnosis broadly

informs treatment. However, more specifically, clients and therapists collaborate

to identify specific client problems and these specific problems are much more

helpful for treatment planning than psychiatric diagnosis. Even further, case

formulation (aka case conceptualization) is the bridge between client diagnosis or

problem and specific treatments to be implemented. Before exploring these issues

in greater depth, consider the following questions:

• What assessment procedures will I use with clients to identify problems and

monitor progress?

• What problems have the client and I identified as the focus of our work

together?

• How do these problems translate into mutual therapy goals?

• What means or methods (theoretically based or empirically supported) will

the client and I use as we work toward achieving these goals?

• How will we measure progress toward our goals?

• How will we know if and when it’s time to refer the client for an alternative

or adjunctive treatment?

• How will we know when it’s time for therapy to end?

Your answers to these questions will depend on many factors, including, but not

limited to, (a) your treatment setting, (b) your theoretical orientation, (c) client

preference, (d) client resources, (e) third-party payer requirements and limits.

Many different treatment-planning models exist. A sampling of eclectic or

atheoretical models include the BASIC ID (Lazarus, 2006), DO A CLIENT MAP

(Seligman & Reichenberg, 2012), and the “treatment planners” (Jongsma et al.,

2006). A great many theoretically based conceptual systems are also available

(Greenberg, 2002; Luborsky & Crits-Christoph, 1998; Shapiro, 2002; Woody,

Detweiler-Bedell, Teachman, & O’Hearn, 2003).

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Choosing Effective Treatments

There are entire books that focus on selecting effective treatments (Seligman &

Reichenberg, 2012). We begin our brief coverage of this growing area with an

overview of two general models.

The Psychosocial Treatment Planning Model

The psychosocial model focuses on psychological and social/cultural experiences

as causing and contributing to the maintenance of emotional and behavioral

problems. This model identifies psychological and social/cultural interventions

as ideal approaches to treatment. To develop a psychosocial treatment plan,

therapists conduct an initial intake interview as described in Chapter 7, wherein

client and therapist collaboratively explore (a) what brings the client to therapy

(presenting problem and initial goals), (b) the client’s personality style and personal

history (the person), and (c) the client’s current life circumstances (the situation).

After exploring these fundamental issues, goals are established interactively with

the client and a plan for goal attainment is developed. Based on this model, the case

formulation and proposed interventions emphasize psychological, social, cultural,

and behavioral components (Bisson et al., 2010; Miklowitz, Goodwin, Bauer, &

Geddes, 2008). Additionally, this approach involves an emphasis on collaborative

client problem identification and a lesser emphasis on establishing a definitive

psychiatric diagnosis. This treatment planning model can include a focus on

problems and/or a focus on solutions and goals (see Putting It in Practice 10.1 for

as assessment approach based on one theoretically based psychosocial model).

PUTTING IT IN PRACTICE 10.1

Gathering Family History Information

for Assessment and Treatment Planning

It may not always be easy to get clients to talk about their family and or

family background. One strategy for facilitating an open and balanced

discussion about family factors in any area (including suicide, family

history of mental disorder, etc.) is the genogram or Adlerian family

constellation interview. This strategy or approach has been described

elsewhere by many authors and is briefly reviewed here (Carlson et al.,

2006; Mosak & Maniacci, 1999; J. Sommers-Flanagan & SommersFlanagan,

2012).

Draw a Genogram or Family Tree

As appropriate, early in a clinical interview, we typically initiate a family

constellation interview by saying something like, “Of course, we’ve just

met and I don’t know you very well, and so one of the ways I have of

getting to know you better is to draw a family tree. Is that okay?” In

nearly every case, perhaps due to natural curiosity, clients agree to help

draw a family tree.

