Limitations of Formal Diagnostic Systems Such as the DSM and ICD

Before proceeding, it seems expedient to review some of the important limitations of traditional diagnostic approaches, such as the DSM-5. Only through knowledge of a system’s weaknesses can its strengths be utilized safely.

One of the most obvious limitations remains the fact that diagnoses are labels. As labels, they can be abused. One such abuse occurs when clinicians fall into the trap of using diagnoses as stereotypical explanations for human behavior. It should be remembered that a diagnosis provides no particular knowledge about any given patient. It merely suggests possible characteristics that may or may not be generalizable to the patient in question. In addition, as we saw in Chapter 6, it is critical to uncover the person beneath the diagnosis, a point elegantly stated by the gifted physician Sir William Osler, many years ago, when he commented, “It is much more important to know what sort of patient has a disease than to know what sort of disease a patient has.”¹⁵

Moreover, diagnostic formulations are evolving processes and as such should be periodically re-examined. There is a realistic danger that patients can become stuck with inappropriate diagnoses, a problem that can only be avoided through persistent reappraisal. In a similar fashion, the clinician should remain healthily aware of the potential ramifications of certain diagnostic labels with regard to the patient’s culture and family. By way of example, the label of schizophrenia can result in the loss of a job or in the development of a scapegoating process within a given family. Considerations of these problematic aspects of diagnosis related to cultural issues should be integral parts of sound clinical care.

In this regard, the kulturbrille effect, introduced in our last chapter, can cause problems such as over-pathologizing, if the interviewer is not aware of cultural norms. For instance, where I trained in medicine at the University of North Carolina in Chapel Hill, it was not uncommon for patients to talk about “root-working,” which was a culturally accepted folk belief that some people could perform malicious magic by burying and manipulating certain roots. Obviously, with some people who were suffering with schizophrenia this became part of a delusional belief system. But it was important for clinicians to realize that all patients who discussed root-work were not necessarily psychotic. In some patients it was merely an accepted belief and not evidence of psychopathology. In advanced diagnostic systems such as the DSM nomenclature and ICD, it is stressed that clinicians should be aware of such cultural norms so as to avoid such misattributions.

The issue of the significance of a specific diagnostic label to the patient himself or herself can be of marked importance. For this reason, I frequently ask patients if anyone has given them a diagnosis in the past. If the answer is “yes,” one can follow with questions such as, “What is your understanding of the word schizophrenia?” or “Do you think that diagnosis is right?” The answers to these questions can provide valuable insight into the patient’s self-image, intellectual level, and previous care.

With these limitations in mind, we can now begin our exploration of the DSM-5 in more detail. In 1980, the DSM-III system introduced many of the innovations, such as multiaxial formulation, that formed the foundation of the contemporary DSM systems. A bridge between the two systems called the DSM-III-R appeared in 1987, and added its own new ideas and refinements. The DSM-IV itself was published in 1994. In 2000, the DSM-IV-TR (Text Revision) was published, which did not change any diagnostic criteria but added much useful information about psychopathology and the subtleties of the diagnostic system to enhance the system as an educational tool, while keeping its mat­erial updated to reflect advances in evidence-based research.

It is to the DSM-5 system that we will now turn. We will not attempt to review diagnostic criteria now, because these are discussed in subsequent chapters. Instead we will look at those principles that help to make diagnostic formulation possible in the first 50 minutes. As diagnostic systems evolve they necessarily experiment with various changes, many of which are good, and occasionally, a few are not so good. There are some significant improvements in the DSM-5, but we will begin our study by noting what I, personally, feel is a potential regression in the system. This book focuses on contemporary practice, but I feel that this brief exploration of historical context can help the reader to be a better clinician both now and in the future.

The Loss of Multiaxial Formulation: a Historical Footnote

To me, one of the most compelling aspects of the DSM-III and the DSM-IV-TR was the fact that these systems pushed the interviewer to consider various contextual perspectives while formulating a diagnostic picture. Each perspective was placed upon one of five axes.

