How does the diagnostic process proceed? - Chapter 1

A psychodiagnostic examination can start in two ways: the client can be referred to the diagnostician or the client can go to the diagnostician himself. Once at the diagnostician, he analyzes the client's request for help as well as the referrer's request. These are not the same type of questions. The client's request for help could be about how to overcome his compulsive behavior, while the referrer's request might be about obsessive-compulsive disorder.

Based on these questions, the diagnostician asks three types of questions:

• Does she have an obsessive-compulsive disorder?
• What factors have caused this disorder and what factors perpetuate it?
• Which treatment is right for this patient?

A diagnostic scenario is drawn up based on these questions. This contains a preliminary theory about the client's behavior. Subsequently, this theory is tested using five steps:

• Hypotheses are formulated;
• A specific research tool is chosen that can help to test the hypotheses;
• Criteria are established for when the hypotheses are or are not rejected;
• The instruments are administered, and the results are analyzed;
• Based on the results, the hypotheses are accepted or rejected.

On the basis of this assessment, they will come to a diagnostic conclusion.

What is the diagnostic cycle?

It is useful to build up the psychodiagnostic process according to De Groot's empirical (scientific) cycle. This empirical cycle consists of observation, induction, deduction, testing and evaluation. Yet this is not standard applied by diagnosticians.

What are the 5 basic questions in clinical psychodiagnostics?

There are five types of questions that often arise in psychodiagnostics. With each of these questions it is important to have a certain knowledge of psychology (knowledge base). It is best if the diagnosis answers the five basic questions in sequence and goes through the steps in the diagnostic cycle. These are the five basic questions:

1. Recognition: What are the problems?

The question that can be asked here is: what is the problem, what succeeds and what goes wrong? The recognition phase includes an inventory, description, ordering, categorization and an estimate of the seriousness of the problem behavior. The difference between and a diagnostic formulation should be considered. Classification is about categorizing someone's behavior based on the DSM. A disadvantage of a categoric classification is that it is quite limited and leads to "labeling". An advantage is that it improves the communication between information. A diagnostic formulation, on the other hand, contains more detailed information about a client's behavior and takes more into account the context in which this behavior is in place. The authors of the book advocate a diagnostic formulation.

2. Explanation: Why are there problems?

The question that can be asked is 'why are the problems there?' The statement contains 3 parts:

• The (partial) problem;
• The conditions that explain the occurrence of the problem;
• The causal relationship between 1 and 2.

The statements can be classified according to:

• The locus. This is the person or the situation. The statement can therefore be person-oriented or situation-oriented;
• The nature of the control. This is about the cause or the reason. The difference between these two is that the cause is the preliminary conditions, while the reason is the voluntary choice. 
• Synchronous and diachronous explanation conditions. Synchronous explanatory conditions occurred with the behavior and diachronic explanatory conditions preceded the behavior. For example, in psychodiagnostics, the structural explanation is synchronous, there is ego weakness. The psychogenetic explanation is then diachronic, due to oral problems in the early life of the individual;
• Inducing and continuing conditions. The inducing conditions cause a behavioral problem and the continuing conditions maintain the behavior.

When dealing with a problem, it is best to look for the factors that perpetuate the problem, because they can be influenced.

3. Prediction: How will the problems develop?

The question that can be asked is: how will the problems develop in the future? This is expressed as probabilities, for example: what is the probability that the client will be able to fully resume work in the future? It is about the relationship between a predictor and a criterion. The predictor is the behavior that is present now, and the criterion is the future behavior. If there is not enough theoretical knowledge available, it is recommended to consult with colleagues.

