They want to know the diagnosis so they can prescribe the right pill or they are recognizing that the typical placebo effect for mild to moderate depression or anxiety isn’t sufficient for this person and they are trying to figure out why. I usually turn referrals like that into psychotherapy cases and it usually only takes about ten minutes into the interview for me to see why they need more treatment than can be provided in primary care.
I find that--especially early on--an over-emphasis on 'using gold-standard (which is an instance, often, of 'begging the question')' approach to get the
right diagnosis 'quickly' betrays a lack of sophistication on the part of the person pushing it.
There are SO MANY surplus/incidental motives attached to 'getting the/a diagnosis' in mental health these days that we really need to think carefully about the process of rushing to diagnoses (and any pressure to do so) early on in the process of psychotherapy treatment engagement.
I consider diagnostic determinations to be open-ended (just like clinical case formulations) and not things that I am under pressure to 'settle in concrete' within X sessions. My role as a psychotherapist involves using diagnoses as well as other elements of the case formulation as useful 'tools' in order to facilitate more effective treatment. I also see assessment/intervention (or, more properly, assessment --> intervention --> assessment --> intervention...(and so on...)) as an iterative process that unfolds over time and not a 'one time' thing that is 'established.' I know that in other contexts ('consult to do assessment for 'X' condition' or forensic/neuropsych evals) it's different but as a psychotherapist I find that being rushed/pressured/threatened/manipulated in any way to 'come to' a particular diagnosis or 'rule out/ dismantle' a particular diagnosis pollutes the process.
Also, formally speaking, a DSM diagnosis is an instance of a scientific
description rather than an instance of scientific
explanation. From DSM-III onward, there was an explicit focus on developing DSM criteria that were--to the extent possible--theory-free and simply empirical. Now, once a DSM diagnosis is established (for example, PTSD), researchers proceed to utilize those
descriptive criteria to figure out patients to include/exclude in their scientific studies on 'those with PTSD' to begin to get some info regarding the task of scientific
explanation (generally, at the population-level (those with PTSD as a population)). We need to keep these things conceptually separated at the level of assessing/diagnosing and case-formulating with the individual client, however. 'What the research says (in general, in aggregate, and nomothetically)' regarding 'people with PTSD' is going to apply, if at all, imperfectly to the individual sitting across from me who has been diagnosed (however competently or incompetently) with PTSD. This comes up all the time with patients who assert such things as, 'I have PTSD and that makes me angry all the time and I can't control what I do and so I need you to write a letter stating that I am unemployable as a result.' Nope, won't say anything in writing under my license that I don't actually believe. And just because you 'passed' a ('***GOLD STANDARD***') CAPS structured interview process doesn't mean you actually have PTSD. Any reasonably intelligent malingerer spending a few hours on the internet going straight to publicly available info could 'pass' the CAPS interview with flying colors. It does nearly nothing to protect against semi-intelligent and semi-informed attempts to malinger PTSD. It is based entirely on self-report of symptoms. Its only value to me is as a means of 'catching' the casual malingerer/mis-attributor/over-reporter of symptoms flat-footed with a lack of pre-scripted detail when you ask for detail. Sure, it's better than the PCL-5 but is it better than 'The PCL-5 plus sophisticated semi-structured psychiatric interviewing around particular symptoms by an experienced clinician?' Not sure that question has ever even been addressed in the literature, let alone answered definitively. The current emphasis of the CAPS as a 'gold standard' for accurately diagnosing PTSD in VA samples is utterly laughable to people who practice in that environment on a daily basis. It has its uses, but the push that is currently underway to require a CAPS for everyone in order to address these complex issues is simply another heavy-handed, autocratic, bureaucratic, shotgun-to-swat-a-gnat, one-sized-fits-all, good-idea-faerie-who-hasn't-seen-a-patient-in-ten-plus-years, 'cursed-be-the-gold-that-gilds-the-straightened-forehead-of-the-fool (Tennyson reference)' arrogant bullcrap idea that will further demoralize the outpatient providers.