On Axis I, clinicians were prompted to delineate the patient’s presentation in terms of the classic psychiatric diagnoses such as major depression, bipolar disorder, schizophrenia, anorexia nervosa, OCD, and post-traumatic stress disorder (PTSD). Indeed, all psychiatric disorders – with the exception of personality disorders and intellectual disabilities – were listed on this first axis. It was on Axis II that clinicians were to list personality disorders as well as personality traits, whether the traits were problematic or sometimes beneficial in nature. Medical disorders and other biologic conditions such as pregnancy were placed on the third axis. It was on Axis IV that the clinician could help place the patient into their contextual matrix by addressing processes such as family, friendships, living conditions, financial concerns, and cultural issues. Finally, on the last axis, the interviewer considered in what fashion the above concerns and disorders were impacting on the patient’s relatively recent and immediate functioning.

The beauty of the system was the fashion in which it emphasized a holistic approach to conceptualizing the patient’s presentation while simultaneously preventing biological reductionism. This multiaxial approach metacommunicated that the field of psychiatry emphasized the importance of a contextual understanding of the patient. Indeed, the multiaxial system demanded that clinicians look at the patient contextually.

The DSM-5 has removed the mutiaxial system and, to my knowledge, is now the only major international diagnostic system that is not multiaxial. I mention it as being odd (a personal opinion) in that it seems to fly in the face of the current emphasis upon person-centered medicine, whether one is dealing with diabetes and cancer or schizophrenia. It should be noted that the final arbiters of the DSM-5 still felt that contextual factors, whether they be cultural, interpersonal, or environmental are important. Indeed, they recommend that such factors be routinely addressed in separate notations with all patients, but this recommendation seems to be undermined by the elimination of specific axes where it was required that these factors would be routinely addressed.

I feel that the lack of these axes, especially in our current age of time constraints, may invite a lack of attention to core aspects of care by harried clinicians. For instance, placing personality function and disorders on a separate axis in the DSM-IV-TR reminded clinicians that it is always important to understand the personality functioning of the patient and how it might impact on Axis I disorders such as OCD or schizophrenia. It further pushed clinicians to sensitively uncover the unique personality attributes of each patient, for such personality predispositions can be invaluable in understanding how a patient responds to his or her symptoms as well as in collaboratively developing treatment plans that fit the needs of that patient’s unique personality traits.

In any case, despite the lack of formal axes in the DSM-5, I myself find it useful when listing the DSM-5 diagnoses to always address the presence or absence of personality disorders and medical disorders separately, to remind myself (and the reader of my clinical assessment) of the importance of such factors. By way of illustration, in the chapters on differential diagnosis in Part II of this book, I will demonstrate how to do so in our clinical vignettes.

Later in this chapter, we will see that factors such as psychological, social, and spiritual aspects are comprehensively addressed in the two other treatment planning frameworks that I suggest routinely employing in addition to the DSM-5: matrix treatment planning and understanding the core pains of the patient.

Major Psychiatric Disorders (Other Than Personality Disorders)

At first glance the DSM-5 may appear confusing because of the large number of diagnostic entities that it contains. But there is little need for concern. The craft in using this system lies in approaching the task by first uncovering the general diagnostic probabilities and then delineating the specific diagnoses (Figure 7.2).

As the initial interviewer listens during the opening phase and the body of the interview, the symptoms of the patient will suggest diagnostic regions worthy of more elaborate expansion. This primary delineation will lead the clinician to one or more of the following easily remembered regions of adult psychopathology:

Looked at in this simplified fashion, the first step in utilizing the DSM-5 appears considerably more manageable than at first glance. In order to succeed, the clinician must be well grounded in psychopathology, as will be discussed in Part II of this book. This knowledge base will allow the interviewer to quickly determine which of the thirteen areas are most pertinent. As the interview progresses, the clinician can reflect upon whether each of these broad areas has at least been considered, thus avoiding errors of omission.

Once the primary delineation has been made, the interviewer can proceed with the secondary delineation, in which the specific diagnoses subsumed under the broad diagnostic areas are explored and the more exact DSM-5 differential diagnosis is determined. Thus, if the clinician suspects a mood disorder, the clinician will eventually hunt for criteria substantiating specific mood diagnoses such as major depressive disorder, bipolar disorder, dysthymia, cyclothymic disorder, other specified or unspecified depressive disorders, and other specified or unspecified bipolar disorders. This secondary delineation would be performed in each broad diagnostic area deemed pertinent.

