Episode Transcript
[00:00:00] Speaker A: Foreign.
Welcome back to the Zest for Therapy podcast, sponsored by Zest for Life Counseling. We are your hosts, Courtney Dohman AM FT and Celeste Webster, mswi back with another episode of Voices in the Field, where we host Q&As with new and seasoned therapists to learn from their expertise, specialties, and experiences.
[00:00:25] Speaker B: As a disclaimer, while we are therapists, we. We are not your therapists. This podcast is intended for information and entertainment purposes only. Does not constitute therapy, clinical supervision, or medical advice. Opinions expressed are our own and subject to change as research evolves. We do our best, but we're human, and that means we may make mistakes.
[00:00:42] Speaker A: Okay, so today we get to dive into the topic of diagnosing, diagnosing 101. So how to diagnose, do you tell your clients? Do you not? Insurance diagnosing, and all of our other beginner questions. All the things.
[00:00:58] Speaker B: To answer some of our questions, we are joined by Grace sue, also an MFT in Kansas who is from my graduating cohort at Oklahoma State.
[00:01:10] Speaker A: Okay, so, Grace, tell us a little bit about yourself. Get us. Let us get to know you and the work that you do.
[00:01:15] Speaker C: All right. Hi. Well, I am Grace, and I am an LMFT licensed Marriage and family therapist. I'm working towards my clinical licensure, so I'll get that C in a couple years. Fingers crossed.
And I know Courtney from our days back at osu, and I'm so excited to be here.
[00:01:34] Speaker B: Go Pokes.
Okay, so what. What would you say are some of, like, the basics around diagnosing? Like what.
What is. Like, the basic things that people know, need to know when they're in their master's program or just getting out on their own. Own?
[00:01:54] Speaker C: Yeah. No, that's a great question. I feel like my idea and just even relationship with diagnosing has changed so much from grad school to being out in the real world and going from a place where it can be like, kind of. It feels very overwhelming of it could be so many different things to just kind of hitting the pause button for a little bit and just being like, okay, all the symptoms here, they have a name, they have a place, they have a space.
And just figuring out, kind of.
[00:02:29] Speaker A: Just.
[00:02:29] Speaker C: Figuring out what direction feels good, but also being informed. So this is where assessments can come in really handy.
I don't believe assessments alone should mean a diagnosis because it doesn't take into account context, it doesn't take into account the therapeutic relationship you have. But it can be a great way to back up your diagnosis and to confirm if you're going the right direction. So if you're going towards, like, a mood disorder or if you're going towards anxiety or if you're going towards, like, ptsd.
[00:03:00] Speaker A: Yeah. Honestly, I love that. I feel like we do a lot of similar things within the agency that we work at, where it's like, they say, like, the three pillars are using assessments, Your, like, clinical intuition and the DSM interview and stuff like that. So, like, using all of those things together to inform the decision rather than, like, cool. You said yes to all these things on the assessment. Like, let's go.
[00:03:25] Speaker C: So, yeah, that's where it can get dangerous.
[00:03:28] Speaker A: Yes, absolutely.
[00:03:29] Speaker B: One, two. Like, a lot of the assessments will say on it, like, this does not diagnose a person with this thing. And so I think that just kind of like, reminds me, or like all of us, of, like, the clinical intuition is a big part of that. Like, your training and being able to, like, assess things is super important.
And I know, like, starting out, that does feel really overwhelming. Like, when you're learning all of the diagnoses that are in the DSM and then you're like.
Like, if somebody's having difficulty concentrating, do you know how many diagnoses that specific thing falls under?
[00:04:07] Speaker A: Like, at least not just adhd. Just kidding. No, it's not just adhd. I'm just kidding.
[00:04:12] Speaker B: So I love that, like, almost like the piece of hope of, like, at some point it will no longer feel overwhelming because you'll kind of have a sense of.
Of the symptoms, but also your clinical intuition. And you'll be way more familiar with the DSM at that point too.
[00:04:28] Speaker C: Right?
[00:04:29] Speaker A: Yeah.
So we are here for Q and A. So there are many questions that we have on our list, so we'll just get started with some of them.
The first one is, do you need an assessment to diagnose somebody? What do you think? We kind of answered that a little bit, but no.
[00:04:44] Speaker C: Yeah, we talked about a little bit. I think it's a. Again, I think it's a great tool and a great support.
Could you do it with just the initial, like, therapist interview and then confirming that the symptoms you see match the dsm?
