Wednesday, May 3, 2017


Q. I’ve heard that mental health professionals use a manual to diagnose each client. I would like to know more about this. Can you tell me what areas are evaluated using this manual and is it reliable? 

A. The Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association, was designed to provide a clear description of each diagnostic category so that clinicians and researchers could learn, communicate about and treat individuals in a consistent and effective way. The intent was to define a given disorder by listing its specific symptoms or behaviors so that it is distinguished from every other disorder. 

Though the Diagnostic Manual has been criticized in a variety of ways over some period of time, it has had great influence in the mental health field. Insurance companies and the pharmaceutical industry rely on it to monitor the appropriateness of treatment. Clinicians must use the Diagnostic Manual in order to submit insurance claims for clients.

The Diagnostic Manual includes five areas of evaluation. The first one includes all of the psychological diagnostic categories except for personality disorders. Number two includes personality disorders (in grained personality patterns such as paranoid, schizoid, narcissistic) and mental retardation. Number three lists general medical conditions which may be affecting the client’s functioning. Number four describes interpersonal and environmental factors or problems (such as job loss, marital problems). Number five is called the Global Assessment of Functioning (GAF) which is a measure of the individuals over all level of functioning. 

Mental disorders can not be as precisely diagnosed as heart conditions or cancer but the Diagnostic Manual does provide a framework, including a range of behavior or symptoms, to assist clinicians in evaluating a client’s mental and emotional functioning.

There are problems with this, however. Human nature and personality are complex, involving mind, body, spirit and emotions. It is difficult to pigeon hole or label individuals and this is often done after just a fifty minute evaluation. Also labels can change. We grow, learn and mature through out life and often our past labels no longer fit us.

It is sad when someone has been given a mental health diagnosis incorrectly but it follows them in their medical chart endlessly or when they have changed and this change is not recognized. Also, because of the need to qualify for insurance coverage, the tendency is to use the diagnosis that will give the most coverage. This can encourage giving a more severe diagnosis than necessary.

In the April 2001 issue of Social Work, Dr. Dennis Saleebey suggests another problem, the need for a sixth category detailing Diagnostic Strengths. The Global Assessment of Functioning (GAF) defines competent functioning mainly as the absence of symptoms.  In Saleebey’s suggested sixth category of Diagnostic Strengths clinicians would list the strengths of each patient. This would include skills, talents, virtues, interpersonal abilities, family support, a strong faith and so forth. 

This idea is supported by the work of Daniel Goleman in his book Emotional Intelligence in which he gives evidence that characteristics such as self-awareness, persistence, empathy, and optimism produce successful, happier and healthier lives. 

The Diagnostic Manual is an essential and valuable tool in the field of mental health.  I agree with Saleebey, however, that there is a need to include the patient’s strengths in the evaluation. Too often the mental health field focuses on what’s wrong rather than what’s positive or valuable in a person’s life or make up. 

When choosing a therapist, find one who will recognize your strengths in the midst of your symptoms and problems.  Pay attention also to your own strengths. As I said before in a prior post, choosing a therapist with a similar world view is important no matter what. This is especially true if your faith is very important to you or if you want to explore spiritual issues. To do otherwise is like trying to communicate in two different languages.  

Blessings, Dottie

“Plans go wrong for lack of advice; many counselors bring success. Proverbs 15:22 NLT

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