Diagnostic Process in Counseling

The process by which counselor attempt to reach out and to understand has been the subject of great controversy and not a little confusion and misunderstanding over the years. The earliest attempt to describe the process was termed, perhaps unfortunately, “diagnosis” (Williamson, 1939).

The term was borrowed largely from medicine and came to process connotations and meanings that were quite foreign, and in some instances, repugnant to counselor. In any event, the process of diagnosis and its role within the total intervention process is quite different in counseling from what it is in medicine.

Traditionally, the process of diagnosis in medicine has been concerned primarily with the presence of disease entity within the patient. Measles, mumps, chicken pox, polio, pneumonia, and influenza are disease entities. They present distinct symptoms, are caused by specific infectious agents, and have known differential treatments associated with them. Much of the progress of medical science has involved the identification of disease entities, the discovery of their causes, and the formulation of specific remedies. In this sense, diagnosis typically involves the study of symptoms, the use of laboratory tests, and finally a prescribed course of specific treatment. Within this model diagnosis necessarily precedes treatment and represents a distinct stage in the total process of treatment.

However, even in medical settings attempts to apply this type of process to so-called “mental illnesses” have not been notably successful. The nature of presumed disease entities in the “functional mental illnesses” has proved to be different from those types of pathology for which specific organic causes can be established (Eysenck, 1961).

Evidence about the relatively low reliability and limited utility of traditional psychiatric diagnoses led Eysenck to suggest that the whole notion of disease entities should be banished from modern psychology. Nonetheless, despite this controversy, work on the medical model of diagnosis in psychopathology has proceeded.

The American Psychiatric Association has published three editions of its Diagnostic and Statistical Manual of Mental Disorders. The Third Diagnostic Manual (DSM III) designed to be a more reliable system for diagnosing mental disorders within a medical, disease entity model (American Psychiatric Association, 1980), includes somewhat more specific and operationally defined criteria than were found in the first two manuals. However, it should be understood that for most of the categories the criteria are still based upon clinical judgment and have not been fully validated.

The DSM III is considerably more comprehensive than earlier editions and marks a clear attempt to bring a wider range of human concerns, including developmental, educational and vocational, problems under the rubric of “mental disease.” In this sense, it is as much a political document, staking out the territory of organized psychiatry, as it is an attempt to provide a scientifically defensible system of classification (McReynolds, 1979).

In previous chapters we have discussed the philosophical and professional limitation of the intra psychic disease entity models. Many counselors have reacted negatively to the medical model of diagnosis and for very good reasons. The risk of stigmatizing clients with labels that are both vague and frightening, the possibilities of creating “person blame” approaches that solve social problems by scapegoating powerless people, and the erosion of personal responsibility by translating all sorts of human concerns into sicknesses have caused many counselors and counseling theories to shun traditional models of diagnosis and to regard the term itself as anathema.

We should note that not even all psychiatrics diagnosis support disease entity models. Benjamin (1981) reviewed the history of psychiatric diagnosis and deplored attempts at “remedicalizing” psychiatric diagnosis. Menninger (1963) proposed that unitary models of diagnosis be developed to enable clinicians to conceptualize levels of client functioning without involving notions of specific disease entities with all of the untested assumptions that these entail. He noted that disease entity models totally fail to describe upper levels of human functioning, or what he called being “weller than well.” Prugh (1973) has proposed a unitary model that develops a diagnostic system based on the departures from the optimal personal and family functioning of children at specific age levels.

Such unitary models seem useful in evaluating efforts both at preventing obstacles to optimal functioning and at enhaching  personal growth. One advantage of unitary models is that they can consider both the assets and resources available to individuals as well as the obstacles. What follow is a unitary diagnostic model to describe levels of functioning in relation to human effectiveness.