As already described in Chapters 3 and 4, these explorations occur during the main body of the interview. Most importantly, they are done in a highly flexible fashion, always patterning the questioning in the style most compatible with the needs of the patient and the clinical situation. Consequently, the clinician expands these diagnostic regions in a unique fashion with each patient, mixing them with various other content regions and process regions. When done well, the result is an interview that feels unstructured to the patient yet delineates an accurate diagnosis.

V-codes represent conditions not attributable to a mental disorder that might be useful as areas for the focus of therapeutic intervention. Examples include academic problems, occupational problems, uncomplicated bereavement, low interest and follow-through with medications, marital problems, parent–child problems, and others. Sometimes these codes are used because no mental disorder is present, and the patient is coping with one of the stresses just listed. They can also be used if the clinician feels that not enough information is available to rule out a psychiatric syndrome, but, in the meantime, an area for specific intervention is being highlighted. Finally, these V-codes can be used with a patient who carries a specific psychiatric syndrome but for whom that syndrome is not the immediate problem or the focus of intervention. For example, an individual with chronic schizophrenia in remission may present with marital distress.

Personality Disorders

The basic approach to differential diagnosis with personality disorders follows the same two-step delineation that we found to be useful in delineating the non-personality related psychiatric disorders above. In the first delineation, one asks whether the interviewee’s story suggests evidence of long-term interpersonal dysfunction that has remained relatively consistent from adolescence onwards. If so, the patient may very well fulfill the criteria for a personality disorder or disorders.

After determining that a personality disorder may very well be present, the clinician proceeds with the secondary delineation in which specific regions of personality diagnoses are expanded. This secondary delineation will result in the generation of a differential from the following list:

In Chapter 14 we will examine in great detail the many fascinating subtleties involved in exploring personality structure during an initial interview. One area not covered by the DSM-5 but sometimes of great value in understanding personality functioning is the role of defense mechanisms. Defense mechanisms range from those commonly seen in neurotic disorders such as rationalization and intellectualization to those seen in more severe disorders such as denial, projection, and splitting.

Understanding a person’s unconscious defense mechanisms (in classic psychoanalytic thought, defense mechanisms are viewed as being generally unconscious) can help the interviewer to uncover a more accurate picture of the person beneath the diagnosis. Defense mechanisms represent unconscious coping skills that protect a person from intense anxiety and/or unconscious ideas, images, or desires that would create intense guilt or shame. A detailed exploration of the various defense mechanisms, as they unfold in ongoing psychotherapy, is beyond the scope of this book, but the interested reader will find an excellent survey of them in the DSM-IV-TR, where a proposed possible axis called “the Defensive Functioning Scale” is outlined.¹⁶

Non-Psychiatric Medical Conditions

Non-psychiatric medical conditions such as diabetes, hypertension, seizures, etc., were listed on Axis III in the DSM-IV-TR. In the DSM-5, such disorders are now merged into a listing of the psychiatric disorders that are present.

The importance of an awareness of the potential presence of non-psychiatric medical disorders cannot be emphasized too much. In my opinion, all patients who exhibit psychological complaints for an extended time period should be evaluated by a physician, nurse clinician, or physician’s assistant to rule out any underlying physiologic condition or causative agent. To not perform this examination is to risk a real disservice to the patient, because entities such as endocrine disorders and malignancies can easily present with psychological symptoms. The astute clinician will always keep in mind that one can easily misattribute depression or anxiety that is being caused by an undiagnosed medical illness, such as hyperthyroidism, a low-grade encephalitis, or a frontal lobe brain tumor, to a current stressor. Just about anybody who develops a medical illness will have unrelated concurrent stressors in his or her life, for stress is a common aspect of living.

A person with an undiagnosed, slow-growing brain tumor that is resulting in a moderately severe depression with angry outbursts could be undergoing a severe financial loss with foreclosure that is completely unrelated to the brain tumor. An unwary clinician can quickly ascribe the depression and anger to the foreclosure (because the patient also is ascribing the depression and anger to his finances and loss of his house), thus missing the real cause of the mood disturbance and disruptive behaviors – a potentially fatal brain tumor. Proceeding with psychotherapy, without having uncovered the malignancy via a referral to a medical specialist, will result in precious time lost as the malignancy continues to grow and potentially metastasize. A keen persistence in ruling out the presence of a contributing non-psychiatric medical disorder can help clinicians to avoid such potentially dangerous red herrings.

