The diagnostic approach in clinical psychology and mental illness

¶ … Mental Illness' / the Diagnostic Approach in Mental Health and its Relevance to Clinical Psychology

Psychological and medical practices have developed from two separate traditions. The latter evolved with traditional healers passing on diverse oral traditions concerning healing preparations and therapies to students. The reason behind a particular treatment being effective for an ailment held no importance; the only thing that counted was the observation that, in a particular circumstance, a specific treatment appeared to work. For instance, if a willow bark extract was effective in relieving people of headaches, it was accepted without question. It was only in later eras that scientific inquiry was used for validating traditional treatments as well as finding new ones. For example, scientific analysis revealed the presence of aspirin -- a substance with pain-relieving properties -- in the bark of the willow tree. As oral lore definitively associated the ailment and the cure, treatment of ailments in those days (just like today) was dependent on diagnosis. Patient symptoms are first ascertained with care, and subsequently, the treatment (linked traditionally to those specific symptoms) is administered (Richmond, 2015). Psychology works completely differently from medicine. It began by searching for symptoms that can be explained and treated using science. This was the early form of psychology, which can be attributed to Lightner Witmer in 1896 (McReynolds, 1987).

In spite of several years of justifiable denunciation of psychiatric diagnosis, both psychologists and psychiatrists continue using it on a large scale. A majority of psychologists have limited mental health-related knowledge -- typically, only what they can recall from their undergraduate classes in 'abnormal psychology'. Nevertheless, a new survey financed by the Psychology Network of the Higher Education Academy (Cromby, Harper, & Reavey, 2007), revealed that most courses in abnormal psychology employed textbooks designed based on the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which consist of outmoded psychiatry critiques, and are unable to come up with an expressly psychological perspective to the subject matter (Cromby, Harper, & Reavey, 2007).

Monthly publication, The Psychologist frequently presents debates with regard to diagnosis and psychologists (e.g., Pilgrim, 2000). A number of psychologists, however, continue employing it. Their typical argument is that diagnosis, though challenging, offers a valuable 'shorthand' kind of communication vital to multi-disciplinary tasks. Research scholars and clinicians analyze some issues concerning diagnosis and contend that it doesn't improve, but rather, muddles, our understanding. The reason for diagnoses' continued adoption is also cited. As it is a knotty aspect, one substitute research suggestion is to try to analyze actual experiences of individuals. A pilot model to achieve this deals with experiences like strange notions or hearing voices. It is often-implied that the extensive utilization of psychiatric medication supports diagnosis' validity (Cromby, Harper, & Reavey, 2007). The psychosis report in the Division of Clinical Psychology (2000) of the British Psychological Society suggested a shift from diagnosis to formulation-based psychology. This paper will look into diagnostic clinical psychology approaches.

Theories

Psychodynamic Psychotherapy

This approach is derived from Freud's psychoanalysis, whose key goal is awakening the unconscious, that is, making clients cognizant of their personal, primitive drives (in other words, drives pertaining to aggression and sex) and the different defenses mankind employs for keeping them at bay (Gabbard, 2005). An analysis of transference of clients towards their psychotherapist and free association application are key psychoanalysis tools. Transference denotes the tendency of taking and transferring emotions or unconscious thoughts in relation to a significant individual (for instance, a parent) onto another individual (in this case, the psychotherapist).

Humanistic Psychology

This school of psychology originated during the fifties as a response to psychoanalysis as well as behaviorism, chiefly because of Carl Rogers' client-centered therapy (popularly called Rogerian psychotherapy) and Rollo May and Viktor Frankl's existential psychology (Plante, 2005). In Rogers' view, clients only required three things -- empathy, congruence, and absolute positive regard -- from their therapist for positive therapeutic outcomes (McMillan, 2004). Through the use of phenomenology, first-person and inter-subjectivity categories, humanistic psychology attempts to look at the overall individual rather than mere disjointed components of an individual's nature (Rowan, 2001).

Behavioral and Cognitive Behavioral Theory

Cognitive behavioral therapy's (CBT's) basis is that the way one thinks (cognition), acts (behavior) and feels (emotion) are connected and act together complexly. In the CBT perspective, specific dysfunctional means of understanding and evaluating the world (usually through beliefs or schemas) can be an emotional distress factor, or can bring about behavioral problems. A number of cognitive behavioral treatments are aimed at ascertaining and establishing the dysfunctional, subjective ways of interacting or responding, and via different practices, assist clients in rising above these in such a way as to improve personal well-being (Beck, Davis, & Freeman, 2007). Numerous methods are applied, for instance, Socratic questioning, maintenance of a log for cognition observation, and systematic desensitization. Tailored approaches falling into the CBT category have emerged as well (e.g., mindfulness-based cognitive therapy and dialectical behavior therapy) (AABT, 2006).

