December 8, 2019
Welcome to What’s Better This Week? Episode 3: What’s A Diagnosis Anyway?
Last week we covered what happens in an initial assessment session, the complications that assessment appointments bring when attempting to have a solutions focused practice in a clinical environment, and we finished with our hypothetical patient leaving their first (of three) assessment appointments.
So what happens after they leave my office? What do we do during their second assessment appointment? How do we prepare them for their third assessment appointment? All good questions. I’m glad you asked them.
After I’ve walked the patient back to the waiting room, there are certain things I have to go back and do that are not in line with solutions focused practice.
I have to add a mental status exam note (or MSE) to my documentation. This is a requirement in clinical practice. But just because something’s a requirement doesn’t mean that we can’t be solutions focused about it.
Generally speaking any standard MSE might read like:
Patient presented through Same Day Access, dressed appropriately, appeared alert and well-oriented. There was no evidence of disruption in speech flow or content, memory, or perception. Current mood observed as dysphoric with affect congruent to mood. Thoughts were organized and goal-directed. Judgment appeared good, and insight appeared moderate.
Patient presented with:
But what is we reframed the presenting symptoms to be not only more solutions focused, but more accurate to the patients truth, and more in line with our practice of taking a step down approach, and honestly more accurate to the patients presentation in general and instead the it read:
Desire to decrease stressors regarding housing
Desire to decrease stressors regarding living situation.
Hopes to increase mood, and desire to decrease feelings of depression.
Well, look at that. By reframing the “objective” (if there ever can be such a thing) MSE’s presenting “ problems to be solutions focused we reorient ourselves and our patient’s documentation away from the typical “patient is depressed,” “patient is angry” to where our patients are back in control, and are being proactive. My what a different way of thinking about our patients. What a different way of framing them to our colleagues. What a way of taking back control from the insurance companies where we must ethically, in a clinical fashion, report clinical symptoms each and every session (which means that everything we do to assist our patients, somehow, must also ethically link to these symptoms and further the patients goals of decreasing them or improving them!). It takes something that is antithetical to SFBT practice, and moves it in a way that most aligns to our core beliefs.
Then, and this is of course where my scruff gets a little more ruffled. I have to provide some kind of diagnosis, because if I don’t, insurance won’t pay for the session. And if we, as an agency, don’t receive insurance payments we can’t continue to function as a clinic; and I, as a practitioner, deserve to receive compensation for my labor. I have to eat. I have to pay my bills. And so, I have to provide a diagnosis.
Here is another touchpoint.
We must remain ethical. We must remain truthful. We must remain solutions focused. We must balance each session and conversation in order to connect our patients conversation and scaling and best hopes to their mental health concerns which means we must, at times, also guide them in ways we might not have to in a pure SFBT environment. And so diagnosis becomes tricky, and important, because it will become relevant every single session
That said, how we approach the concept of diagnosis with regard to a computer screen, and with regard to a human patient, remain two very different things.
Sometime during the first session, when I am given permission to provide psychoeducation on SFBT to my patients, I will discuss with them that a diagnosis is only important to us if it’s relevant to the patient, and that some patients find it relieving, or useful in establishing a framework to understand what has been going on in their lives, and others require it for state or federal benefits. I stress the greater importance of removing barriers, and that the work we’ll be doing together does not require a diagnosis, nor does it require great discussion on what someone’s diagnosis is. I also share that generally the institution most concerned with a diagnosis is the insurance company, so they’ll pay for treatment. I provide psychoeducation that all a diagnosis is, is a label for a cluster of symptoms, and that what we’re concerned with is how those cluster of symptoms come together to create barriers for them, and what we’re going to do to reduce, mitigate, and remove those barriers so they (that is to say our patients) can live the lives they want.
So, here is where you will have a dialectic: while you’re going through this process for purposes of explaining to the insurance company, and justifying your SFBT practice, you are going to have on your clinical, psychopathology hat, because you need to. Because otherwise marginalized communities can’t receive SFBT treatment. You will formulate and postulate and pontificate once in your case conceptualization somewhere in the assessment document and be done with it (though you will have to be extraordinarily accurate, so I urge you to take your time - all of your SFBT work will have to come together and connect with this later, and we’ll get much deeper into that as we go on).
The other side of the dialectic coin is that, because you’ve taken time to explain the meaning of what a diagnosis actually is (a cluster of symptoms) and what you and the patient are going to be concerned with (how those symptoms create barriers) you are then free to continue in a solutions focused way (“how did you make that work?”, “that sounds hard, how have you been coping”) to complete the rest of the assessment tabs.
So whether a patient is “screening positive” for trauma, schizophrenia, mood, eating disorders, gambling disorders, substance use disorders, we can use the same solutions focused skills as discussed in last weeks episode, because when it does come time to discuss these (during the treatment planning session), we won’t be using the clinical labels of diagnosis, we’ll be using the solutions focused language of barriers. In situations where we would have to refer out (ie. Eating Disorders for parallel treatment) the same is still true in our individual sessions where we discuss everything else under the sun.
This is the balance. We are literally being honest to ourselves (in maintaining our SFBT practice); our patients in explaining to them why we talk in terms of barriers and not diagnosis (while still providing them the opportunity to talk about diagnosis if they want), and the insurance company by providing them with as accurate a diagnosis as the DSM-V can muster, which we will link all treatment to in the future. We are, in essence, creating multiple work products out of the same session, or presenting the same data in different ways, so it can be processed and assessed in the ways that it needs to be, so that each receiver of our information can receive it best (and if that’s not Solutions Focused, I’m really not sure what is).
There’s an excellent article on Alpha, Para, and Infrasignal I will link to in the podcast notes that is heavily correlated to this.
So now, we have completed the information gathering necessary for our second assessment session.
I then explain where we are in the assessment process. I explain at their next appointment I’ll be asking them some final questions about themselves and their world, and asking for a urine sample. The time has now come to summarize what has been completed with the patient. I ask them what questions they have (not “if” they have questions, but what questions they have). I check with each and every patient as to whether or not they have thoughts, plans, or intents or harming themselves or others, and then I get them scheduled for their third and final assessment appointment.
so Next Week: the third appointment, which again comes right before the treatment planning session. These seems like a good place to leave off because, again, if you’re frustrated by not getting more imagine what our patients are frustrated by , by having to wait a total of four sessions before they can finally begin treatment.
Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is, actually not patiently waiting for cuddles, but sitting on top of me while I record this.
The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue
, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you next Sunday with more; until then, make good choices.