If you are. If everything is congruent and it's lining up with each other and you have enough information to cooperate? Like, yes, this is what I'm seeing. Based on abcde, I don't believe that you would necessarily need the diagnosis to make it, or, excuse me, necessarily need the assessment to make it official, but I think that it can be just a good element of that best practice, where you are doing everything you can and where you have almost that standard set of routine. Because without the assessment piece, it can feel like you're like nothing's ever the same.
And each person and each of their symptoms and how they present those are all going to be unique.
But if your first step is assessment first, that gives you the direction you need to go. And then you can use your gut and you can use the DSM to just kind of finish it off.
Right.
[00:05:51] Speaker B: I really like that, and I think something too, because I very much agree, like, your clinical interview, like, that's kind of where I'm like, if you have those questions on lock or you have them in front of you and they meet criteria for those things, then they literally meet the criteria for that diagnosis.
[00:06:10] Speaker C: Exactly. And that that assessment piece would just reiterate what you already wrote in your note.
[00:06:15] Speaker B: Yes.
[00:06:16] Speaker C: Like, they met criteria.
[00:06:17] Speaker B: Exactly. And I think it can be helpful for, like, severity. That's probably where I. I like them the most. But, yeah, I think that's great. So how do you kind of approach diagnosing? Like, do you.
I feel like a lot of therapists kind of come to their own way of doing that. I very much have a set way that I do that. So how do you go about giving somebody a diagnosis? What does that process look like?
[00:06:44] Speaker C: So that process has changed a lot for me over the last year. Almost year and a half since I've been out on my own. Since then, I've been in inpatient settings. I've been in integrated care at a medical provider's office.
And then now I'm in private practice doing play therapy.
And so just a lot of different areas, and they all diagnosed differently.
Something that I took away from my time in the kind of medical mental health world was having that diagnosis filing cabinet just kind of ready to go.
But also it took a lot of.
[00:07:24] Speaker B: Time to get there.
[00:07:25] Speaker C: And we were expected to be able to provide a diagnosis within 15 minutes.
[00:07:30] Speaker B: Right.
[00:07:30] Speaker C: That was kind of the unspoken rule.
And I learned that my style is more conversational and that without that time constraint, I can naturally find ways to bring up timeline, to bring up intensity, to bring up. Was it just you? Was it a family thing? So that way, you know, if it's like a systemic. Like if there's some systemic trauma that influenced it, or if it was like an isolated. Where they're the only ones who are feeling this way.
And so just finding. So now that I've gone through all the different places that I've Been. It helps me just figure out how I want to be. And so right now, for me, that looks like that conversational route, but also, if they're feeling stuck or feeling like they don't know how to answer that question of just, like, tell me what it's like, then I can go more into that closed question route of, do you feel like this applies? Yes or no. And then if yes, I can have them put it in their own words. But sometimes just the tell me how you feel can be so overwhelming. It's like I don't even know where to start.
And we might end up missing some things. So sometimes I'll even just.
I feel it. And this is. I don't know if this is related to the question or not.
The more I found myself diagnosing, I. You kind of notice certain patterns.
And for me, this sounds weird.
Certain diagnoses kind of have a smell to me. Not like a literal human smell, but just like, there's a sense, there's an energy, as if you were smelling it. Like, when you walk in, it's like, oh, they just cleaned this room. And you like the smell of Clorox. You know it anywhere.
And I found myself finding that same kind of sensing, the energy, that kind of mental smelling, if it's going. If it's a mood disorder, if it's borderline, if it's schizophrenia. So just noticing, like, the different elements of. And kind of that helps direct that. But that goes back to the intuition, too.
[00:09:37] Speaker B: And I think, too, like, that goes back to a lot of our training, like, at Oklahoma State, Like, I don't know if I've talked about this on the podcast, but, like, turning off the videos to watch people's body language and then saying, like, what are you seeing? Because the reality is, like, affect is tied to, like, if somebody is depressed, they will have, like, a blunt affect, flat affect, constricted. Like, there's going to be these things that you can see, or when they're saying, like, certain phrases of, like, yeah, I've just, like, really not felt like myself. It's been a really, really hard year.
You're like, oh, it's been a really hard year.
[00:10:19] Speaker C: Right?
[00:10:19] Speaker B: Like, so, very, like, quickly being able to say, okay, here's maybe some flags where I can assess more for that.
Yeah.
[00:10:29] Speaker A: So you kind of touch on this just a little bit because you're, like, kind of doing the diagnosing process with your clients at some point. Right. But do you always, or do you sometimes tell people their diagnosis?
[00:10:44] Speaker C: If it feels like the environment is safe to do so and that the client is receptive to that conversation. I always want that to be my go to. I won't say always just because there's always. There could be a situation where, you know, if things are really escalated in the room and it's like, I know exactly what I'm seeing. I'm. You're presenting everything right now. But if I'm having.