Methods used for Diagnosis

Before commencing with diagnostic methods, an elucidation of what the word 'diagnosis' means is required. The medical concept of diagnosis covers disease identification process as well as disease designation. Arriving at a 'diagnosis' entails clinical examinations and observations, which aid in identifying disease characteristics believed to be producing specific symptoms in a person. The existence of a diagnosis implies that the causal disease's nature has probably, or definitely, been determined. All patients having an identical diagnosis are believed to be suffering from the same ailment or biological abnormality. That is, the basis for determination of their outcomes is nature of their illness, within the series of outcomes linked to that specific illness. Through diagnosis, patients may also be anticipated to demonstrate response to a certain set of medications believed or known to alter the given disease process. In fact, diagnosis' chief practical function in the field of medicine is determining the right treatment to be pursued.

Adoption of the diagnosis concept in the area of psychiatry indicates equivalence of psychiatric categorization and clinical diagnosis through the inference that a physical dysfunction gives rise to psychiatric issues. Thus, diagnosis in the psychiatric field must establish treatment nature just like in the field of medicine. A few preliminary classification systems in psychiatry metaphorically and loosely apply the word "diagnosis." In order to diagnose or identify a behavioral or mental disorder, two psychiatric classification schemes are usually employed (BPS, 2012).

DSM

The APA Diagnostic and Statistical Manual of Mental Disorders is an authoritative list of what are to be considered mental disorders (Frances & Widiger, 2012). It is the standard mental illness classification utilized by U.S. mental health specialists. It is meant to be applied in every medical setting by healthcare practitioners of diverse theoretical orientations. Healthcare workers like psychologists, psychiatrists, counselors, social workers, rehabilitation therapists, occupational therapists, nurses and physicians can make use of it. DSM-5 may also be employed in community-based and clinical research. It forms a central instrument in gathering and disseminating precise statistical information on public health. DSM comprises three basic components: diagnostic classification, descriptive text, and sets of diagnostic criteria (APA, 2015).

Diagnostic classification represents a formal listing of mental ailments recognized in the Manual. Every individual diagnosis is associated with a certain diagnostic code, employed generally by individual healthcare and health-related organizations and providers for the purpose of billing and data collection. The codes originate from a universal coding system -- International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) -- for all healthcare workers in America.

For all disorders that are cited within the DSM, there is a collection of diagnostic conditions that indicate symptoms, which have to be present (for a certain minimum period of time), along with a listing of other conditions, symptoms, and disorders that have to be dismissed for qualifying for any particular diagnosis. Though these measures facilitate increased reliability of diagnosis (that is, the probability of two physicians arriving at an identical diagnosis when they utilize DSM for patient assessment), it is imperative to bear in mind that the criteria have to be utilized by qualified professionals through clinical judgment; a layman isn't entitled to utilize it like a cookbook for the amateur.

The third DSM component is descriptive text accompanying all individual disorders. DSM-5 offers details on distinct disorders under different titles (APA, 2015). One of the early drafts of the DSM is said to have included the declaration that mental ailments form a subcategory of medical ailments; this statement was omitted from subsequent versions, following an APA (American Psychological Association) complaint (Kutchins & Kirk, 1997). Additionally, a tremendous effort was applied by the research team for proving DSM III categories' reproducibility or consistency, with scant focus on their validity. The above step was essential so that concepts described in the DSM could be legitimately applied in the context of medical research methodologies like clinical trials and epidemiological works (Moncrieff, 2010).

The International Classification of Diseases

ICD represents the customary diagnostic instrument for clinical, epidemiology, and health management purposes. It is utilized by healthcare workers like doctors, nurses, health information coders and managers, researchers, patient organizations, lawmakers, healthcare-related IT specialists, and insurers for classifying health issues (like diseases) recorded on multiple vital and health records (which include death certificates) (WHO, 2015).