4. Indication: How can the problems be solved?

The question posed here is 'how can the problems be solved?' What treatment does a patient need? Before an indication can be given, the explanation and prediction phase must be completed. In addition, a diagnostician must have:

• Knowledge about treatments and practitioners
• Knowledge about the relative usefulness of treatments
• Knowledge about the acceptance of the indication by the client. An indication strategy has been developed for this, which includes 4 principles:

1. The client perspective is explored and made explicit;
2. The diagnostician provides the client with information about treatment methods, processes and practitioners;
3. The expectations and preferences of the client are compared with what the diagnostician finds suitable and useful and in consultation a number of possible treatments are formulated that both accept;
4. The client chooses a practitioner and a treatment.

5. Evaluation: Have the problems been resolved?

The question posed here is 'have the problems been solved sufficiently after the treatment?' This phase looks at:

• Whether the diagnosis and treatment proposal have been taken into account in the therapy;
• Whether the process and treatment caused the change in behavior. This can be determined by looking at whether the behavior has decreased without being attributed to the treatment, or it can be shown that it made it through the treatment by means of n = 1 designs.

How does the diagnostic process proceed?

The first task of a diagnostician is to analyze and specify the request and request for help, in addition he consults file data, these are reports from previous psychodiagnostic or medical research and information about, for example, school, work or family. In the analysis of a request for help, the client's perception is mainly explored with the aid of an interview or broad band screening instruments (for adults the MAP and for children the CBCL).

After the analysis of the application, there is a reflection phase, in which the diagnostician must be aware of his bias, these are prejudices. Subsequently, all questions from the applicant and client are arranged in a diagnostic scenario. From this a preliminary theory about the problem behavior of the client is drawn up from which the hypotheses follow. It is important that not all problems end up in the recognition phase, only the problems that very much limit the client and for which he or she seeks help.

What are the steps in the diagnostic examination?

The diagnostic examination consists of six steps: hypothesis formation, choice of research tools, formulation of testable predictions, administration and scoring, argumentation and report.

1. Hypothesis formation

The hypotheses that are formulated in the recognition phase are about whether there is a question of psychopathology. For hypotheses in the explanatory phase, the diagnostician uses a list of explanatory factors and chooses which one to investigate. The knowledge of the diagnostician is important in predictive hypotheses. The indication phase is mainly about which treatments and therapists are best suited to the client.

2. Choice of research resources

To answer the recognition question, the diagnostician can make use of instruments, observations, anamnestic information and data from informants. The explanation phase includes tools that focus on explanatory factors such as intelligence, cognitive skills, and context factors such as the family situation. In the prediction phase, use can be made of instruments that have predictive validity. Finally, an aid questionnaire can be used in the indication phase.

3. Formulation of testable predictions

Once the research resources have been selected, criteria must be drawn up against which the results are weighed up. Criteria can be, for example, based on the number of dimensions from the DSM that must occur in the client. The criteria must be drawn up in advance so that the diagnostician is not influenced by bias.

4. Administration and scoring

The collection and scoring of the diagnostic instruments provide both qualitative and quantitative information. The results are interpreted with the help of norm tables. The observations during the administration of the tests is also important information that is thoroughly investigated. The results are then compared against the criteria.

5. Argumentation

After the results are known, they are fed back to the hypotheses and predictions. The reliability of the instruments and sources are taken into account. If the results match the hypothesis, the hypothesis is retained. If the results contradict the hypothesis, the hypothesis will be rejected. Finally, possibly new information from the studies will also be summarized and may lead to a new diagnostic cycle.

6. Report

The report includes the results in the same steps as the diagnostic process. This report is passed on to the referrer. In the report, the conclusions of the investigation are substantiated. It indicates whether the conclusions are based on facts or whether they are interpretations. The report must be clearly described so that the applicant reads it as the diagnostician intended. If the referrer has no additions, questions or improvements to the report, the report is transferred orally to the client.

What are Diagnosis Treatment Combinations (DCBs)?

Diagnosis treatment combinations assure the client that the treatments initiated are evidence-based. Because each treatment has a fixed duration and rate, this is efficient to work with for the insurance companies. The disadvantage of working with DCBs is that clients often have multiple complaints or have no clearly defined problems, which makes it difficult to find appropriate treatment.