Diagnostic Approaches in Mental Health and Clinical Psychology

Introduction

Psychological and medical practices have developed from two separate traditions. Medicine 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 discovering new ones. Scientific analysis, for example, 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 as 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 quite differently from medicine. It began by searching for symptoms that could 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 courses in abnormal psychology. Nevertheless, a survey financed by the Psychology Network of the Higher Education Academy (Cromby, Harper, & Reavey, 2007) revealed that most abnormal psychology courses employed textbooks designed around the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. These textbooks contain outdated psychiatry critiques and are unable to offer an expressly psychological perspective on the subject matter (Cromby, Harper, & Reavey, 2007).

The monthly publication The Psychologist frequently presents debates regarding diagnosis and psychologists (e.g., Pilgrim, 2000). A number of psychologists, however, continue employing diagnosis. Their typical argument is that, though challenging, it offers a valuable shorthand form of communication vital to multi-disciplinary work. Research scholars and clinicians analyze various concerns about diagnosis and contend that it does not improve, but rather muddles, our understanding. The reason for diagnosis' continued adoption is also frequently cited. As it is a knotty aspect of practice, one alternative research suggestion is to analyze actual experiences of individuals. A pilot model to achieve this deals with experiences such as unusual thoughts or hearing voices. It is often implied that the extensive utilization of psychiatric medication supports diagnosis' validity (Cromby, Harper, & Reavey, 2007). The psychosis report of the Division of Clinical Psychology (2000) of the British Psychological Society suggested a shift from diagnosis to formulation-based psychology. This paper examines diagnostic clinical psychology approaches.

Theoretical Frameworks in Clinical Psychology

Psychodynamic Psychotherapy

This approach is derived from Freud's psychoanalysis, whose key goal is awakening the unconscious — that is, making clients aware of their primitive drives (pertaining to aggression and sex) and the various defenses employed for keeping those drives in check (Gabbard, 2005). Analysis of clients' transference toward their psychotherapist, and the application of free association, are key psychoanalytic tools. Transference denotes the tendency to take emotions or unconscious thoughts relating to a significant individual (such as a parent) and redirect them onto another person (in this case, the psychotherapist).

Humanistic Psychology

Humanistic psychology originated during the 1950s as a response to psychoanalysis and behaviorism, chiefly through Carl Rogers' client-centered therapy (popularly known as Rogerian psychotherapy) and the existential psychology of Rollo May and Viktor Frankl (Plante, 2005). In Rogers' view, clients required only three things from their therapist — empathy, congruence, and unconditional positive regard — for positive therapeutic outcomes (McMillan, 2004). Through the use of phenomenology and first-person and inter-subjective categories, humanistic psychology attempts to consider the whole individual rather than mere disjointed components of a person's nature (Rowan, 2001).

Behavioral and Cognitive Behavioral Theory

Cognitive behavioral therapy (CBT) is based on the premise that the way one thinks (cognition), acts (behavior), and feels (emotion) are interconnected and interact in complex ways. From a CBT perspective, specific dysfunctional ways of understanding and evaluating the world — usually through beliefs or schemas — can be a source of emotional distress or can produce behavioral problems. A number of cognitive behavioral treatments are aimed at identifying and addressing these dysfunctional, subjective ways of responding, and through various techniques, assist clients in overcoming them in ways that improve personal well-being (Beck, Davis, & Freeman, 2007). Numerous methods are applied, including Socratic questioning, maintaining a thought log for cognitive observation, and systematic desensitization. Tailored approaches within the CBT category have also emerged, such as mindfulness-based cognitive therapy and dialectical behavior therapy (AABT, 2006).

Methods and Systems Used for Diagnosis

Before discussing diagnostic methods, it is useful to clarify what the word "diagnosis" means. The medical concept of diagnosis covers both the process of identifying a disease and designating it by name. Arriving at a diagnosis entails clinical examinations and observations, which aid in identifying disease characteristics believed to be producing specific symptoms in a patient. The existence of a diagnosis implies that the nature of the causative disease has probably, or definitively, been determined. All patients sharing an identical diagnosis are presumed to be suffering from the same ailment or biological abnormality — that is, the basis for determining outcomes rests on the nature of the illness within the range of outcomes associated with that specific condition. Through diagnosis, patients may also be expected to respond to a certain set of medications believed or known to alter the given disease process. In fact, the chief practical function of diagnosis in medicine is determining the right course of treatment.

Adoption of the diagnosis concept in psychiatry implies equivalence between psychiatric categorization and clinical diagnosis, inferring that a physical dysfunction gives rise to psychiatric issues. Thus, diagnosis in psychiatry must establish the nature of treatment just as it does in medicine. Some early classification systems in psychiatry apply the word "diagnosis" metaphorically and loosely. To diagnose or identify a behavioral or mental disorder, two psychiatric classification schemes are commonly employed (BPS, 2012).

DSM

The APA Diagnostic and Statistical Manual of Mental Disorders is an authoritative listing of what are considered mental disorders (Frances & Widiger, 2012). It is the standard mental illness classification used by mental health specialists in the United States, and is intended to be applied in every medical setting by healthcare practitioners of diverse theoretical orientations. Healthcare workers including 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, and it serves as a central instrument in gathering and disseminating statistical information on public health. The DSM comprises three basic components: diagnostic classification, descriptive text, and sets of diagnostic criteria (APA, 2015).

Diagnostic classification represents a formal listing of mental disorders recognized in the manual. Each individual diagnosis is associated with a diagnostic code, employed broadly by healthcare organizations and providers for billing and data collection. The codes originate from a universal coding system — the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) — used by all healthcare workers in the United States.

For all disorders cited within the DSM, there is a collection of diagnostic criteria indicating the symptoms that must be present (for a specified minimum duration), along with a listing of other conditions, symptoms, and disorders that must be ruled out before qualifying for any particular diagnosis. Though these measures facilitate increased diagnostic reliability — that is, the likelihood of two clinicians arriving at an identical diagnosis when using the DSM for patient assessment — it is important to bear in mind that the criteria must be applied by qualified professionals using clinical judgment; a layperson is not entitled to use it like an amateur's cookbook.

The third DSM component is the descriptive text accompanying each individual disorder. DSM-5 offers details on distinct disorders under various headings (APA, 2015). One of the early drafts of the DSM is said to have included a declaration that mental ailments constitute a subcategory of medical ailments; this statement was omitted from subsequent versions following a complaint by the American Psychological Association (Kutchins & Kirk, 1997). Additionally, considerable effort was applied by the research team to prove the reproducibility or consistency of DSM-III categories, with scant attention paid to their validity. This was considered necessary so that concepts described in the DSM could be legitimately applied in the context of medical research methodologies such as clinical trials and epidemiological studies (Moncrieff, 2010).

The International Classification of Diseases

The ICD is the standard diagnostic instrument for clinical, epidemiological, and health management purposes. It is used by healthcare workers including doctors, nurses, health information coders and managers, researchers, patient organizations, policymakers, healthcare IT specialists, and insurers for classifying health conditions recorded across a wide range of vital and health records, including death certificates (WHO, 2015).