If I choose this moment to talk about the name that these behaviors and these symptoms have, that's not going to be perceived very well.
So I try and think of safety, not only, like, physical, but emotional. Like, are they ready to hear this yet?
[00:11:23] Speaker B: And I think that's like a really good note to, like, you want that to be. It can also be like a therapeutic intervention, like, for somebody to finally understand, like, what they're experiencing. And so recognizing like, that is kind of a constraint of our field is if you're using insurance, you will have some sort of billable diagnosis if you're being seen.
I think a lot of people, like, just getting into the field don't realize that until you're already in it and you're like, oh.
And so a lot of those contextual factors.
So while we're on the topic, insurance.
What, Grace? What is insurance diagnosing?
[00:12:08] Speaker C: Oh, insurance. Oh, insurance.
[00:12:11] Speaker B: Yeah.
[00:12:13] Speaker C: So that's been. That has been a journey. So I started dealing more with the insurance, with diagnosing back when I was doing the outpatient community primary care.
And it was more of just like, we're documenting the symptoms, we're documenting their experience, we're giving. We're putting a name to it, if the name is appropriate. And sometimes that name is unspecified, and that's okay because the symptoms are real and it's presenting in a very real way. And something heartening that I found that I wouldn't always say about insurance is that they do recognize unspecified diagnoses as, like, billable. And that just means that the client is able to continue to receive services either at no cost or at the discounted cost according to their plan.
And so it doesn't have to be. It kind of. It made me feel good to know that it doesn't have to be like this or nothing. Yeah. That they. They are working on that scale.
That being said, insurance, still, they have things that aren't covered. They have certain reactions, especially reactions to trauma or stress.
Some things are covered, but it just. It depends on the specific wording you use, the code you use. When you go between DSM 5 and ICD 10 and they're not all on the same page. So it can be frustrating. For sure.
[00:13:41] Speaker B: Yeah. And something that we talked about in our program as well is like, and I think you have really great experience for being able to tell, like, what does insurance actually reimburse for? What do they accept? What can you bill insurance for?
And one of the things that at least in our ethics, our ethics class was talking about, like, the temptation or the desire to like, give somebody a diagnosis you, you know, insurance will cover, but that they do not actually have.
[00:14:16] Speaker C: Yes. And to. To that with any conversation, stick to your ethics and do what's best for your client.
And it. As long as you're doing both of those things, you're doing the best that you can.
And there some. I. Yeah, because there is that desire of like, well, I know the. What insurance won't do, but I also know what they will do.
And you want to help your client and you could even make the argument like, oh, this is for their best interest.
But if you're giving them a diagnosis that isn't in line with their care, that could be hurting them down the line too. And it's not only hurting them, it's hurting your license.
And that's. Yeah. So.
But there's. I found that there are a lot of ways to kind of work through and finding what symptoms are they showing and what are the other possible names that maybe the insurance world uses that. But that may not be the first word that comes to my mind.
But as long as the symptoms are accurately being reflected, then I think you're doing the best that you can.
Right?
[00:15:25] Speaker A: Yeah. The necessary evil almost of insurance sometimes. But yeah, absolutely. Stick to the ethics.
Okay, this next question is maybe you have experience with this. Hopefully you do. When do you request, like a medical rule out?
[00:15:42] Speaker C: That's another good question.
So if I'm talking when I was back at the. Working in like, medical settings, like, usually they were there already for a medical reason. So that was part of that was helpful, just being able to collaborate with the doctor right down the hall instead of having to go through like the ROI process across town.
But it was really. But basically just anytime that I'm noticing or hearing that there's a physical symptom that's being experienced with things. So if there's like, I'm getting headaches every day, it's like, well, headaches can be a sign of stress, that can be linked to anxiety, that can be linked to depression.
But also if you're experiencing headaches every day, like, that's Something that's outside of that mental health only scope.
And so just if they don't have a regular doctor, it's like, it might be good just to have just an overall physical, just to see how you're doing.
[00:16:38] Speaker B: Absolutely.
[00:16:39] Speaker A: Because I recently I had experience with somebody that has narcolepsy and seeing all the overlap, it's just like trying to sift through the weeds sometimes. So. Absolutely. Yeah.
[00:16:53] Speaker C: No, that's fair.
[00:16:54] Speaker A: Yeah.
[00:16:54] Speaker C: Because.
[00:16:54] Speaker B: Yeah, like, if you're trying to make sure that you're giving somebody an accurate diagnosis, like coming in with a lot of fatigue, like, understanding is that depression, or do they have some sort of, like, medical reason for why they're fatigued?
