SNHU: Abnormal Psychology: Clinical Perspectives on Psychological Disorders Chapter 2 Notes

• Case Report: Peter Dickinson
• Demographic information: 28-year-old Caucasian male.
  • Presenting problem: Peter's girlfriend of one year, Ashley, referred him to an outpatient mental health clinic. He is in his second year of working as a defense attorney at a small law firm. Ashley reported that about six months ago, Peter's parents began divorce proceedings, at which point she noticed some changes in his behavior. Although his job had always been challenging, Peter was a hard worker who devoted himself to his studies throughout his academic career and had been just as motivated at his current job. Since the divorce, however, Ashley reported that Peter had only been sleeping a few hours a night and was having trouble keeping up with his caseload at work. It had gotten so bad that the firm considered firing him. When he was seen at the psychotherapy clinic, Peter reported that the past six months had been very difficult for him. Although he stated he had always been a “worrier,” he couldn't get his parents' divorce off his mind, and it was interfering with his ability to focus and perform well at his job. He described most of the worried thoughts as fears that his parents' divorce would destroy their lives as well as his. He stated that he would worry that somehow their divorce was his fault, and that once the thought entered his mind, it would play on repeatedly like a broken record. He also explained that Ashley had threatened to break up with him if he didn't “get it together,” about which he also spending a great deal of time was worrying. He stated that he constantly worried that he had ruined her life and that this thought was also very repetitive. Peter was noticeably anxious and irritable throughout the session, especially when talking about his parents or about Ashley. Early in the session, he expressed that he had been feeling very tense all day and that his stomach was “in knots.” Throughout the session, his legs and hands were fidgety, and he stood up and sat down in his chair several times. He stated that since starting his new job, he had become very short-tempered with people, and often felt “wired” and tense, and as a result had a difficult time concentrating on his work and sleeping soundly. He explained that he couldn't remember the last time he felt calm or didn't worry about anything for an entire day. He also stated that he could barely think about anything other than his parents' divorce and his relationship problems with Ashley, even if he tried to get his mind off it. He reported that prior to learning of his parents' divorce; he was mainly “obsessive” about his work, which he noted was similar to how he was as an undergraduate and in law school. He stated that he was usually afraid that he would make an error, and would spend more time worrying about failing than actually doing his work. As a result, he said, he often had little time for friends or romantic relationships because he would feel guilty if he were engaging in pleasurable activities rather than focusing on his work. A serious relationship of four years ended after his ex-girlfriend grew tired of what she had called his “obsession” with working and his neglect of their relationship. Currently, faced with losing his job and another important relationship, Peter stated that he realizes for the first time that his anxiety might be interfering with his life.
  • Relevant history: Peter reported that his mother had a history of panic attacks and his father had taken anxiety medication, though he was unable to recall any further details of his family history. He stated that since he could remember he had “always” felt anxious and often worried about things more than other people. He remembered a particular instance in high school when he barely slept for two weeks because he was preparing for an argument for his school's debate team. Peter stated he has never had any psychotherapy or taken any psychiatric medication. He reported that although his worrying often makes him feel “down,” he has never felt severely depressed and has no history of suicidal ideation.
  • Symptoms: Difficulty sleeping through the night, restlessness, difficulty concentrating, irritability. Peter stated that he found it difficult to control the worry and he spent most of his time worrying about either his parents' divorce, work, or his relationship with Ashley.
  • Case formulation: Peter meets all of the required DSM-5 criteria for Generalized Anxiety Disorder (GAD). He had been displaying excessive worry for more days than not for at least the past six months, was unable to control his worry, and presented four of the six main symptoms associated with GAD. Additionally, Peter's worry was not related to fears of having a panic attack (as in Panic Disorder), or about being in social or public situations (as in Social Anxiety Disorder). His anxiety was causing him significant problems at work and in his relationship with Ashley. Finally, Peter's anxiety was not the result of substance use.
  • Treatment plan: Peter's treatment plan will involve a combination of two approaches. First, he will be referred to a psychiatrist for antianxiety medication to ease the physical symptoms of his anxiety. Cognitive behavioral psychotherapy will also be recommended, as this has been shown to be the most effective current therapeutic modality for treating GAD.