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Chapter 10 Diagnosis and Treatment Planning 349

We then proceed to draw a genogram, starting with the client

himself/herself and extending back in time to his/her grandparents

(Shellenberger, 2007). Usually, because of time constraints, we focus

primarily on the client’s siblings, parents, and grandparents—although

a brief discussion of prominent aunts, uncles, cousins may emerge. With

some culturally diverse clients who have collectivist ways of being, this

process can become even more inclusive. In some cases, the focus is

less on biological parents and more on kinship relations, foster parents,

or adoptive parents.

Convey Interest and Curiosity About the Family of Origin

Every family is unique; the genogram or family tree provides a structure

for exploring that uniqueness. The genogram provides a visual method

for identifying not only family structure, but also chronology. Along

with the genogram, a timeline can be drawn to identify when significant

events occurred (parental divorce, remarriage, moving from one

residence to another, school problems or successes, etc.).

Ask a Balance of Positive and Negative Questions

The Adlerian family constellation interview includes specific questions

about how the client viewed or views different family members and

family relationships (Sweeney, 2009). One of the great things about the

family constellation interview is that it focuses on the client’s perceptions

or descriptions of his/her family—which is not inherently positive or

negative. Potential questions or prompts include:

• Give me three words to describe your mother (father, sister, brother,

etc.).

• Who did (do) you feel closest to in your family?

• Who did (do) you fight the most with?

• Who was (is) your mom’s favorite?

• Who was (is) your dad’s favorite?

• Who was (is) the best musician (athlete, artist, student, etc.)?

• Who was (is) the goody-goody kid?

• Who got in the most trouble?

• Who can you talk with when you need to talk?

• Who is impossible to talk with?

Other questions that can be integrated into a family constellation

interview have been described elsewhere (Mosak and Maniacci, 1999;

Sweeney, 2009).

Use the Family Constellation Interview to Gather Family History Data

In addition to information about divorce, remarriage, step-parents and

other family history data, the family constellation interview provides an

excellent structure for inquiring about the family’s mental health history.

(continued)

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350 Part Three Structuring and Assessment

(continued)

Specifically, to assess for relevant suicide risk factors, you might ask the

following:

• Has anyone in your family had mental health troubles like depression,

schizophrenia, or bipolar disorder?

• Does anyone in your family have any special positive qualities or

a positive legacy (like being a great musician, athlete, business

person)?

• Has anyone in your family ever committed suicide? If so, what do

you know about that situation?

• Has anyone in your family ever attempted suicide, but then decided

to live? If so, what do you know about that situation?

• Has anyone in your family been arrested or convicted of a crime or

had big troubles with drugs or alcohol?

• Out of everyone in your family, who do you feel closest to (or who

do you think is your best role model)?

As you can see, the family constellation model is a flexible tool for

evaluating many family history dynamics in an interesting and engaging

format. We especially like to use it for getting to know adolescents early

in therapy (J. Sommers-Flanagan & Sommers-Flanagan, 2007b).

The Biomedical Treatment Planning Model

The biomedical or psychiatric approach to conceptualizing client problems and

identifying client treatments is a powerfully compelling paradigm that continues

to increase in popularity and dominance (Overholser, 2006; J. Sommers-Flanagan

& Campbell, 2009). Using this approach, therapists formulate client problems as

illness based and perform diagnostic assessments to identify biomedical treatments.

If you review the psychiatric literature, you’ll see many statements

articulating the biomedical perspective using disease and illness language. For

example, “Depressive disorders are often familial recurrent illnesses associated

with increased psychosocial morbidity and mortality” (Birmaher et al., 2007,

p. 1503).

The biomedical approach views therapists as experts who know DSM-5 diagnostic

criteria and related efficacy research and apply this expertise accordingly.

This approach emphasizes accurate diagnostic labeling, a primary purpose of

which is to assist in identification of appropriate medication treatment.

In practice, most therapists recognize that integrating psychosocial and biological

treatment-planning approaches is useful and do so to some extent. This

is referred to as the biopsychosocial model (Engel, 1980; Engel, 1997). However,

when biomedical and psychosocial treatments are combined, the biomedical

approach (also known as the medical model) tends to dominate case formulation

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Chapter 10 Diagnosis and Treatment Planning 351

and treatment planning (Sommers-Flanagan & Campbell, 2009; see Multicultural

Highlight 10.1 for a different perspective on the biopsychosocial model).