[00:17:09] Speaker A: Yeah, super important.
[00:17:11] Speaker B: What would you say are some of, like, I don't know, like the common, like, pitfalls that new therapists fall into with diagnosing?
[00:17:20] Speaker C: I. I think some of the pitfalls and just challenges that can come from diagnosing as a new clinician is just that sense of doubt and that kind of imposter syndrome that likes to creep in and wondering if you're thinking it through enough, if you're doing enough, if there's maybe a better diagnosis out there that you're just not thinking of or not seeing.
And I think it can be really hard to get out of and that can even be really scary and make people not want to work with diagnosing at all.
And I think that the more, the more you do it, like, the more you go through that assessment, critical thinking and then confirming process, the more you're going to realize you know more than you think.
And if you decide and if you are going along with treatment and you learn new information that changes the entire direction of the diagnosis, then you learn from that. You can update it. Nothing is etched in stone.
[00:18:24] Speaker B: Great.
[00:18:25] Speaker A: Honestly, even as you caught the eye at the end of MSWI for me, but even coming to the end of my internship, it's like the. The confidence definitely builds. Like at the beginning, it's like total stress zone with diagnosing. But then you get to the end, it's like, okay, well, actually, like, I've been going to school for this for a reason. Like, I actually know things.
[00:18:46] Speaker C: So.
[00:18:46] Speaker A: Yeah, absolutely.
Kind of maybe speaking to that, maybe we can jump around on the questions. What if somebody feels like, oh, I put the wrong diagnosis and now it's like, they're on their file.
Like, and maybe you've told them about that diagnosis too. Like, hey, we've diagnosed you with xyz. Like, well, how do you approach that situation.
[00:19:11] Speaker C: And that's a great question because that's a very realistic scenario. And it doesn't have to be one surrounded by shame or guilt. And it can just be started with an open conversation where it can start with kind of like a review. It gives you a chance to kind of throw it back to the intake. It's like, hey, so we talked about this. This is the diagnosis that we've talked about. This is how we've discussed the relationship of the diagnosis to you, whether you find identity in it or whether you don't really care about it, whatever the situation is.
And also this is what I've been seeing since our intake.
I've been seeing these changes in you, or I've been seeing these new things come up, or you were willing to share this experience that you had with me just a few weeks ago.
And with all of this new information combined with how I met you during your intake, I think we might have a new name to work with.
And so it's just kind of like introducing them slowly to this new name and seeing how they feel about it. See and acknowledge if there's any grief or sadness with. If there's, like, feeling a sense of loss towards that first diagnosis, or if they have this sense of, oh, wow, that fits so much better.
And just being. Taking it slow and just helping them get to know that new name. And then they can start to build that new relationship with it.
[00:20:49] Speaker B: Yeah. And I can see, like, when you're talking about the conversational style, even just how you're talking about. I was like, yeah, like, that is so your style, which is awesome. I think people.
That gives people the space to kind of figure out what their relationship is with those symptoms or with those diagnosis diagnoses. I think that's really great.
[00:21:10] Speaker C: Yeah.
[00:21:11] Speaker B: And maybe there's some things about that that I can adopt, because typically I'm like, so just straightforward and transparent. I'm like, you're feeling this, this, this. And I'll ask those questions of like, do you ever feel like this? Do you ever feel like that? Kind of roll some things out if you're like this, do you feel like that? And, okay, well, I'm seeing. Seeing all this.
That sounds like anxiety. Do you agree with that? And they're like, oh, yeah. Or they're like, huh? Actually, yeah. And then I'm like, great. So with that information, can I put that on your file to bill insurance? And they're like, oh, yeah, I don't care.
And so I think that's great. Just to see Like, a different style of doing it because, again, I feel like I get so into my routine that I think it's always nice to change things up and learn from other providers.
[00:22:00] Speaker A: Also adding to that, like, as like a new therapist as well, like you mentioned imposter syndrome earlier. That definitely, I feel like, feeds into the fear that comes with this question of, like, what if I diagnose wrong? You know, And I've even had to have just, like, conversations with people of, like, hey, this is evolving. And, like, the diagnosis has changed because of all these reasons. Like, what do you think? So, like, having a similar conversation, like, I think just even having this conversation helps to take the edge off of.
We don't have to, you know, stick to one thing and, like, feel like we are wrong or whatever because we're changing different things. Maybe things have changed or maybe, maybe we were wrong. But, like, it's. It's a conversation too. So anyways, taking the edge off.
[00:22:48] Speaker B: And I think too, like, if you have had that conversation with your clients, they'll also understand why you gave them the original diagnosis.