• 2.1: Psychological Disorder: Experiences of Client and Clinician
• Psychologists are health care professionals off erring psychological services. Those working in the field of abnormal psychology examine not only the causes of abnormal behavior, but also the complex human issues involved in the therapeutic process.
• There are many types of clinicians who approach clinical work in a variety of ways, based on their training and orientation. Psychiatrists are people with degrees in medicine (MDs) who receive specialized advanced training in diagnosing and treating people with psychological disorders. Clinical psychologists have an advanced degree in the field of psychology and are trained in diagnosis and therapy. Clinical psychologists cannot administer medical treatments, but some U.S. states, such as Louisiana and New Mexico, as of 2011, grant them prescription privileges.
• There are two types of doctorates in psychology. The doctor of philosophy (PhD) is typically awarded for completing graduate training in research. In order to be able to practice, people who get their PhD's in clinical psychology also complete an internship. The doctor of psychology (PsyD) is the degree that professional schools of psychology award and typically involves less training in research. These individuals also must complete an internship in order to practice. Counseling psychologists, with either a doctorate in education (EdD) or (PhD) also serve as clinicians.
• Professionals with master's degrees also provide psychological services. These include social workers, master's-level counselors, marriage and family therapists, nurse clinicians, and school psychologists.
• The mental health field also includes a large group of individuals who do not have graduate-level training but serve a critical role in the functioning and administration of the mental health system. Included in this group are occupational therapists, recreational therapists, and counselors who work in institutions, agencies, schools, and homes.
  • 2.2: The Diagnostic Process
  • In order to treat psychological disorders, clinicians must first be able to diagnose them. The diagnostic process requires, in turn, that clinicians have a systematic approach to classifying the disorders they see in their clients. A diagnostic manual serves to provide consistent diagnoses across people based on the presence or absence of a set of specific symptoms. Without an accurate diagnostic manual, it is impossible for the clinician to decide on the best treatment path for a given client.
  • The profession uses two factors in evaluating a diagnostic manual's ability to do its job. The first is reliability, meaning that practitioners will apply the diagnoses consistently across individuals who have a particular set of symptoms. A manual would not be very useful if the symptom of sad mood led one clinician to assign a diagnosis of some sort of depressive disorder and another to assign a diagnosis of some type of anxiety disorder. The second factor is validity, meaning that the diagnoses represent real and distinct clinical phenomena.
  • Clinicians use the standard terms and definitions contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. We have organized this text according to the most recent version, which is the DSM-5, or fifth edition (American Psychiatric Association, 2013). The DSM-IV organized diagnoses using five separate axes. It defined an axis as a category of information regarding one dimension of an individual's functioning. The multiaxial system in the DSM-IV-TR was intended to allow professionals to characterize clients in a multidimensional way. In addition, DSM-5 contains a “Section III,” which includes assessment measures and diagnoses not considered well-established enough to be part of the main system. These diagnoses may become incorporated into the next edition of DSM-5 or a “DSM-5.1,” should clinical and research data support their inclusion.

• Most mental health professionals outside the United States and Canada use the World Health Organization's (WHO) diagnostic system, which is the International Classification of Diseases (ICD). WHO developed the ICD as an epidemiological tool. With a common diagnostic system, the 110 member nations can compare illness rates and have assurance that countries employ the same terminology for the sake of consistency.
• The DSM-IV-TR contained a separate “axis,” or dimension for specifying the client's physical illnesses. By specifying the client's physical illnesses, the clinician transmits information that has important therapeutic implications.
  • Ex. - A person with chronic heart disease should not receive certain psychiatric medications. In addition, knowing about a client's medical condition can provide important information about the mental disorder's etiology, which is its presumed cause. It would be useful to know that a middle-aged man appearing in treatment for a depressive disorder for the first time had a heart attack six months ago. The heart attack may have constituted a risk factor for the development of depression, particularly in a person with no previous psychiatric history.
