James Fitzgerald Therapy PLLC

When a potential therapy client enters treatment, the diagnostic assessment process is essential in determining their mental health condition, identifying treatment needs, and forming an effective therapeutic plan. This process follows a structured approach based on clinical best practices, ethical standards, and professional guidelines.

1. Initial Consultation and Clinical Interview

The first step is an initial intake session, where the therapist gathers comprehensive information about the client’s presenting concerns, history, and current functioning. This may include:

• Identifying the primary reason for seeking therapy
• Gathering personal, family, and medical history
• Exploring psychosocial factors such as relationships, employment, and life stressors
• Discussing substance use, trauma history, and previous mental health treatment
• Assessing risk factors, including suicidal ideation or self-harm

2. Administering Standardized Assessment Measures

After the clinical interview, therapists often use standardized assessment tools to support diagnostic accuracy. These measures help confirm clinical impressions, track symptom severity, and guide treatment planning.

3. DSM-5-TR Diagnostic Criteria Review

Using the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision), the therapist evaluates symptoms against diagnostic criteria. Diagnoses are based on:

• Duration, intensity, and frequency of symptoms
• Functional impairment and distress caused by symptoms
• Exclusion of alternative explanations such as medical conditions or substance use

4. Collaborative Discussion and Feedback

Once a diagnostic impression is formed, the therapist discusses findings with the client. This includes:

• Educating them about their diagnosis (if applicable)
• Discussing how the diagnosis informs treatment options
• Allowing space for client questions and concerns
• Emphasizing that a diagnosis is a tool, not a label, and can evolve over time

5. Treatment Planning and Next Steps

A collaborative treatment plan is developed based on assessment findings, incorporating evidence-based interventions such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Internal Family Systems (IFS), or medication referrals when necessary.

Common DSM-5-TR Assessment Measures

The DSM-5-TR includes several standardized measures to assess mental health conditions. These include:

Level 1 Cross-Cutting Symptom Measures

• Adult Version (Self-Report and Clinician-Rated)
• Child/Adolescent Version (Parent-Report and Clinician-Rated)

Level 2 Cross-Cutting Symptom Measures (for more in-depth symptom evaluation)

• Depression (PHQ-9, PROMIS Emotional Distress – Depression)
• Anxiety (GAD-7, PROMIS Emotional Distress – Anxiety)
• Anger (PROMIS Emotional Distress – Anger)
• Sleep Disturbance (PROMIS Sleep Disturbance)
• Mania (Altman Self-Rating Mania Scale)
• Substance Use (WHO AUDIT, DAST-10)

Disorder-Specific Assessment Measures

• PTSD Checklist for DSM-5 (PCL-5)
• Obsessive-Compulsive Disorder (Yale-Brown Obsessive Compulsive Scale)
• Psychosis (Prodromal Questionnaire-Brief Version)
• Borderline Personality Disorder (McLean Screening Instrument for BPD)
• Autism Spectrum Disorder (Autism Spectrum Quotient)
• ADHD (Adult ADHD Self-Report Scale – ASRS)

These measures support a comprehensive understanding of symptom severity and diagnostic considerations.

The Importance of Transparency, Ethics, and Fidelity

Sharing the diagnostic assessment process with clients is crucial for several reasons:

1. Transparency and Informed Consent

Clients have the right to understand how their diagnosis is determined and how assessment measures are used. Providing clear explanations fosters trust, reduces uncertainty, and ensures that clients feel empowered in their care.

2. Ethical Compliance

Professional ethics require therapists to involve clients in their treatment process. The American Psychological Association (APA), American Counseling Association (ACA), and National Association of Social Workers (NASW) all emphasize the necessity of clear communication about assessments, diagnostic procedures, and treatment decisions.

3. Reducing Stigma and Misunderstanding

Many clients fear being “labeled” with a diagnosis. By educating them on the function of a diagnosis—helping to guide treatment rather than defining them—therapists can reduce stigma and encourage clients to engage with their mental health journey more openly.

4. Fidelity to the Assessment Process

Following a structured, evidence-based assessment process ensures accuracy and consistency in diagnosis and treatment planning. By adhering to DSM-5-TR criteria and utilizing standardized tools, clinicians enhance diagnostic reliability and effectiveness in treatment.

Conclusion

The diagnostic assessment process is a foundational step in therapy that helps clients understand their mental health, guides effective treatment, and ensures ethical, transparent, and client-centered care. By sharing this process openly, therapists uphold ethical integrity, empower clients with knowledge, and foster a collaborative therapeutic relationship built on trust and informed decision-making.