Diagnosing mental health conditions is more art than science – always was, always will be. The diagnosis of general medical conditions is not without an art component, but physical medicine has a major advantage over mental health medicine: the ability to objectify findings. Diagnostically speaking, there is an obvious, self-evident advantage to be able to confirm findings by way of blood work, scans and pictures (as in X-rays). In mental health, there is not one single blood test or reliable scan to aid in diagnostic confirmation. It’s just the way it is for now, and I suspect for a long time to come.
The skilled mental health diagnostician is not seeking perfection as there is no such thing. Instead, this clinician is seeking diagnostic assuredness. It begins with a thorough assessment of the presenting client and not a memorization of the DSM. In fact, the mental health bible stays on the sidelines, serving only as confirmation and as a reference for coding purposes. Savvy practitioners rely on the “art of the question.” That’s not to say they don’t bring an excellent command of the signs and symptoms of the mental disorder spectrum to the process. They do. But the essence of their skill lies in the ability to frame a series of insightful, intuitive questions around the client’s presenting problem. Adroitly, assertively, yet tactfully, they approach assessment with tactical precision and are aware that success with any client means this: the language controls the discussion; the discussion controls the relationship; and the relationship controls the quality of the outcomes. As such, the highest premium is placed on rapport building.
Observation is also important. The nuances of client head movements, facial expressions and overall body language are every bit as important as the changes in their vocal delivery. What these clinicians see in a client is every bit as important to them as what they hear.
The inability to confirm a diagnosis by way of objective findings notwithstanding, mental health work has another strike against it – the intimacy of the practice setting. When a patient visits his or her primary care physician, there are often layers of staff – receptionists, lab technicians, nurses, and physician’s assistants – to sift through before seeing the doctor. Mental health settings tend to be more one-on-one, so it’s natural for someone to guard their information at first. The experienced mental health clinician tackles this head on by first putting the client at ease before getting down to work.
Systematically then, the clinician shapes the client’s responses and non-verbal behavior – gathered though their questioning and aided by insight and intuition – into a diagnosis. Then and only then does the hard work of helping the client reach their expectations for treatment begin.
A final point. Those professionals who are undeniably accomplished and highly sought after understand that while diagnoses have utility, there will probably never be clear, undeniable “markers” as found in general medicine and that the notion of chemical imbalances and neurotransmitter difficulties is highly speculative. So they don’t go there; they deal instead with what and how the patient presents.