• In providing a total diagnostic picture of the client's psychological disorder, clinicians may also decide it is important to specify particular stressors that are affecting the individual's psychological status.
• Clinicians can use a set of codes in the ICD that indicate the presence of psychosocial and environmental problems known as “Z” codes.
  • These may be important because they can affect the diagnosis, treatment, or outcome of a client's psychological disorder.
    • Ex. - A person first showing signs of an anxiety disorder shortly after becoming unemployed presents a very different diagnostic picture than someone whose current life circumstances have not changed at all in several years.
  • For the most part, environmental stressors are negative. However, we might consider positive life events, such as a job promotion, as stressors.
    • Ex. - A person who receives a major job promotion may encounter psychological difficulties due to his or her increased responsibilities and demands with the new position.

• Culture-bound syndromes are behavior patterns that exist only within particular cultures. To qualify as a culture-bound syndrome, the symptoms must not have any clear biochemical or physiological sources. Only that particular culture, and not others, recognizes the symptoms of a culture-bound syndrome.
• Certain psychological disorders, such as depression and anxiety, are universally encountered. Within particular cultures, however, idiosyncratic patterns of symptoms are found, many of which have no direct counterpart to a specific diagnosis. These conditions, called culture-bound syndromes, are recurrent patterns of abnormal behavior or experience that are limited to specific societies or cultural areas.

• 2.3: Steps in the Diagnostic Process
• The diagnostic process involves using all relevant information to arrive at a label that characterizes the client's disorder. This information includes the results of any tests given to the client, material gathered from interviews, and knowledge about the client's personal history. Clinicians use the first phase of working with clients to gather this information prior to proceeding with the treatment itself.
  • Key to diagnosis is gaining as clear a description as possible of a client's symptoms, both those that the client reports and those that the clinician observes.
  • The clinician also must attend carefully to the client's behavior, emotional expression, and apparent state of mind.
    • Ex. - The client may express anxiety, but his behavior may suggest that instead he is experiencing a mood disorder.
    • Clinicians first listen to clients as they describe the experience of their symptoms, but they must next follow this up with a more systematic approach to diagnosis
      • A variety of assessment tools give the clinician a framework for determining the extent to which these symptoms coincide with the diagnostic criteria of a given disorder.
        • The clinician must determine the exact nature of a client's symptoms, the length of time the client has experienced these symptoms, and any associated symptoms.
        • In the process, the clinician also obtains information about the client's personal and family history.

v By asking questions in this manner, the clinician begins to formulate the principal diagnosis—namely, the disorder most closely aligned with the primary reason the individual is seeking professional help.

• For many clients, the symptoms they experience reflect the presence of more than one principal diagnosis. In these cases, we use the term comorbid, meaning literally two (or more) disorders. Comorbidity is remarkably common. A major investigation, known as the National Comorbidity Survey (NCS), showed that over half of respondents with one psychiatric disorder also had a second diagnosis at some point in their lives. The most common comorbidities involve drug and/or alcohol abuse with other psychiatric disorders.
• Differential diagnosis, the ruling out of alternative diagnoses, is a crucial step in the diagnostic process. It is important for the clinician to eliminate the possibility that the client is experiencing a different disorder or perhaps an additional disorder.
  • Ex. - Peter states that he is anxious, and his symptoms suggest the disorder known as “general anxiety disorder,” but Dr. Tobin needs to consider whether this diagnosis best suits his symptoms or not. It is possible that Peter suffers from panic disorder, another anxiety disorder involving the experience of panic attacks. His symptoms may also suggest social anxiety disorder. Alternatively, he might be suffering from adjustment difficulties following the divorce of his parents or the stress of his job. He may even have a substance use disorder, an undiagnosed medical condition, or even a third disorder. Dr. Tobin's initial diagnosis must be tested against these possibilities during the assessment period of treatment.
  • The diagnostic process can take anywhere from a few hours to weeks depending on the complexity of the client's presenting symptoms. The client and clinician may accomplish therapeutic work during this time, particularly if the client is in crisis.