Factors to Consider

In addition to considering the preceding general models, identifying appropriate

treatments requires that therapists consider the following information:

Client Diagnosis/Problem and Empirically Supported Treatments

Although exceptions exist, evidence-based treatment guidelines or approaches

exist for many psychiatric diagnoses (e.g., major depression, obsessive compulsive

disorder, post-traumatic stress disorder). This is one reason why it’s crucial for

providers to have well-developed diagnostic skills. However, there are also many

cases in which it’s more difficult to select an evidence-based treatment (Eells,

2009). Examples include:

• Your client’s diagnosis is unclear.

• There are comorbid (more than one diagnosis) conditions that complicate

treatment selection.

• Your client is opposed to using an evidence-based strategy.

• You’re not trained in a specific evidence-based strategy.

• Your client has problems-in-living that don’t qualify for a psychiatric

diagnosis.

The past 10–15 years has seen a strong movement toward evidence-based

treatment planning. This approach is derived from the medical model, but emphasizes

reliance on research data and often integrates psychosocial interventions.

Most evidence-based treatments are cognitive-behavioral, oriented toward psychiatric

diagnosis, and relatively time limited (Dickerson & Lehman, 2011; Drisko &

Grady, 2012; Kosciulek, 2010).

Interestingly, although third-party payers require medical diagnosis for reimbursement,

they often prefer treatment plans that emphasize behavioral problem

indices over diagnoses (Jongsma, Peterson, & Bruce, 2006). Similarly, although

they sometimes push practitioners toward using evidence-based treatments, they

also prefer briefer treatments, such as solution-focused brief therapy, despite the

minimal empirical evidence attesting to the efficacy of such therapies (Corcoran &

Pillai, 2009; Gingerich & Eisengart, 2000; Kim, Smock, Trepper, McCollum, &

Franklin, 2010). Overall, when working with third-party payers, it’s important to

speak the language of psychiatric diagnosis, but also to be able to link client symptoms

or problems directly to specific evidence-based, theoretically supported, and

solution-focused interventions.

There are a number of websites you can use to identify evidence-based or

empirically supported treatments. To explore these therapies and the process by

which they have achieved empirically supported status, see the website for Division

12 of the American Psychological Association (http://www.apa.org/divisions/

div12/cppi.html).

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MULTICULTURAL HIGHLIGHT 10.1

Listening to the Dalai Lama: A Social-Psycho-Bio Model

At a conference at Emory University, Charles Nemeroff, MD, presented

a paper to His Holiness the Dalai Lama (Nemeroff, 2007). In his presentation,

Nemeroff noted with authority that one-third of all depressive

disorders are genetic and two-thirds are environmentally based.

Nemeroff then discussed the trajectory of “depressive illness,” presenting

findings from animal and human studies of trauma and depression.

Nemeroff concluded that trauma seems to initiate a biologically based

depressive tendency in the brains of some individuals (and mice) but not

others. At one point during the presentation there was a flurry of interactions

between the Dalai Lama, his interpreter, and Dr. Nemeroff. Finally,

the interpreter posed a question to Dr. Nemeroff, saying something

like: “His Holiness is wondering, if two-thirds of depression is caused by

human experience and one-third is caused by genetics, but humans who

are genetically predisposed to depression must have a trauma to trigger

a depressive condition, then wouldn’t it be true to say that all depression

is caused by human experience?” After a brief silence, Nemeroff

conceded, “Yes. That would be true.”

Such admissions, as well as our own observations, have led us to

believe that the ordering of the terms in the biopsychosocial model

may be misleading. It may be more accurate to say social-psycho-bio,

because early social interactions or relationships create psychological

or cognitive patterns that eventually contribute to particular biological

states.