Critical Evaluation of Diagnosis and DSM

The creation of the DSM's fifth edition (i.e., DSM-5) has revitalized and further propelled critical discussion with regard to diagnosis' role and status in the area of mental health. This edition of the manual has garnered significant censure. Of particular importance is the criticism faced with regard to this highly popular, widely applied, and virtually mandatory manual's role in medicalization processes (Pickersgill, 2013). Issued and managed by the American Psychiatric Association, this manual is promoted as a hi-tech accomplishment based on science and data. The DSM's design and arrangement imparts a picture of accurate, rigorous criteria, which may be applied for formulating a mental ailment's diagnosis. This degree of precision has convinced a number of medical professionals to reach the conclusion (without any critical analysis) that the manual establishes and defines distinct, clear-cut disorders in a way that proves valuable and convenient to professionals as well as consumers. It comes with a fair share of benefits. When utilized appropriately, it can prove greatly reliable. However, this only implies that healthcare professionals who make use of this manual frequently reach an identical diagnosis. Practitioners and researchers express concerns regarding the fact that their inferences, while consistent, are usually erroneous, and might end up causing more damage than cure (Conner, 2015).

Theory Applied to Practice

The DSM manual has invariably provided an explicit approach to patient diagnosis. In other words, the person either 'has' or 'is free from' a particular ailment. Every individual who undergoes the examination (evaluation) and diagnosis process can definitely be placed in one category -- either 'yes' or 'no' -- in relation to a specific type of psychopathology. Of late, and particularly with regard to certain syndromes (like, personality disorders), increasing empirical support and emphasis is being placed on non-categorical psychopathological approaches. In specific, the dimensional model has been out forward by several doctors and medical scholars (e.g., Costa & Widiger, 2001; Trull & Durrett, 2005; Widiger & Trull, 2007). As per this perspective, the problem isn't an ailment's absence or presence. Rather, it is with regard to which point on a dimension or continuum the symptoms of a patient fall. Consider the example of a client (say, Robert) who strongly tends to elude social settings as he fears rejection and disapproval from others. An uncompromising system would necessitate that his psychologist establish whether or not he suffers from a certain disorder -- probably avoidant personality disorder or social phobia. On the other hand, a system that is dimensional would not necessitate a 'no' or 'yes' reply. Rather than facing a dichotomous decision, the psychologist will be required to rank Robert's condition on a scale of nervous evasion of social circumstances. That is, instead of a straightforward 'present' or 'absent' decision, the psychologist will have to ascertain which point on the continuum ideally represents the symptoms displayed by Robert (Pomerantz, 2013).

Professional & Ethical Issues

The matter of diagnosis is delicate in the context of professional psychology. A large number of psychologists feel a degree of ambivalence concerning the professional necessity to diagnose the disorder of a client prior to commencing therapy (Welfel, 2010). Earlier, diagnoses were generally regarded as demeaning labels or irrelevant categories. However, in the year 1980, the American Psychiatric Association issued its 3rd edition of DSM (i.e., DSM-III), and as its nosology proved to have better clinical use than earlier editions of the manual, diagnosis grew into the keystone of medical practice (Maxmen, Ward, & Kilgus, 2009). At present, some practicing psychologists do have doubts about psycho-diagnosis' value, but there are very few who avoid making diagnoses. As client disorder diagnosis has now become a tradition in clinical settings, it is imperative that it occurs to the highest degree of accuracy possible. Clients with correctly-diagnosed issues will be able to receive superior quality treatment, and, in turn, have greater likelihood of improving. On the other hand, those with incorrectly-diagnosed issues may receive the wrong treatment, poor prognosis, and end up wasting both money and time. Doctors who incorrectly diagnose a patient's condition may also end up wasting a considerable amount of effort and time, and may be faced with legal and ethical sanctions. Psycho-diagnosis isn't precisely a clinical or scientific process. Rather, it represents a multifaceted task that requires comprehensive understanding of the system of diagnosis, superior information collection and interviewing skills, and sound clinical judgment. Because of this complexity, qualified doctors can have genuine differences in opinion with regard to illness diagnosis of any given patient (Thomason, 2014).

Numerous APA-prescribed (2002) ethical values and codes are relevant in the psycho-diagnosis context. According to principle C, psychologists uphold the values of scrupulousness and integrity and don't involve in dishonesty, ruses, or deliberate misrepresentation of information. According to standard 9.03, psychologists procure informed permission for providing diagnoses, including confidentiality limits and a clarification of third-party involvement. The above statements establish clearly that deliberate misdiagnosis is an unethical act. Psychologists may also tend to over-diagnose patient problems solely for patient benefit, as there would be no need for treatment, otherwise. However, as payment is made only if, and after, treatment is availed, they cannot avoid the manifestation of self-interest. As intentional under-diagnosis can actually ensure that client treatment isn't eligible for recompense, it may appear to be more humane and a less serious unethicality than overstated diagnosis. However, since it is a form of dishonesty, it contradicts APA's ethical principles. Furthermore, if under-diagnosis by a practitioner leads to incorrect treatment, they may face a lawsuit for clinical malpractice (Kirk & Kutchins, 1988).