    • Ex. - Dr. Tobin will start Peter on antianxiety medications right away to help him feel better. However, her ultimate goal is to arrive at as thorough an understanding as possible of Peter's disorder. This paves the way for her to work with Peter throughout the treatment process.
    • Once the clinician makes a formal diagnosis, he or she is still left with a formidable challenge—to piece together a picture of how the disorder evolved. With the diagnosis, the clinician can assign a label to the client's symptoms.
      • The label does not tell the client’s full story.
      • To gain a full appreciation of the client's disorder, the clinician develops a case formulation: an analysis of the client's development and the factors that might have influenced his or her current psychological status.
        • The case formulation provides an analysis that transforms the diagnosis from a set of code numbers to a rich piece of descriptive information about the client's personal history. With this descriptive information, the clinician can design a treatment plan that is attentive to the client's symptoms, unique past experiences, and future potential for growth.
          • Ex. - Understanding the client from a developmental perspective is crucial to provide a thorough case formulation. In Dr. Tobin's work with Peter, she will flesh out the details of her case formulation as she gets to know him better in the initial therapy phases. Her case formulation will expand to include Peter's family history, focusing on the divorce of his parents, as well as the possible causes of his perfectionism and concern over his academic performance. She will try to understand why he feels so overwhelmed at work and gain a perspective on why his relationship with Ashley has been so problematic. Finally, she will need to investigate the possible role of his mother's panic attacks and how they relate to Peter's experience of anxiety symptoms. To aid in differential diagnosis, Dr. Tobin will also evaluate Peter's pattern of substance use as well as any possible medical conditions that she did not detect during the initial assessment phase.
          • Clinicians need to account for the client's cultural background in making diagnoses. A cultural formulation includes the clinician's assessment of the client's degree of identification with the culture of origin, the culture's beliefs about psychological disorders, the ways in which the culture interprets particular events, and the cultural supports available to the client.
            • We might expect cultural norms and beliefs to have a stronger impact on clients who strongly identify with their culture of origin. The client's familiarity with and preference for using a certain language is one obvious indicator of cultural identification. A culture's approach to understanding the causes of behavior may influence clients who strongly identify with their culture. Exposure to these belief systems may influence the expression of a client's symptoms.
            • Even if a client's symptoms do not represent a culture-bound syndrome, clinicians must consider the individual's cultural framework as a backdrop. Members of a given culture attach significant meanings to particular events.
              • Ex. - within certain Asian cultures, an insult may provoke the condition known as amok, where a person (usually male) enters an altered state of consciousness in which he becomes violent, aggressive, and even homicidal.
              • Ex. - In Peter's case, although he is a product of middle-class white background, it is possible that cultural factors are influencing his extreme preoccupation with his academic performance. Perhaps his family placed pressure on him to succeed due to their own incorporation of belief in the importance of upward mobility. They may have pressured him heavily to do well in school, and as a result, he felt that his self-worth as an individual depended on his grades. As an adult, he is unable to shake himself from this overly harsh set of values.
              • Clinicians should look within the client's cultural background as a way of determining available cultural supports. Clients from certain cultures, particularly Black, Hispanic, Latino, and Asian, have extended family networks and religion, which provide emotional resources to help individuals cope with stressful life events.
              • Cultural formulations are important to understanding psychological disorders from a biopsychosocial perspective. The fact that psychological disorders vary from one society to another supports the claim of the sociocultural perspective that cultural factors play a role in influencing the expression of abnormal behavior.
                • 2.4: Planning the Treatment
                • Clinicians typically follow up the diagnosis phase by setting up a treatment plan, the outline for how therapy should take place. In the treatment plan, the clinician describes the treatment goals, treatment site, modality of treatment, and theoretical approach.
                • The decisions the clinician makes while putting the treatment plan together reflect what he or she knows at the time about the client's needs and the available resources. However, clinicians often revise the treatment plan once they see how the proposed intervention methods are actually working.
                • The first step in treatment planning is for the clinician to establish treatment goals, ranging from immediate too long term. Ideally, treatment goals reflect what we know about both the disorder and the recommended therapy, and the particular needs and concerns of the individual client.