Like, they will understand why at the time you gave them that. And then with this new information, it's a new thing. Like, the thing that's coming to my mind is, is bipolar, like, really common for somebody to come into therapy in a very depressed state? State, yeah.
And if you have never worked with bipolar before, you're not really familiar. Some of those, like, flags or like, bipolar 2 can be a little bit easier to miss.
And so that's one where, like, as soon as you get that other information, you are no longer dealing with depression like you are. You are dealing with bipolar. So that's a, I think, a common example of where therapists might have that experience.
So it's going to happen.
[00:23:42] Speaker C: Yeah, I love that you said that because that's definitely something I relate to as well, is meeting with a patient or a client who's previously been treated for depression and you just decide to ask the other question of, oh, does this feel familiar? Or you notice that there's a family history of bipolar and that makes you want to double check.
And what I love about that specific conversation from, like, depression to bipolar is that they're both mood disorders. And so you kind of have that umbrella metaphor of, it's like, we were discussing and treating depression under the umbrella, and bipolar is still under the umbrella. It's just on the other side.
[00:24:26] Speaker B: Oh, I love that metaphor. That's really good.
Yeah, that's really good.
[00:24:31] Speaker A: Maybe one more question.
[00:24:33] Speaker B: Yeah, okay.
[00:24:35] Speaker A: How Many sessions would you say you need before assigning a diagnosis? Like, how you've arrived to it? Maybe like a previous agency, it was like 15 minutes. Right. But like, how about you?
[00:24:51] Speaker C: I still find myself doing it at session one.
And I.
And sometimes that means, like, it's unspecified because maybe we didn't have the full amount of time to go into.
It's like, it could be depression, could also be a bipolar type kind of sticking out. And so you can have that unspecified mood disorder as kind of a starting point, and then you can continue to assess as you go because you're constantly working towards just understanding and wanting to make sure that you are putting. Putting your best foot forward and doing best practice.
[00:25:31] Speaker B: I love that because again, like, you're not just like putting something on there to bill insurance. Like, you want to make sure that they have whatever you are billing. You also don't want your client to get stuck with something that insurance can't reimburse for. Like to have a full first intake session that they can't bill insurance for. A lot of people can't afford that even in, like an outpatient setting. In an inpatient setting. And so I think that's where understanding, like the unspecified or understanding, okay, adjustment disorder, the criteria is a lot quicker. And a lot of people will fit under that diagnosis. Not everybody, obviously, like, don't just slap that diagnosis around.
That's, I think, another pitfall of diagnosing. But it's really easy to qualify for an adjustment disorder. And even if you've started down the road of, okay, yes, they also have some anxiety symptoms. You can say adjustment with anxiety, like symptoms of anxiety or adjustment with symptoms of depression or adjustment with symptoms of anxiety and depression. And that's enough to continue seeing them. Like, that's enough to continue the work that you're doing.
And you can still have those really good conversations about it as you go along with. Throughout their treatment.
[00:26:48] Speaker C: Yeah, exactly. I couldn't agree more.
[00:26:51] Speaker A: Yeah. Okay, well, last. Last question for real, before we let you leave, because we've just enjoyed all these questions. But to close as our audience is all like, new therapists, or maybe they're still feeling new.
Something we ask all the people that we have on the podcast is what advice would you give a new therapist in the field? So not necessarily like too diagnosing, but what's the advice you give to a new therapist?
[00:27:17] Speaker C: Okay, some advice I would love to give to all of the up and coming therapists is to just have this sense of belief in yourself.
And as long as you are doing everything you can to be the best version of yourself for you and for your clients.
You have nothing to apologize for. You have nothing to be ashamed of.
And just put that best foot forward, forward. And know that this is a huge growing process.
You are meant to grow. And growing hurts.
And that is okay.
[00:27:55] Speaker B: I love that even just like, the concept of, like, you're up and coming, like you are growing into something and that means that you're still growing. You can't have already accomplished an amazing thing when you're just starting out, figuring out how to do it and focusing on, like, doing the best for yourself and your clients. Like, taking care of yourself really is part of taking care of your clients.
So I really appreciate that. Grace, thank you so much for taking time out of your day to come on the podcast. We really appreciate it.
[00:28:29] Speaker C: Thank you so much for having me.
[00:28:31] Speaker B: Yeah, we've loved it. So thanks for being here. Thanks for all of our listeners for tuning in.
If you have any thoughts that you want to share about diagnosing or other topics that we've covered, let us know on our substack. The link is in our description of the episode where you can give us feedback, request episodes, and know when a new episode comes out. So we'll see you in our next episode.