Evidence-Based Relationships

As discussed in Chapter 5, relationship factors are significantly associated with

positive treatment outcomes (Norcross, 2011). As a consequence, to develop an

empirically informed treatment plan, relationship factors should be incorporated

into treatment planning. For example, specific interactions such as collaborative

goal setting and progress monitoring are relationship based and also constitute

technical strategies (Norcross, 2011). Furthermore, making sure you attend to the

development and maintenance of a strong working alliance is essential to positive

outcomes. This is true despite the fact that the manner in which you develop and

maintain a working alliance will vary from client to client; alliance building should

be integrated into your treatment plan.

Therapist Skill or Expertise

Therapist competence is always an ethical and practical consideration in treatment

planning (S. K. Anderson & Handelsman, 2013). Specifically, as you design

a treatment plan, you must have expertise in whatever approaches you’re incorporating

into the plan. For example, if you have no training or experience in a

particular treatment technique (e.g., hypnosis or eye-movement desensitization

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reprocessing), that technique shouldn’t be employed—or if it is employed, it

should be done under close supervision.

Therapist Preference

Therapist preference matters. Mental health professionals vary in their preferred

theoretical orientation. Some adhere to psychoanalytic treatment formulations;

others are behavioral in their approach to treatment. As long as an informed

consent is provided that explains your theoretically or empirically supported

treatment and possible treatment alternatives, it’s perfectly appropriate for clinicians

to offer clients their preferred form of treatment (J. Sommers-Flanagan &

Sommers-Flanagan, 2012).

Client Preference

Client preference also matters. Given the choice, clients may prefer one form of

treatment over another. For example, some clients struggling with maladaptive

habits prefer short-term, specific behavioral therapy to successfully change the

habit. Others prefer depth work, seeking to understand the role or purpose of

the habit in their lives. Still others prefer medication treatment. Client treatment

preference can strongly influence treatment compliance.

Client Resources

Professional counseling and psychotherapy is expensive. Some clients have coverage

from insurance companies or other third-party payers. Each health care

program has specific benefits and limits for mental health-care coverage. The

client’s health-care coverage and the resources available after the coverage runs

out are important practical and ethical considerations in charting a treatment plan.

Unfortunately, considering available resources doesn’t mean simply picking

a problem that fits into the number of paid sessions available or the number of

sessions a client can budget from private funds. Certainly, it’s important to clarify

primary and secondary problems and to recognize that problems can’t always be

addressed in a given course of treatment. Ethically, therapists are required to

choose among theoretically or empirically based treatments and to see the client

through to some kind of responsible closure or offer reasonable alternatives, such

as a transfer to another counselor or service (S. K. Anderson & Handelsman,

2010). Therefore, in agreeing to a course of treatment, you must assess your

own resources as well, including availability, willingness to reduce fees, adequate

referral network, appropriate supervision, and access to collateral professionals

(attorneys, medical personnel, etc.).

Besides resources represented in finances and insurance benefits, and the

resources represented in the person and practice of the professional, there are

other resources to be considered in treatment planning. These include client

motivation, ego strength, and psychological mindedness of the client. It’s your

duty to assess, formally or informally, each client’s capacity to engage in treatment.

Treatment Matching

Treatment matching can occur along a number of dimensions. As noted previously,

specific treatments are commonly matched with specific psychiatric disorders or

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354 Part Three Structuring and Assessment

symptoms. However, in recent years, an alternative perspective that emphasizes

therapy principles instead of diagnosis has gained increased scientific recognition.

Beutler (2011) has developed a treatment matching approach referred to as

systematic treatment selection. This model uses empirically driven principles to help

clinicians select specific treatment approaches. Some of Beutler’s main principles

include:

• Clients who have greater functional impairments are more likely to respond

to medication approaches.

• Clients with more aggressive symptoms or externalizing styles tend to respond

more favorably to symptom-focused approaches.

• Conversely, clients who are more inhibited or have more internalizing symptoms

tend to respond more favorably to insight-oriented approaches.

• When client resistance to treatment is high, less directive therapies are more

effective.