                • The immediate goal of treating clients in crisis is to ensure that their symptoms are managed, particularly if they are at risk to themselves or others.
                  • Ex. – Peter needs psychiatric treatment in order to bring his anxiety symptoms under control.
                    • The clinician may need to hospitalize a client who is severely depressed and suicidal. The treatment plan may only include this immediate goal until the clinician gains a broader understanding of the client's situation.
                    • Short-term goals are aimed at alleviating the client's symptoms by addressing problematic behavior, thinking, or emotions. The plan at this point might include establishing a working relationship between the clinician and client, as well as setting up specific objectives for therapeutic change.
                    • Another short-term goal might be to stabilize a client taking medications, a process that might take as long as several weeks or longer if the first round of treatment is unsuccessful.
                      • Ex. - In Peter's case, Dr. Tobin will need to ensure that the medications he is receiving are in fact helping to alleviate his anxiety. She will also need to work with the psychiatrist to monitor any adverse side effects.
                      • Her short-term goals with Peter will also include beginning to examine the nature of his anxiety and how he can start to manage his symptoms using psychological interventions.
                      • Long-term goals include more fundamental and deeply rooted alterations in the client's personality and relationships. These are the ultimate aims of therapeutic change. Ideally, the long-term goals for any client are to cope with the symptoms of the disorder and to develop a strategy to manage them, if not achieve complete recovery
                        • Ex. - Dr. Tobin's long-term goals with Peter are to take him off the medication. At the same time, she would plan to help him gain an understanding of the causes of his symptoms, and in the process, reduce their severity if not eliminate them altogether.
                        • Unlike psychiatrists, psychologists do not receive medical training and therefore do not have the undergraduate pre-medical training or the years of medical school, internship, and residency that physicians receive.
                        • Treatment sites vary in the degree to which they provide a controlled environment and in the nature of the services that clients will receive. Clients who are in crisis or are at risk of harming themselves or others need to be in controlled environments. However, there are many other considerations including cost and insurance coverage, the need for additional medical care, availability of community support, and the projected length of treatment. In some cases, clinicians recommend client treatment in outpatient settings, schools, or the workplace.
                          • Psychiatric Hospitals
                            • In a psychiatric hospital, a client receives medical interventions and intensive forms of psychotherapy. These settings are most appropriate for clients at risk of harming themselves or others and who seem incapable of self-care.
  • Specialized Inpatient Treatment Centers
    • Clients may need intensive supervision, but not actual hospital care. For these individuals, specialized inpatient treatment centers provide both supportive services and round-the-clock monitoring. These sites include recovery treatment centers for adults seeking to overcome substance addiction. Clinicians
  • Outpatient Treatment
    • By far, the most common treatment site is a private therapist's outpatient clinic or office. Community mental health centers (CMHCs) are outpatient clinics that provide psychological services on a sliding fee scale for individuals who live within a certain geographic area. Professionals in private practice offer individual or group sessions.
    • Clients receiving outpatient services will, by necessity, receive more limited care than what they would encounter in a hospital, in terms of both the time involved and the nature of the contact between client and clinician. Consequently, clinicians may advise that their clients receive additional services, including vocational counseling, in-home services, or the support of a self-help organization, such as Alcoholics Anonymous.
  • Halfway Houses and Day Treatment Programs
    • Clients with serious psychological disorders who are able to live in the community may need the additional support that they will receive in sites that are intended to serve the needs of this specific population.
    • These facilities may be connected with a hospital, a public agency, or a private corporation.
    • Halfway houses are designed for clients who have been discharged from psychiatric facilities, but who are not yet ready for independent living. A halfway house provides a living context with other deinstitutionalized people, and it is staffed by professionals who work with clients in developing the skills they need to become employed and to set up independent living situations.
    • Day treatment programs are designed for formerly hospitalized clients as well as for clients who do not need hospitalization, but do need a structured program during the day, similar to what a hospital provides.
  • Other Treatment Sites
    • Clinicians may recommend that their clients receive treatment in the places where they work or go to school.