It should also be remembered that the presence of a serious medical condition such as diabetes or congestive heart failure (even when it is unrelated to any psychiatric symptoms or disorders) represents a major stressor to the patient. Such conditions can significantly impact on the patient’s resiliency and ability to cope with his or her psychiatric disorder. Such considerations are of immediate importance in collaborative treatment planning and mobilizing familial/social/medical supports.

In this same light, a medical review of systems and a past medical history should become a standard part of an initial psychiatric assessment. Other physical conditions that are not diseases may also provide important information concerning the holistic state of the interviewee. For instance, it is relevant to know if the interviewee is pregnant or a trained athlete, because these conditions may point towards germane biologic and psychological issues, sometimes indicating potential strengths, such as routine exercise or yoga practice, that can be capitalized upon as parts of the treatment plan.

Psychosocial Context and Stressors

Although there is no specific axis for assessing psychosocial factors in the DSM-5, their importance is emphasized. Indeed, the DSM-5 recommends routinely assessing psychosocial factors and documenting the assessment as a special notation in all diagnostic assessments. Unfortunately, as mentioned earlier, I fear that without the mandate of a specific axis requiring an exploration of these factors, they may frequently be under-explored.

Nevertheless, this exploration, when done well, allows the interviewer to examine the crucial interaction between the patient and the environment in which he or she lives. All too often interviewers can be swept away by the complexities, intrigues, and symptoms of specific psychiatric disorders, failing to uncover the reality-based problems confronting the people coping with these disorders. These reality-based concerns frequently suggest avenues for therapeutic intervention as well as uncovering unexpected support systems.

By way of illustration, an interviewer may discover that secondary to a job layoff, the home of the patient is about to be foreclosed. Such information may suggest the need to help the patient make contact with a specific social agency or may suggest referral to a social worker.

This area of inquiry also remains of paramount importance in the successful use of crisis intervention counseling, time-limited therapies, and solution-focused therapies. Any time a patient presents in crisis, it is generally useful to determine what perceived stressors have brought the patient to the point of seeking professional help. A question such as the following is often useful: “What stresses have you been coping with recently?” or “What was going on for you that made you decide to actually come here tonight as opposed to coming tomorrow or some other time?”

Level of Current Functioning and Impairment

Once again, the DSM-5 has eliminated a designated axis for recording information regarding the patient’s level of function (formally Axis V in the DSM-IV-TR). However, the DSM-5 does acknowledge the importance of such explorations. In this regard, the World Health Organization’s Disability Assessment Scale (WHODAS) is included in Section III of the DSM-5, but the WHODAS is not easy to use in the tight time constraints of an initial assessment. The absence of a designated axis for requiring a sound assessment of current functioning, to me, invites potentially inferior exploration.

A robust assessment of actual current functioning pushes the clinician to carefully review evidence of immediate coping skills as affected by symptomatology. It is important to utilize behavioral incidents in this exploration, for patients, if merely asked for their opinions, may give misleading answers. By way of example, an acutely psychotic patient who does not want to be admitted to hospital may reply with a simple “not often” when asked, “Are the voices bothering you frequently?” Utilizing validity techniques such as behavioral incidents and symptom amplification as described in Chapter 5, the clinician may find that the dialogue develops more along the following lines:

By starting with a symptom amplification and then repeatedly using the behavioral incident technique, the clinician has found not only that the voices are bothersome but also that they are frequent and potentially dangerous.

The clinician may find it to be opportune, during the exploration of current functioning, to ask directly about elements of the wellness triad, hunting for strengths, skills, and interests as described in Chapter 6, for all of these attributes may be of value in helping the patient to cope more effectively with their current problems. Also keep in mind with regard to current functioning that sources outside the patient, such as family, friends, roommates, and employers frequently provide more valid information than the patient. Once again, when questioning collaborative sources, behavioral incidents can be used to enhance validity.