• When clients are engaged in treatment, more directive therapies are successful

(Beutler, 2011; Beutler, Forrester, Gallagher-Thompson, Thompson, &

Tomlins, 2012).

Although empirically driven guidelines are useful, like any approach, there are

limitations. For example, the following two cases illustrate exceptions to treatment

matching based on client preference and client history.

CASE EXAMPLE—RESPECTING CLIENT PREFERENCES

Opal, a 63-year-old Caucasian woman, was referred for counseling by

her personal physician. She was referred because of repeated panic

attacks. Her life history was rich and varied in many fascinating respects.

The biggest trauma or loss she disclosed was the death of her oldest

daughter to breast cancer 2 years earlier. This daughter, Emily, had been

a strong, feminist woman with a successful career who had often chided

her mother for her “old-fashioned, subservient ways.”Opal was married

to her third husband, a farmer named Jeff. Jeff was wealthy and traditional

in his views of marriage. Opal’s job was to keep the house clean,

prepare meals that met with Jeff’s approval, and “keep herself presentable.”

Her panic attacks began about six months before the referral

and, at first, happened exclusively outside grocery stores as Opal was

preparing to buy the week’s groceries. Opal was forced to seek a neighbor’s

assistance in obtaining groceries because Jeff refused to be seen

in a grocery store.

After three sessions devoted primarily to assessment, collaborative

goal setting, psychoeducation, and alliance building, the counselor

developed enough of a relationship with Opal to suspect that she would

not do well with depth work regarding her grief, her conflicts over her

marital role, and other related issues. However, it seemed important to

involve Opal in this treatment decision. The counselor explained two

treatment options: (1) continue training to manage panic attacks with

behavioral strategies, imagery, and medication or (2) begin to explore

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the meaning of the panic attacks, their possible linkage to role conflicts,

and perhaps even looking at Opal’s deep and mostly buried grief and

anger over losing her daughter. Without hesitation, Opal indicated she

had no interest in any depth work unless it was absolutely necessary.

The treatment plan continued along cognitive-behavioral lines. After

eight more sessions, Opal resumed grocery shopping on her own. She

left therapy feeling a sense of accomplishment and closure. She assured

the counselor she would be back if “things didn’t hang together in her

head.”

As this case illustrates, client problems can be multilayered and complex.

Although Beutler’s system might suggest that an insight-oriented treatment plan

would be a good match for Opal’s internalizing symptoms, her life situation and

related treatment preference made insight-oriented approaches a poor fit.

CASE EXAMPLE—MATCHING TREATMENT

APPROACH WITH CLIENT HISTORY

Jane came to see a counselor because she was worrying excessively

about her 3-year-old daughter, Kate. Jane had picked Kate up from day

care approximately a month earlier, and Kate had said, “Mommy, I hate

it when they stick yucky things in my mouth.” Jane experienced a rush

of fear and carefully questioned Kate, afraid that someone at the day

care had abused or violated Kate. Kate, clearly alarmed by her mother’s

reaction, refused to talk about day care. This interaction unleashed all

sorts of worries for Jane. She found that she could no longer leave

Kate at day care and was paying for an in-home nanny. Finances were

strained. In addition, Jane would no longer allow Kate to play with her

boy cousins or her older half-brother. This was causing marital strain.

Finally, Jane was having trouble allowing Kate out of her sight, which

was, as Jane said, “making everyone totally crazy.”

Directly addressing Jane’s behavior by pointing out the irrational

nature of her fears and urging her to create a chart and reward herself

for leaving Kate for longer and longer periods were treatment options

in this case. In addition, these options might stand a good chance of

success. However, as many astute readers might have guessed, Jane’s

sudden overfocus and self-proclaimed overreaction to her daughter’s

situation were clues to an unaddressed life experience of Jane’s. Jane

had been sexually molested by her uncle at age 4. She remembered

the uncle kissing and fondling her, often forcing his tongue down her

throat, but she had never told anyone about her experiences.