    • School psychologists are trained to work with children and teenagers who require further assessment or behavioral interventions.
    • In the workplace, Employee Assistance Programs (EAP) provide employees with a confidential setting in which they can seek individual treatment in the form of counseling, assistance with substance abuse, and family treatment.
    • Modality of Treatment
      • The modality, or form in which the clinician offers psychotherapy, is another crucial component of the treatment plan.
      • Clinicians recommend one or more modalities depending on the nature of the client's symptoms and whether or not other people in the client's life should be involved.
      • Clients receive treatment on a one-to-one basis in individual psychotherapy.
      • In couple’s therapy, both partners in a relationship, and in family therapy, several or all family members are involved in treatment.
      • In family therapy, family members may identify one person as the “patient.” The therapist, however, views the whole family system as the target of the treatment.
      • Group therapy provides a modality in which clients who face similar issues can openly share their difficulties with others, receive feedback, develop trust, and improve their interpersonal skills.
      • A clinician may recommend any or all of these modalities in any setting. Specific to psychiatric hospitals is milieu therapy, which is based on the premise that the milieu, or environment, is a major component of the treatment. Ideally, the milieu is organized in a way that allows clients to receive consistently therapeutic and constructive reactions from all who live and work there.
        • Milieu therapy- A treatment approach, used in an inpatient psychiatric facility, in which all facets of the milieu, or environment, are components of the treatment.
  • After decades of debate regarding which treatments are most effective, and for whom, psychologists adopted the principles of evidence-based practice in psychology—clinical decision making that integrates the best available research evidence and clinical expertise in the context of the cultural background, preferences, and characteristics of clients.
    • In other words, clinicians should base their treatments on state-of-the-art research findings that they adapt to the particular features of the client, taking into account the client's background, needs, and prior experiences. Clinicians currently use these criteria as the basis for curricula in graduate programs and postdoctoral continuing education.
• 2.5: The Course of Treatment
• The way treatment proceeds is a function of the clinician's and client's contributions. Each has a part to play in determining the outcome of the case, as does the unique interaction of their personalities, abilities, and expectations.
• A good clinician does more than objectively administer treatment to a client. The best clinicians infuse a deep personal interest, concern, and respect for the client into the therapeutic relationship.
• In optimal situations, psychotherapy is a joint enterprise in which the client plays an active role. It is largely up to the client to describe and identify the nature of his or her disorder, to describe personal reactions as treatment progresses, and to initiate and follow through on changes.
• Most people are much more comfortable discussing their medical, legal, financial, and other problems outside the realm of emotions. Social attitudes toward psychological disorders also play a role. People may feel that they should be able to handle their emotional problems without seeking help. They may believe that, if they can't solve their own emotional problems, it means they are immature or incompetent.
• Most people would, though, feel less inclined to mention to acquaintances that they are in psychotherapy for personal problems. The pressure to keep therapy secret usually adds to a client's anxiety about seeking professional help. To someone who is already troubled by severe problems in living, this added anxiety can be further inhibiting. With so many potential forces driving the individual away from seeking therapy, the initial step is sometimes the hardest to take. Thus, the therapeutic relationship requires the client to be willing to work with the clinician in a partnership and to be prepared to endure the pain and embarrassment involved in making personal revelations. Moreover, it also requires a willingness to break old patterns and to try new ways of viewing the self and relating to others.
  • 2.6: The Outcome of Treatment
  • Peter was prescribed antianxiety medication through the psychiatrist at the mental health clinic. Within four weeks, he reported that he was able to sleep through the night and was feeling less restless. His psychotherapy focused on relaxation techniques such as deep breathing as well as cognitive techniques such as labeling and challenging his worrying, and coming up with various ways to cope with stress rather than worrying excessively. Therapy was also helpful for Peter to discuss and sort through his feelings about his parents' divorce, and to understand how his anxiety affected his romantic relationships.
