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D.J., Klein, B., Lau, M.A., Roudfoot, J., Ritterband, L., White, J. and Williams, C. ( 2010) Oxford Guide to Low Intensity CBT Interventions. Oxford: Oxford University Press.

       Papworth, M., Marrinan, T. and Martin, B. ( 2013) Low Intensity Cognitive BehaviourTherapy: A Practitioner's Guide. London: SAGE.

       Richards, D.A. and Whyte, M. ( 2011) Reach Out: National Programme Student Materials to Support the Delivery of Training for Practitioners Delivering Low Intensity Interventions (3rd edition). London: Rethink.

      To access the online resources accompanying this chapter, please visit: https://study.sagepub.com/farrand

      3 Diagnoses and Problem Descriptors: Labelling Problems, Not People

      Joshua E.J. Buckman, Rob Saunders and Stephen Pilling

      Learning Objectives

      By the end of this chapter you should be able to:

       Demonstrate an awareness of the main diagnoses seen in services that have implemented low-intensity cognitive behavioural therapy

       Critically evaluate diagnostic classifications systems predominantly based on a symptom severity threshold being crossed

       Apply the Probable Diagnosis Decision Support Tool to determine likely diagnoses

       Critically evaluate the clinical value of thorough assessment and the identification of diagnoses for low-intensity cognitive behavioural therapy service users and services

      Background

      Understanding the nature and context of the problems that have brought someone to seek help from psychological therapies services is crucial to the effective delivery of treatment. Central to this is an understanding of how those problems have evolved, the experience of the problems, including current symptoms and the impact of them on functioning. All of these factors help determine a diagnosis. Some people arrive for an assessment with a clear sense of the problems they are struggling with. They may have had a number of previous assessments, received diagnoses and received a number of treatments or therapies. For others, the assessment might be the first time they have been able to talk about their problems in any depth with a health professional. In either case, the language people use to describe their problems may not fit with medical models of disorder and corresponding diagnostic categories, or it may not be thought to be congruent with such diagnoses. It is common for people to talk about ‘feeling low', ‘stressed’ or ‘having a panic attack’ over and above any other problems being experienced. This may help point towards probable diagnoses but equally may not encompass the range of problems they are having. A good assessment is essential to teasing this apart and better understanding the nature of the presenting problems. In all scenarios, there are three key elements to any assessment in low-intensity CBT (LICBT) services.

      Key Point

      Key elements to assessment in LICBT services:

       Developing a shared understanding of the problems that have brought someone to the assessment, rooted in their own personal experiences.

       Developing an understanding of how those problems might be resolved

       Agreeing an initial plan to begin resolving those problems.

      Some people may arrive at assessment with a clear sense of their problems whereas others may not be able to describe them, be unsure how they have developed or are maintained and become worried that things cannot change. To support people who come to psychological therapy services develop an understanding of their problems that they find useful, LICBT practitioners need to draw on the knowledge and experience they gained through training. This may pertain to the nature of problem presentations, the course of such problems and evidence on the effectiveness of interventions. With this knowledge and experience, LICBT practitioners may reach a probable diagnosis with their patient that can be reviewed after further assessment or treatment.

      Reflection Point

      Reflect on what it is like when you are unwell and visit a health professional. What role does diagnosis play for you, in terms of your expectations of what is going to happen and for the care you might receive.

      When done well, assessments and thoughtful consideration of problems and probable diagnoses, developed collaboratively with patients, can be important interventions in their own right. After the assessment session in psychological therapy services that include LICBT interventions, such as Improving Access to Psychological Therapies (IAPT) services in England (Chapters 1 and 20), approximately 40 per cent of service users do not require or want treatment, are referred on, or are signposted elsewhere. Ensuring that assessments are done well, information is gathered and advice developed on the basis of them is communicated effectively (Chapter 2) is therefore of great importance (Clark, 2018). It provides the framework on which appropriate identification of the LICBT intervention to address the probable diagnosis is made (Part II).

      Problem Descriptors

      Reaching a probable diagnosis is fundamental to practice in LICBT; the way they are recorded in IAPT is in the form of problem descriptors. The main features upon which the probable diagnosis is reached may then be expressed by patients in the form of a problem statement (Chapter 2).

      Key Point

      Problem descriptors:

       remain provisional at the start, during and end of treatment

       can be reviewed and amended with further assessment or if the agreed focus of therapy changes

       represent the presenting problem or probable diagnosis as the agreed focus of treatment

       align with International Classification of Diseases, 10th edition codes – for example, ICD-10 F32 for a depressive episode or F40.1 for social phobia (WHO, 1992)

       inform treatment planning using NICE recommended interventions for the probable diagnosis

       determine the appropriateness of offering an LICBT intervention

       inform the most appropriate LICBT intervention for each probable diagnosis.

      Presenting Characteristics of Common Mental Health Disorders (CMDs)

      The key characteristics of problems and symptoms identified during assessment (Chapter 2) and summarised in the problem statement inform the recognition and subsequent probable diagnosis using the ICD-10 (WHO, 1992). Those addressed below are focused on common mental health problems receiving a probable diagnosis within a stepped care service delivery model such as provides the organisation structure for the IAPT programme (Chapter 1). However, it should be recognised that people can present with symptoms associated with severe and enduring mental health difficulties. On these occasions the LICBT practitioner would refer the patient to the appropriate step in the stepped care model or follow the service risk protocol when necessary.

      Depression

      To meet criteria for a diagnosis of depression, symptoms must occur nearly every day and impact functioning in everyday life.

      Key Point

      Core symptoms:

       Pervasive and persistent low mood (feeling down, depressed or hopeless)

       Anhedonia (a loss of pleasure or interest in usually enjoyable activities)

       Lacking in energy, increased tiredness or fatigue

       Withdrawal from everyday activities.

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