As a part of treatment, Jane was able to access community support

groups for adults who had experienced child sexual abuse. She used her

(continued)

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356 Part Three Structuring and Assessment

(continued)

therapy time carefully, exploring her pattern of ignoring her own pain

and refusing to talk about her emotions. Although it may have helped

in the short run, a behavioral approach to Jane’s anxiety wouldn’t have

addressed Jane’s underlying needs.

Jane’s anxiety is another example of an internalizing symptom. In this case,

Beutler’s model correctly matches Jane with a more insight-oriented treatment

approach. These two case studies illustrate the importance of using an eyeswide-open

approach when selecting treatment plans. The unique individual and

situational factors linked to a client may be far more important than empirical data

suggesting a particular treatment approach is best for a particular client problem.

Case Formulation and Treatment Planning:

A Cognitive-Behavioral Example

As mentioned previously, whether you’re using a psychosocial (problem focused)

or biomedical (diagnostic) model, case formulation is the bridge between clinical

assessment and treatment planning. Persons (2008) identified four case

formulation steps from the cognitive-behavioral (CBT) perspective:

1. Create a problem list.

2. Identify possible mechanisms causing the problems.

3. Identify precipitants (triggers) that currently activate the problem.

4. Consider historical origins of the client’s problem.

Using a case adapted from Ledley et al. (2010), the steps of CBT case formulation

will be described and then linked to a specific treatment plan.

The Problem List

Michael, a 40-year-old White male, referred himself for therapy due to being

socially anxious “for as long as he could remember” (Ledley et al., p. 59). Based on

an initial assessment, including reflections on his DSM diagnosis, the following

problem list was collaboratively generated:

• Social anxiety.

• Confusion about career choices.

• Family conflict.

The initial and primary problem focus was social anxiety.

Underlying Mechanisms

Persons (2008) described three steps for determining mechanisms underlying

specific problems. Her steps include: (1) select a symptom or symptoms on which

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Chapter 10 Diagnosis and Treatment Planning 357

to focus; (2) select a theory or theories to explain the symptom(s); and (3) use your

theory to extrapolate to the individual case.

For Michael, the presenting problem of social anxiety had several component

symptoms, including fear/anxiety, flushing/sweating, and avoidance behaviors.

Beck’s (2011) cognitive theory was used to help Michael understand his symptoms.

The symptoms—and their cognitive explanations included:

Automatic thoughts occurring before and during social contact

• I always look anxious.

• They will think I’m an idiot.

• They will think I’m incompetent.

Intermediate (distorted) thoughts

• People who make mistakes are rejected.

• I make more mistakes than other people.

• It’s terrible to make mistakes.

• I must “get it right” all the time.

A core schemata or belief

• If I am not perfect, I will be rejected.

(All of the above are adapted from: Ledley et al., 2010, p. 70.)

Current Precipitants (Triggers)

During his initial interview, two situational triggers for Michael’s social anxiety

were identified. These included: (1) casual social encounters; and (2) public

speaking. Michael also reported specific automatic thoughts that occurred in

anticipation of and during these social contacts.

Problem Origins

Cognitive-behavioral therapy (CBT) is a form of therapy that focuses primarily on

the present. Nevertheless, there are good reasons why CBT includes exploration

of the origins of clients’ problems. Ledley et al. (2010) explain the rationale

for this:

...spending some time exploring early experiences during the process

of assessment can reveal some valuable clues to the clinician as to how

problem behaviors developed in the first place and why maladaptive

thoughts and behaviors are maintained in the present. Furthermore,

sharing his or her personal history makes a client feel more understood

which can serve to strengthen the therapeutic relationship. (p. 71)

Michael’s Treatment Plan

Recall that case formulation is the bridge from the client’s presenting problem

to the treatment plan. Using Persons’ (2008) model, there will be a focus on

cognitive mechanisms that create and sustain Michael’s symptoms. Treatment

will include specific components that directly address the cognitive mechanisms

underlying Michael’s symptoms. In this case, the treatment plan included use of

an evidence-based treatment manual for social anxiety.