  • Dr. Tobin's reflections: Typical of many individuals with GAD, Peter has always felt like a constant “worrier,” but this anxiety was recently aggravated by a stressful event: his parents' divorce. Additionally, his lack of sleep was likely contributing to his difficulty with the concentration that is necessary for keeping up with the standards of work required by his career. Since he had been doing well at work up until this point, he may not have felt that his anxiety was a problem. His anxiety may have also gone unnoticed due to the intense pressure and sacrifice that face all individuals who work in Peter's career area. It was clear however, that Peter worried about many issues to a greater degree than do others in his situation. At the time he presented for treatment, however, it was clear that his inability to control his worry over his parents and his girlfriend were causing major problems in his work and social life. Not only had that, but his past anxiety caused problems that he did not recognize at that time. For many people who suffer from GAD, the longer it goes untreated the worse it may get. Fortunately for Peter, his girlfriend recognized that he was struggling and was able to obtain help for his overwhelming anxiety. I am pleased with the progress of therapy so far, and am hopeful that given his many strengths, Peter will be able to manage his symptoms through the psychological methods over which he is gaining mastery. Peter has the potential to be a successful lawyer, and given the strength of his relationship with Ashley, I am hopeful that he will be able to turn his life around with only a slight chance of re-experiencing these symptoms.
    • Summary
    • The field of abnormal psychology goes beyond the academic concern of studying behavior. It encompasses the large range of human issues involved when a client and a clinician work together to help the client resolve psychological difficulties.
    • People working in the area of abnormal psychology use both “client” and “patient” to refer to those who use psychological services. Our preference is to use the term “client,” reflecting the view that clinical interventions are a collaborative endeavor.
    • The person providing the treatment is the clinician. There are many types of clinicians who approach clinical work in a variety of ways based on training and orientation. These include psychiatrists, clinical psychologists, social workers, counselors, therapists, and nurses. The field also includes those who do not have graduate-level training. These include occupational therapists, recreational therapists, and counselors who work in institutions, agencies, schools, and homes.
    • Clinicians and researchers use the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) which contains descriptions of all psychological disorders. In recent editions, the authors of the DSM have strived to meet the criterion of reliability so that a clinician can consistently apply a diagnosis to anyone showing a particular set of symptoms. At the same time, researchers have worked to ensure the validity of the classification system so that the various diagnoses represent real and distinct clinical phenomena.
    • The DSM-5 presents diagnoses organized into 22 chapters. The classification system is descriptive rather than explanatory, and it is categorical rather than dimensional.
    • The diagnostic process involves using all relevant information to arrive at a label that characterizes a client's disorder. Key to diagnosis is gaining as clear a description as possible of a client's symptoms, both those that the client reports and those that the clinician observes. Differential diagnosis, the ruling out of alternative diagnoses, is a crucial step in the diagnostic process.
    • To gain full appreciation of the client's disorder, the clinician develops a case formulation: analysis of the client's development and the factors that might have influenced his or her current psychological status.
    • A cultural formulation accounts for the client's cultural background in making diagnoses.
    • Culture-bound syndromes are behavior patterns that we find only within particular cultures.
    • Clinicians typically follow up the diagnosis phase by setting up a treatment plan, the outline for how therapy should take place. The first step in a treatment plan is for the clinician to establish treatment goals, ranging from immediate to long-term.
    • Treatment sites vary in the degree to which they provide a controlled environment and in the nature of the services that clients receive. These include psychiatric hospitals, specialized inpatient treatment centers, outpatient treatment ranging from a private therapist's outpatient clinic or office, or a community-based mental health center. Other treatment sites include halfway houses, day treatment programs, or places of work or school.
    • Modality, or the form in which one offers psychotherapy, is also a crucial component of the treatment plan. It can be individual, family, group, or milieu therapy. Whatever treatment of modality a clinician recommends, it must be based on the choice of the most appropriate theoretical or combination of perspectives.
    • In optimal situations, psychotherapy is a joint enterprise in which clients play an active role. In the best of all possible worlds, the client remains in treatment until the treatment runs its course, and the client shows improvement and maintains the improved level of functioning. While not always successful, therapy is usually effective, and the majority of treatments do result in significant improvement.