Developing a Successful Private Practice - Psychiatric Diagnosis: Dr. Lynn Friedman - Johns Hopkins

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 helpful to provide a diagnosis. For example, schizophrenia and bipolar illness 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 to 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, serious 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 therapists, 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, in these situations, 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 can fit somewhere), I just don't find it very helpful 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 informing as opposed to categorizing and stigmatizing. Just my thoughts.

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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
http://www.corporationsonthecouch.com
http://www.drlynnfriedman.typepad.com
http://www.twitter.com/dcpsychologist
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Comments

[Tamara Suttle]

Lynn, thanks so much for posting on the DSM and diagnoses. Like you, I refrain from doing so unless it's absolutely in the client's best interest to do otherwise. It is encouraging to see that at least your students are being taught the limitations of diagnosing and the DSM. (One of my colleagues years ago suggested that it was an acronym for the Dark Side of Man. Ha ha.)

I am looking forward to speaking with you about your class. It's really great to hear that a program is concerned about students knowing the business side of the mental health professions!

Tamara G. Suttle, M.Ed., LPC
http://www.TamaraSuttle.com
http://www.AllThingsPrivatePractice.com

[Jessie Vinik]

Dr. Friedman,

Thanks for sharing your thoughts on the use of DSM diagnosis in private practice.

Given that you do not make a formal diagnosis for most of your patients, am I correct to assume that the standard invoices you provide for your patients do not contain diagnosis codes? What codes do your invoices include, if any? For example, do you include procedure codes? I suppose if a patient tells you that he or she has no intention of submitting invoices to insurance, there is no need for any such codes.

Thanks,
Jessie Vinik

[April Lehman]

If you are not making a DSM diagnosis for the majority of your clients, is it fair to assume they are paying for their therapy sessions outright (since they are not going through insurance)? I agree with your reasoning that a DSM diagnosis can be a stigmatizing label. It seems unfair though for those who have to go through insurance because its the only way they can afford treatment. I'd like to know your thoughts.

Thanks,

April Lehman

[Lynn Friedman, Ph.D.]

Again, April, I leave the decision regarding whether or not to use insurance entirely up to the patient. If they decide to use insurance, I make a DSM diagnosis since this is required. In any case, irrespective of whether or not they use insurance, I provide them with a detailed explanation as to how I understand their difficulties and how I recommend we intervene.

As for your question, I am little unclear about what seems unfair. Can you clarify that.

Best, LVF

[Lynn Friedman]

That's right, Jesse, I provide codes only at the patient's request. However, as I mentioned in my post, I think in recommending treatment, it's vitally important to be clear with the patient about my diagnostic formulation. That is, I talk with the patient about how I understand their difficulties and how I believe they can be effectively addressed. As I am a psychoanalyst, my conceptualizations are psychoanalytically-informed.

[April Lehman]

Dr. Friedman,

What I mean by "unfair" is in terms of the insurance company. Clients who use insurance because that is the only way they can afford treatment get a formal DSM diagnosis which is forwarded to the insurance company. This starts a paper trail which to my understanding, can be looked up by future employers or maybe during background checks. So, in essence there is this diagnosis looming out there for others to view. On the other hand, for those patients who pay in cash, they don't have to worry about that paper trail from the insurance company. This is just my understanding - please correct me if I'm wrong. I've been told by other professors that they have clients that only pay cash because they have high profile jobs and they want to be kept anonymous and don't want anyone to find out they are in counseling. Clients that have to use insurance don't get that luxury. This is definitely an interesting topic - I appreciate your input.

Thanks,
April Lehman

[Lynn Friedman, Ph.D.]

Ohhh. Now, I understand. Yes. I agree. LVF

[Lisa Smith]

Dear Dr. Friedman,

An interesting article in the March/April issue of Psychotherapy Networker provides an indepth look at the politics involved in trying to get a new diagnosis (Developmental Trauma Disorder) included in the DSM-V. Mary Sykes Wylie explores the tension between researchers, who are the gatekeepers of the DSM, and clinicians, who are the primary users of the manual. Wylie notes that there are high stakes involved in whether or not a diagnosis is included in the DSM, including how clinicians conceptualize--and therefore treat--a client’s problems, insurance reimbursement, and the availability of research funding.

http://www.psychotherapynetworker.org/magazine/currentissue/810-the-long-shadow-of-trauma

As a novice therapist, I find that I have to remind myself the DSM is simply a construct, but is not the last word in conceptualizing the issues that a client is experiencing.

Best,
Lisa Smith