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The following treatment plan is adapted from Ledley et al. (2010):

Session 1

Problem: Michael’s distorted, maladaptive beliefs.

Intervention: Provide educational material on social anxiety.

Goals: Normalize the phenomenon of social anxiety; introduce Michael to the

CBT model.

Session 2

Problem: Michael’s distorted, maladaptive beliefs.

Intervention: Design hierarchy of feared situations.

Goals: Identify feared social situations; plan for how to proceed with exposure.

Session 3

Problem: Michael’s distorted, maladaptive beliefs.

Intervention: Begin cognitive restructuring.

Goals: Teach Michael to identify, question, and reframe his maladaptive

thoughts.

Session 4

Problem: Michael’s distorted, maladaptive beliefs.

Intervention: Continue cognitive restructuring; plan initial exposure experience.

Goals: Continued skill building for identifying, questioning, and reframing his

maladaptive thoughts; teach Michael how to initiate behavioral exposure.

Session 5

Problem: Michael’s beliefs AND his physiological response to social contact

AND his behavioral pattern of avoidance.

Intervention: First exposure session.

Goals: Demonstration and experiential learning about how exposure can

challenge maladaptive beliefs.

Sessions 6–18

Problem: Michael’s beliefs AND his physiological response to social contact

AND his behavioral pattern of avoidance AND his core beliefs about

himself.

Intervention: Continued exposure; continued cognitive restructuring

Goals: Minimize physiological responses to social contact; internalize new

beliefs about social anxiety, avoidance, and modify core beliefs about

the self.

Sessions 19 and 20

Problem: Michael’s beliefs AND his physiological response to social contact

AND his behavioral pattern of avoidance AND his core beliefs about

himself.

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Chapter 10 Diagnosis and Treatment Planning 359

Intervention: Relapse prevention, goal setting, termination

Goals: Prepare and plan for termination, including future expectations and

goals.

The preceding evidence-based CBT treatment plan is, in many ways, the

state-of-the-science in treatment planning. Following Persons’ (2008) approach

to case formulation allows clinicians to individualize treatment, thus expanding

the potential of evidence-based approaches. However, it should be noted that

this approach also has many limitations. For example, third party payers may not

be inclined to commit to a 20-session treatment protocol. Additionally, although

evidence suggests this is an appropriate treatment for White clients from the

dominant culture, there’s no compelling evidence that this approach is either

appropriate of effective for diverse or minority clients.

Multicultural Adaptations

As noted intermittently in this text, contemporary clinicians must address multicultural

complexities during clinical assessment and treatment (Gray & Rose,

2012; Shea et al., 2012). One way this plays out for treatment planning is that

clinicians should engage in mutual exploration to enhance the working alliance

before launching into specific interventions. This chapter closes with Multicultural

Highlight 10.2, where a case is used to illustrate a more tentative approach where

mutual exploration is the primary intervention—rather than a specific empirically

supported intervention or procedure.

MULTICULTURAL HIGHLIGHT 10.2

Cultural Issues in Treatment Planning: A Case Example

Often, client cultural issues take center stage in treatment planning.

The following very brief example is adapted and summarized from “The

Case of Dolores” (Sommers-Flanagan, 2001, in Paniagua, 2001).

Dolores, a 43-year-old American Indian woman, came to counseling

because she was suffering from sadness, difficulty concentrating,

insomnia, and anhedonia. These depressive symptoms were associated

with two major concerns. First, Dolores was upset because her husband

of 23 years, Gabe, was suffering from a serious gambling addiction but

refusing to go to treatment. Second, Dolores was worried that, because

of her diminished functioning and her husband’s gambling, she might

lose custody of her adopted daughter, Sage.