Clinical Application of the DSM-5

To begin applying our first assessment perspective, the DSM-5, we must first organize our data. We will then ask ourselves what, if any, treatment modalities are suggested by the diagnoses we have generated. With regard to major psychiatric diagnoses (other than personality disorders), Debbie’s presentation suggests several diagnostic entities. The primary delineation suggests that her symptoms are those of some type of mood disorder. Regarding the secondary delineation into the specific mood disorders present, she does not appear to currently fit the criteria for a major depressive disorder, but she may represent a variant of persistent depressive disorder (dysthymia). As mentioned earlier, the presence of this disorder might suggest the short-term use of an antidepressant. Dysthymia can also be approached using a variety of psychotherapeutic modalities, including cognitive–behavioral therapy (CBT) and psychodynamic models.

Her history suggests no strong evidence for entities such as schizophrenia or other psychotic processes, although the clinician may want to explore her vivid fantasy productions in more detail to rule out the possibility of delusional material or dissociative identity disorder. There is no evidence of a neurocognitive disorder such as delirium or dementia. Several areas not well explored are the areas of anxiety disorders, obsessive–compulsive disorders, trauma-related disorders, and dissociative disorders. In a later interview these omissions can be easily addressed.

Here we see how the use of a diagnostic paradigm can help prevent problematic errors of omission. Even the best clinician, and I have encountered this process many times in my own work, will not have time to scan for all potentially pertinent diagnoses because of the tight time constraints under which we all work. Through the use of a diagnostic schema such as the DSM-5, one can quickly, and reliably, spot diagnostic areas that were inadvertently missed, opening up the chance to appropriately explore for potentially hidden diagnoses in the next interview. To miss a diagnosis such as PTSD (possibly related to childhood abuse) in a patient with Debbie’s presentation could lead to missed opportunities for treatment intervention, including such opportunities as a survivor’s group.

Regarding personality dysfunction, several possibilities are emerging that may provide important clues as to how to proceed. Many of her symptoms, such as her frequent angry outbursts, her numerous overdoses, and her deep fears of abandonment and being alone, suggest the possibility of the diagnosis of a borderline personality and perhaps a dependent personality. Both of these diagnoses serve to warn the clinician that Debbie may be predisposed to becoming overly dependent upon the clinician. Dependency issues may be important areas for focus in the upcoming therapy. Also of importance is the fact that a large body of literature exists concerning the treatment of the borderline personality, literature that can be easily tapped by the clinician. As a triage agent, the diagnostic label of a borderline personality may also suggest the wisdom of not assigning this patient to a newly trained or poorly skilled therapist, because such patients are frequently difficult to manage. Regarding personality dysfunction, one might further explore entities such as a histrionic personality, a schizotypal personality, or an antisocial personality.

As mentioned earlier, all patients should be conceptualized within the context of their personality structures and predispositions, no matter how striking the presenting symptoms of the patient’s non-personality related symptoms may be. In this fashion, diagnoses such as borderline personality will not be missed. By not recognizing processes such as the potential for borderline dependency early in therapy, the therapist risks missing the diagnosis until well into therapy, by which time the patient may have already become markedly enmeshed and dependent on the therapist. By this point, much painful acting out may have occurred for the patient, and smooth transitions to other treatment options, such as DBT, will have been made more difficult. All of this pain could be avoided by screening for this diagnosis in the initial interview, as was done with Debbie.

An exploration of possible non-psychiatric medical conditions brings many important points to mind. In the first place, Debbie’s depressive symptoms suggest the possibility of a mood disorder due to a general medical condition. She needs a medical examination. If the initial clinician is a psychiatrist, then this clinician has omitted a good medical review of systems. This omission will need to be rectified. Pertinent laboratory work will be ordered, and a physical examination may be indicated.

But the exploration of non-psychiatric medical conditions does not end here. The history of episodic violence may suggest an underlying seizure disorder (caused by head trauma) that may have been routinely missed by previous clinicians. Once again, the interviewer will want to ask questions pertinent to this diagnosis and may consider ordering an electroencephalogram (EEG) or referral to a neurologist. Her worsening of symptoms near her menstrual periods also adds the possibility of a premenstrual dysphoric disorder, which may suggest the use of medications to relieve cramping and an antianxiety agent used for a day or two near her periods to decrease her premenstrual tension or the addition of a low-dose selective serotonin reuptake inhibitor (SSRI) antidepressant.

