Assessing clients' symptoms to make a diagnosis is an importantcounseling skill. Diagnoses are often required for reimbursem*nt forservices through managed care. Client diagnoses can also provide importantconceptual information, and diagnoses can be used alongside a clientconceptualization, to aid in deciding what treatment(s) will be used.
Ethics & Diagnosing
Section E.5 of the 2014 ACA Code of Ethics provides counselors with guidanceregarding diagnosing clients.
Counselors take special care to provide proper diagnosis of mentaldisorders. Assessment techniques (including personalinterviews) used to determine client care (e.g., locus oftreatment, type of treatment, recommended follow-up) arecarefully selected and appropriately used.
ACA,2104, E.5.a
Counselors recognize that culture affects the manner in whichclients' problems are defined and experienced. Clients'socioeconomic and cultural experiences are considered when diagnosingmental disorders.
ACA,2014, E.5.b
Counselors recognize historical and social prejudices in themisdiagnosis and pathologizing of certain individuals and groups andstrive to become aware of and address such biases in themselves andothers.
ACA,2014, E.5.cSee AlsoUltimate Goal of Biblical Counseling! - Lucy Ann MollIdleness and Temptation | TabletalkBBC World Service | Learning EnglishNuances of Biblical Counseling | WTS
Counselors may refrain from making and/or reporting a diagnosis ifthey believe that it would cause harm to the client or others.Counselors carefully consider both the positive and negativeimplications of a diagnosis.
ACA,2014, E.5.d
DSM-5 Diagnostic Criteria
The fifth edition of the Diagnostic and Statistical Manual(DSM-5) is published by the American PsychiatricAssociation. Themanual contains the diagnostic criteria for a wide range ofmental health concerns, including substance use disorder. This book is amust-own for every professional counselor. The DSM-5 isorganized into sections. The first section provides an introduction to themanual, as well as instructions for use. Section II is where you will finddiagnostic criteria and codes, including Substance-Related andAddictive Disorders. Section III provides information regardingemerging assessments, instruments, conceptual frameworks, and models.
Note that the DSM-5 is written with the number "5", rather than theroman numeral "V".
DSM-5 Codes
When reading through the DSM-5, note the diagnostic codes associatedwith each disorder. For example, Alcohol Use Disorder has threespecifiers:
American Psychiatric Association, 2013
- 305.00 (F10.10) Mild: Presence of2-3 symptoms.
- 303.90 (F10.20) Moderate: Presence of4-5 symptoms.
- 303.90 (F10.20) Severe: Presence of6 or more symptoms.
When writing the diagnostic code, always use the code starting with F,as these are the ICD-10 codes. Use of the ICD-10 codes isrequired under HIPAA as of October 1st,2015.
Primary & Provisional Specifiers
When writing DSM-5 diagnoses, it is important to note if the diagnosisis the primary focus of clinical attention or if the counselor needsadditional information to confirm the diagnosis. The "Primary" specifieris included in parentheses after the diagnosis that is the primary focusfor clinical attention, and the specifier "Provisional" is used if thecounselor is not certain that the client meets sufficient criteria for agiven diagnosis.
For example, the DSM-5 diagnostic criteria for Persistent DepressiveDisorder require an adult to have a depressed mood for a minimum of twoyears. If a counselor knows that their client has been depressed for justunder two years, they might use the provisional specifier until sufficienttime has passed to confirm the diagnosis.
A DSM-5 diagnosis might be written as follows:
F.10.20 Alcohol Use Disorder, Moderate (primary)
F34.1 Persistent Depressive Disorder (provisional)
In this example, the primary focus is alcohol use disorder, and thecounselor is waiting to see if the client meets the criteria forPersistent Depressive Disorder. Depending on the diagnosis given,additional specifiers may be included.
Primary & Provisional Specifiers
The primary and provisional specifiers are used to denote a diagnosisthat is going to be the main focus of clinical attention (primary) or adiagnosis that is not yet confirmed (provisional). For example, a clientwho hasn't had symptoms long enough to meet a diagnosis might be given a"provisional" diagnosis, if the counselor believes they will soon meet allthe diagnostic criteria.
When selecting a principal diagnosis, it is important that counselorsconsider multiple factors, including the client's presenting concern aswell as the potential for one diagnosis to cause or impact another. Forexample, if a client's social anxiety is causing their alcohol use, itlikely makes sense for social anxiety to be the principal diagnosis, sincetreating the social anxiety is likely to impact the alcohol use.
Multiaxial Diagnoses
Previous versions of the DSM used a multiaxial diagnostic system. TheDSM-5 no longer uses different axis for different types of diagnoses ordisabilities.
Writing Diagnoses
When writing DSM-5 diagnoses, write one diagnosis per line, and write theprincipal diagnosis on the first line. Only write the "F" codes, as threedigit numeric codes are no longer used.Write diagnoses in this order:
- Diagnostic code
- Name
- Severity (if appropriate)
- Specifiers (if appropriate)
- "principal" or "provisional" diagnosis
For example:
- F10.20 Alcohol Use Disorder, severe, in early remission, in a controlledenvironment (principal diagnosis).
- F40.10 Social Anxiety Disorder (provisional diagnosis).