Even with the minimal information provided in this example, several

cultural issues rise to the fore. Specifically, because Dolores’s major

concerns center around family issues, it’s important to explore the onset

and duration of her concerns in the context of familism—as Dolores’s

symptoms might be more directly associated with her family identity

than with her “self.” Additionally, it could be that the decision to come

to counseling was producing nearly as much stress as her family situation

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360 Part Three Structuring and Assessment

(continued)

because some American Indian tribes consider it disloyal to say negative

things about other family members. Consequently, Dolores’s feelings

about counseling and what it says about her Indian identity (or about

her losing her Indian identity) may be a focus of treatment—especially

if she’s seeing a counselor from the dominant culture.

Dolores’s fears of losing her adopted daughter also bring up cultural

issues. In this case, the adoption was an informal tribal arrangement; she

may need to consult with legal professionals and her tribe to determine

if the adoption is binding. It’s likely the U.S. government would support

the adoption placement under the Indian Child Welfare Act (O’Brien,

1989); therefore, communication with her tribe is more important than

exposing Dolores to the U.S. legal system. Finally, although to some

counselors it may seem that Dolores’s anxiety about losing her child is

overblown, historically, American Indians have experienced intergenerational

trauma when children are taken from families. Hence, Dolores’s

feelings about those historical facts (and personal experiences) should

be evaluated before pathologizing her anxiety.

In summary, for American Indian and other multicultural clients,

treatment planning should be culture specific and culture sensitive. For

example, the following treatment planning interventions might be used:

• Explore Dolores’s feelings about pursuing counseling.

• Explore what Dolores is thinking and feeling when she makes negative

statements about her family members.

• Educate Dolores regarding the Indian Child Welfare Act.

• Encourage Dolores to discuss custody fears with tribal members and

possibly a tribal lawyer.

• Discuss Dolores’s fears of losing her daughter in the context of

multigenerational trauma.

SUMMARY

This chapter addresses basic principles and processes of diagnosis and treatment

planning. Controversies about psychiatric diagnosis abound, but there are important

reasons for all mental health professionals to develop diagnostic skills. A

diagnosis can serve an organizing function and thereby facilitate treatment planning

and treatment process. It can be seen as a working hypothesis and can offer

clients relief by assuring them that others suffer with similar reactions, struggles,

and complaints. The most commonly used diagnostic manual in North America is

the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders); the fifth edition

was published in May, 2013. Because diagnosis always involves some subjectivity,

practitioners are encouraged to be careful and tentative when assigning specific

diagnoses.

Therapists should use a balanced approach to conducting diagnostic interviews,

including (a) a warm introduction to diagnostic assessment with an

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Chapter 10 Diagnosis and Treatment Planning 361

explanation of what the client should expect; (b) an extensive review of client

problems and associated goals; (c) a brief review of client personal history, especially

those historical experiences closely associated with the client’s primary

problem; (d) a brief mental status examination; and (e) a review of the client’s

current situation, including social supports, coping skills, physical health, and

personal strengths. In the diagnostic interviewing context, no one can be expected

to keep all diagnostic parameters in mind. Therapists are encouraged to purchase

or develop their own abbreviated diagnostic checklists so they can adequately

address the specific domains in question for a certain diagnostic inquiry.

Treatment planning flows directly from diagnosis or problem analysis. Professionals

can use psychosocial approaches to treatment planning, wherein the

problem complex is the guide for treatment goals and objectives; or they can

use the medical or biological approach, wherein symptoms are categorized into

a diagnosis, which then dictates treatment choice. It’s also possible to combine

these two and use a biopsychosocial approach, which includes diagnosis but also

addresses specific symptoms and problems interactively with clients.

There are many factors to consider when developing treatment plans. These

include (a) client diagnosis/problem(s); (b) evidence-based relationship factors;

(f ) client resources; and (g) treatment matching variables.

Case formulation is the bridge between client diagnosis/problem and treatment

planning. A sample case formulation and treatment plan from the cognitivebehavioral

perspective is described.

Multicultural adaptations to treatment planning should be considered on a

case-by-case basis. This many involve clinicians engaging in more extensive mutual

exploration to enhance the working alliance before launching into the application

of specific interventions. A case example involving multicultural adaptation is

provided.