Developing a Private Practice - Course blog: The DSM-5 - Some troubling mistakes - Johns Hopkins -Dr. Lynn Friedman

<http://www.psychiatrictimes.com/display/article/10168/1522341?pageNumber=1&verify=0> Read this and consider the implications!  Best to all. LVF

Comments

[Sarah Gilden]

Dr. Friedman - What are your thoughts on providing a formal diagnosis for your clients? Do you believe every patient requires one? Or that it is only necessary for the sake of health insurance reimbursement? Or something somewhere in between. I really struggle with the idea of having to give a diagnosis to every client who walks in the door, regardless if it is warranted. Thanks!

[Lynn Friedman, Ph.D.]

Hi Sarah,

Thank you for your question. My feelings about diagnosis, a la the DSM, are twofold. First, I think that this sort of diagnosis CAN be useful in two ways. If a person has a disorder in which psychopharmacology can be a useful adjuvant to psychotherapy, then it can be very useful to provide a diagnosis. For example, schizophrenia and bipolar I often yield to psychopharmacological intervention. I am not in any way denigrating the very important role that psychotherapy can play in addressing these difficulties (as I believe its' role has been empirically documented). Rather, I feel that medicine has an equally important role to play with these sorts of problems. In fact, failure diagnose the presence of these difficulties is a very serious problem, indeed. Providing this diagnosis to the consulting psychiatrist can play a vital role in ensuring that these patients are treated in a helpful fashion.

On an unrelated vein, insurance companies require diagnoses, a la the DSM, in order to reimburse the patient. Although this feels, to me, a little bit like the tail wagging the dog, my own feeling is that it is important to provide these sorts of diagnoses, for insurance purposes if (and, only if) the patient requests it.

Beyond these two purposes, I rarely (with some exceptions) provide DSM diagnoses. Let me start with the exceptions and then return to my general practice.

As I've already said, if a patient is suffering from a major mental illness - psychoses or major depression (bipolar or to use the old nomenclature, unipolar illness), I will provide a DSM diagnosis. Substance abuse and borderline personality disorders are other arenas in which I might provide such diagnoses. My main goals here are - to inform the psychiatrist and other ancillary clinicians (e.g. family, couple's therapists, etc.) of my assessment of the difficulties and most importantly to inform the patient. That having been said, the matter of diagnosis is delicate and requires tact. It should certainly not be brought up at the end of the session. Rather, the patient needs time to express and explore their feelings about it.

It has been my experience, that if diagnosis is diplomatically addressed, that many, though not all, patients experience a significant relief in being given a diagnosis.

That having been said, I do not diagnose most of my patients with DSM diagnoses UNLESS it is required for insurance purposes. This is because most of the people who I see are mental health professionals, (psychologists, counselors, social workers), physicians, lawyers (as I practice here in Washington), an array of other professionals and their teenage and adult children. Most of my patients are suffering from what we used to call psychoneuroses in the old days: anxiety, depression, dysthymia, relationship difficulties, troubled family relationships, career difficulties, problems getting along with others, self-esteem difficulties, problems with narcissism, etc. Although many fit the categories in the DSM (as these categories are so overbroad nearly everyone could fit somewhere), I just don't find it very useful to label them. In fact, labels can have an iatrogenic effect. And they can be circular. For example: "I have an anxiety disorder so I act anxious." Now, what does that really tell anyone and how does it help the patient? I don't find that this sort of labeling leads to a deepening of ones self-awareness.

However, I do feel that, following a careful psychological evaluation, I am obligated to provide the patient a very clear and explicit formulation as to how I understand their difficulties and how I feel that they can be effectively addressed. In my opinion, this should be synced up with why they have their presenting problem. This sort of formulation is, in my opinion, different than diagnosis in that it clearly addresses the patient's unique struggles and strengths. It informs as oppose to categorizing and stigmatizing. Just my thoughts. Thank you for the question and I look forward to seeing you in class!

Best, LVF

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Lynn Friedman, Ph.D.
Psychologist, psychoanalyst, work-life consultant
Faculty Associate, Johns Hopkins University
5480 Wisconsin Avenue
Chevy Chase, MD 20815
301.656.9050
http://www.drlynnfriedman.com
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http://www.drlynnfriedman.typepad.com
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