Diagnosing Counseling Clients

Assessing clients' symptoms to make a diagnosis is an important counseling skill. Diagnoses are often required for reimbursement for services through managed care. Client diagnoses can also provide important conceptual information, and diagnoses can be used alongside a client conceptualization, to aid in deciding what treatment(s) will be used.

Ethics & Diagnosing

Section E.5 of the 2014 ACA Code of Ethics provides counselors with guidance regarding diagnosing clients.

Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interviews) used to determine client care (e.g., locus of treatment, type of treatment, recommended follow-up) are carefully selected and appropriately used.

ACA, 2104, E.5.a

Counselors recognize that culture affects the manner in which clients' problems are defined and experienced. Clients' socioeconomic and cultural experiences are considered when diagnosing mental disorders.

ACA, 2014, E.5.b

Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves and others.

ACA, 2014, E.5.c

Counselors may refrain from making and/or reporting a diagnosis if they believe that it would cause harm to the client or others. Counselors carefully consider both the positive and negative implications of a diagnosis.

ACA, 2014, E.5.d

DSM-5 Diagnostic Criteria

The fifth edition of the Diagnostic and Statistical Manual (DSM-5) is published by the American Psychiatric Association. The manual contains the diagnostic criteria for a wide range of mental health concerns, including substance use disorder. This book is a must-own for every professional counselor. The DSM-5 is organized into sections. The first section provides an introduction to the manual, as well as instructions for use. Section II is where you will find diagnostic criteria and codes, including Substance-Related and Addictive Disorders. Section III provides information regarding emerging assessments, instruments, conceptual frameworks, and models.

Note that the DSM-5 is written with the number "5", rather than the roman numeral "V".

DSM-5 Codes

When reading through the DSM-5, note the diagnostic codes associated with each disorder. For example, Alcohol Use Disorder has three specifiers:

  1. 305.00 (F10.10) Mild: Presence of 2-3 symptoms.
  2. 303.90 (F10.20) Moderate: Presence of 4-5 symptoms.
  3. 303.90 (F10.20) Severe: Presence of 6 or more symptoms.
American Psychiatric Association, 2013

When writing the diagnostic code, always use the code starting with F, as these are the ICD-10 codes. Use of the ICD-10 codes is required under HIPAA as of October 1st, 2015.

Primary & Provisional Specifiers

When writing DSM-5 diagnoses, it is important to note if the diagnosis is the primary focus of clinical attention or if the counselor needs additional information to confirm the diagnosis. The "Primary" specifier is included in parentheses after the diagnosis that is the primary focus for clinical attention, and the specifier "Provisional" is used if the counselor is not certain that the client meets sufficient criteria for a given diagnosis.

For example, the DSM-5 diagnostic criteria for Persistent Depressive Disorder require an adult to have a depressed mood for a minimum of two years. If a counselor knows that their client has been depressed for just under two years, they might use the provisional specifier until sufficient time has passed to confirm the diagnosis.

A DSM-5 diagnosis might be written as follows:

F.10.20 Alcohol Use Disorder, Moderate (primary)
F34.1 Persistent Depressive Disorder (provisional)

In this example, the primary focus is alcohol use disorder, and the counselor is waiting to see if the client meets the criteria for Persistent Depressive Disorder. Depending on the diagnosis given, additional specifiers may be included.

Primary & Provisional Specifiers

The primary and provisional specifiers are used to denote a diagnosis that is going to be the main focus of clinical attention (primary) or a diagnosis that is not yet confirmed (provisional). For example, a client who hasn't had symptoms long enough to meet a diagnosis might be given a "provisional" diagnosis, if the counselor believes they will soon meet all the diagnostic criteria.

When selecting a principal diagnosis, it is important that counselors consider multiple factors, including the client's presenting concern as well as the potential for one diagnosis to cause or impact another. For example, if a client's social anxiety is causing their alcohol use, it likely makes sense for social anxiety to be the principal diagnosis, since treating the social anxiety is likely to impact the alcohol use.

Multiaxial Diagnoses

Previous versions of the DSM used a multiaxial diagnostic system. The DSM-5 no longer uses different axis for different types of diagnoses or disabilities.

Writing Diagnoses

When writing DSM-5 diagnoses, write one diagnosis per line, and write the principal diagnosis on the first line. Only write the "F" codes, as three digit numeric codes are no longer used. Write diagnoses in this order:

  1. Diagnostic code
  2. Name
  3. Severity (if appropriate)
  4. Specifiers (if appropriate)
  5. "principal" or "provisional" diagnosis

For example:

  • F10.20 Alcohol Use Disorder, severe, in early remission, in a controlled environment (principal diagnosis).
  • F40.10 Social Anxiety Disorder (provisional diagnosis).