With proper training, the DSM-IV-TR can and will be a useful tool in diagnosing and treating patients. When utilized by a professional focused in family and marital counseling, an area where concentration of one individual is uncommon, the professional must also be prepared to make individual diagnoses as the psychological health of one is likely to affect his or her relationships, with the greatest impact felt within the nuclear family. When choosing to use the DSM-IV-TR to diagnosis an individual suspected of having a psychiatric disorder, it is best to start with the information provided on an intake form. From there, one should utilize a screening inventory, such as the Inventory of Common Problems (ICP). Through the use of the ICP, the professional could obtain a greater understanding of the individual client’s issues that may or may not relate or influence their interpersonal problems within the family and may or may not contribute to or be as result of a psychiatric disorder. Additionally, suspecting the presence of a disorder, the counselor should employ the use of an inventory of assessing mental disorders, such as the Psychiatric Diagnostic Screening Questionnaire (PDSQ). “The PDSQ contains 13 scales, each of which is related to a mental disorder as defined by the DSM-IV-TR” (Hood & Johnson, 45), and whereby the results of this assessment, could indicate and substantiate the counselor’s concerns regarding the presence of such disorder. Information should then be compiled as needed for the axis IV and V, whereby gaining a holistic overview of the client’s environment and outside stressors. Special considerations should be made regarding information provided in axis IV, as it may be pertinent to the client’s relationships within the family and may correlate with the family unit’s course of treatment. Once all information has been gathered, and if a disorder presents itself, the counselor should, privately sit down with the individual to explain the disorder and then together they would share this information with the rest of the nuclear family, being careful, not to label the individual, but rather identifying the disorder they are suffering from. Additional factors should be considered, those that the DSM fails to incorporate, i.e. cultural and environmental influences. Once the complete analysis has been done, the counselor would formulate a treatment program, either through medication or developmental counseling or a combination of both, (noting that the DSM does not contain any information of suggestions for treatment), but most surely creating a program that would incorporate the family unit as a whole.
“Sara Brown, age 11, white, female, is has been presented by her foster/adoptive parents for a consultation. She has been placed with the foster parents for 3 years, and although they have spent considerable (to their account) of time and energy in teaching her appropriate behaviors, she has failed to comply. Prior to her placement with her foster parents, she experienced many traumatic life experiences. Her biological father and older brother both died of a drug overdose, her mother continues to abuse illegal drugs as well as several of her older siblings. As result of the drug abuse issues within the family, Faye was often left to care for herself, exposed to many illegal and inappropriate activities to include: drug abuse, criminal activities, police contact with members of the family, and sexual activity. Since placed with her foster parents, she has struggled academically and socially, has low self-esteem, demonstrates inability to act rationally, acts in sexually inappropriate manners, is easily distracted, and experiences sleeplessness, phantom pains, occasional bed-wetting, emotional outbursts, and the inability to sit still or follow directions. Recently, her biological mother’s parental rights were terminated, allowing for her foster parents to formally adopt her, but her symptoms have escalated. Her foster parents are concerned that she may be struggling with ADHD and depression and/or grief issues.”
At the initial meeting, an intake form should be compiled, obtaining any and all available medical and family history, obviously made more difficult as the client is currently in foster care. This should be followed by a thorough interview of the foster parents, current teachers, social worker (as deemed appropriate), and finally with the client. During the interview with the client, an Inventory of Common Problems (ICP) would be administered, whereby the counselor could gain a better understanding of the mental, emotional, and physical issues the client believes she is experiencing. In addition, it would be beneficial to have the client answer the Psychiatric Diagnostic Screen Questionnaire (PDSQ), making sure to focus on self-destructive or harmful thoughts or behaviors that may require immediate attention and/or intervention. Also, appropriate in this case would be intelligence testing, utilizing the Stanford Binet IV, as the foster parents are currently considered with the client poor performance in school. Once all pertinent information has been compiled, a treatment plan should be devised. In the case of Faye, it would seem appropriate that both the medical and developmental models be employed during her diagnosis and treatment, as both, as her symptoms would appear to be inter-related within both models.
If she presents with the qualifying symptoms for ADHD, the developmental model should be utilized first. The counselor should work with the parents to teach and devise plans for working with the client to better stay on task, such as: daily scheduling, positive behavioral reinforcement, presenting one task or step of the task at a time, reducing outside stimuli (such as televisions, music, or environmental noise), and requiring eye contact when speaking. However, if after sometime, this developmental approach fail to work, it would be appropriate to employ the use of the medical model and begin medication for these symptoms.
Additionally, it could be possible that the client could be diagnosed with other DSM disorders, such as: Conduct Disorder, Oppositional Defiant Disorder, Anxiety, Depression, and/or Learning Disabilities, all which are co-occurring disorders with ADHD (Jaffe-Gill, De Benedictis, et al., 2007). An evaluation should be made regarding the severity of these disorders and whether immediate medical attention should be provided to the client, to ensure her safety. If the she appears to be in no immediate danger, it would seem appropriate to employ the use of the developmental model to help the client resolve past and present issues that may be causing her emotional and behavioral state. Hinkle (1998) finds that “Counselors are different from other helping professionals because we focus on the art and science of connecting and bonding with individuals, families, and groups and "sharing the reality of their human experience," whatever that reality may be, and help them find ways to change.” There are many issues that this client may be struggling with that she has been unable to resolve or has been fearful to express, and it would seem that utilizing the medical approach may provide little more than a band-aid to this child’s issues.
When considering a course of treatment, it would seem that the developmental model be utilized with patients who are experiencing disorders related to past or presents stressors, whereas the medical model be employed with clients who present with neurological or psychiatric disorders, unrelated to unresolved emotional issues. Hinkle (1998) presents that “It is important to remember that no single approach is superior to another, but neither are all treatments equally effective or equally ineffective (Hester & Miller, 1985),” but rather a delicate balance between the two must be considered. Counselors, who rely to heavily on the medical model, may fail to “treat” the client, but instead only offer a temporary fix while being medicated. Conversely, those who deny the medical model and chose to only utilize the developmental approach may commit a disservice to those clients whose disorder cannot be treated through counseling process. Regardless of which method one chooses to employ, the DSM-IV-TR will prove to be a valuable tool in providing a diagnosis when the criteria for such a disorder has been met, and will offer the counselor a starting point for treatment. “The DSM-IV does follow a medical model--if you are a medical practitioner If you are a counselor, the DSM may not be a manual of diseases, but simply a description of harmful behaviors, dysfunctions, mental disorders, developmental roadblocks, or whatever one chooses to call them. The DSM does not recommend the prescription of medication or hooking clients up to electrodes, or any other treatment method for that matter” (Hinkle, 1998), and therefore should be used regardless of which model one chooses to employ.
References
Hinkle, S.J. (1998). A Voice from the Trenches: A Reaction to ivey and ivey. Journal of Counseling & Development. 77 (4). Retrieved on April 8, 2008 from Academic Search Premier at http://web.ebscohost.com.library.capella.edu/ehost/detail?vid=1&hid=15&sid=49c7ac45-83cf-4afd-a6ba-7767fb2d5968%40SRCSM1
Hood, A. B., & Johnson, R. W. (2007). Assessment in counseling: A guide to the use of psychological assessment procedures (4th ed.). Alexandria, VA: American Counseling Association.
Jaffe-Gill, E., De Benedictis, T, Smith, M. & Segal, J. (2007). Getting help for children with ADD / ADHD: A Guide to diagnosis and treatment. Retrieved on April 8, 2008 from http://www.helpguide.org/mental/adhd_add_diagnosis.htm
Stephanie Lowrance-Henckel
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