A final medical consideration concerns Debbie’s obesity. One wonders whether there may be an organic etiology for her obesity, such as hypothyroidism or polycystic ovarian disorder. One also wonders as to whether her weight represents a powerful psychological concern, which she was hesitant to discuss because of stigma.

Even though there is no specific axis devoted to assessing psychosocial factors, as mentioned earlier the DSM-5 system suggests that a careful exploration of psychosocial factors should be a part of any evaluation. With regard to Debbie, one questions what the impact of the upcoming wedding will be. Even for the most stable of people, weddings are stressful. Her wedding stresses may be further amplified by cultural bigotries related to same-sex marriage, once again an arena for supportive counseling in future sessions. A review of psychosocial factors also indicates that the interviewer has not explored current stressors very well yet. With regard to triage and the determination of when Debbie should be seen next, it would be useful for the interviewer to have a much clearer picture of the current stressors.

Regarding Debbie’s current functioning, the information is sparse here, reflecting a relative weakness in the database thus far collected. Keep in mind that such database weaknesses are common, and inevitable, in initial interviews, for there is not enough time to collect a perfect database. But it is our diagnostic perspective that prompts us to recognize these weak areas, a recognition that will allow us to explore these important topics in future sessions. A more thorough examination of current functioning would be of value in determining disposition. One also wonders what skills Debbie may possess that may be utilized in her treatment. For instance, her possibly overactive fantasy life, if toned down, may represent a fertile imagination, which could be an asset in her development as an individual. Current functioning and the availability of immediate social supports clearly warrant further exploration.

The above discussion illustrates the immense power of diagnostic systems such as the DSM-5 or the ICD-10 as methods of organizing data in a fashion that generates treatment options and also for “pointing out” areas of important clinical information that may have been overlooked. In addition, if utilized as intended, a clinician employing the DSM-5 system should be routinely looking for the person beneath the diagnosis by better understanding the patient’s personality functioning, biological health, and the complexities of the patient’s psychosocial and environmental stresses.

But these factors may be under-emphasized or overlooked by clinicians because of the absence of specific axes emphasizing their inherent importance in the DSM-5 system. In addition, there are other elements of a holistic assessment (such as spirituality, family dynamics, and cross-cultural nuance) not emphasized by the system. Consequently, even when used as intended, in my opinion, this assessment perspective alone can yield an incomplete picture of the patient. We will now turn to an assessment system that directly focuses upon the areas of relative weakness in the DSM-5, perspectives that may provide us with new insights into Debbie and how to help her.

Introduction

Matrix treatment planning provides a stimulating and practical method of organizing and utilizing the data gained from the initial interview that complements the DSM-5 or the ICD-10. The term “matrix treatment planning,” which I am introducing to the clinical literature in this chapter, is a recent term that I prefer to the more standard and traditionally accepted term “biopsychosocial treatment planning.” They describe the same system.

Although they describe the same system, as we shall soon see, I believe there are advantages to the newer term and the re-emphasis it places upon the interactional principles behind the biopsychosocial model as it was first delineated.

The goal in this section is to provide the initial interviewer with a reasonable conceptualization of what matrix treatment planning offers, how it is used, and its ramifications concerning what information needs to be gathered in an initial interview (as well as during ongoing psychotherapy). To accomplish this task in the sophisticated fashion that it warrants, we will examine exactly what is meant by matrix treatment planning, including the ideas from which it evolved (the biopsychosocial model) and from which it is still evolving.

As with our exploration of the DSM-5 system, there is no attempt to describe the pros and cons of specific treatment interventions here. Rather, the intention is to describe how to maximize the use of matrix treatment planning during the collaborative planning undertaken with the patient in the closing phase of the interview. Although not the intention of this chapter, I believe the reader will find that these principles will also be of use in long-term treatment planning.

Indeed, initially, our exploration of matrix treatment planning will require a somewhat extended side-trip from our interviewing map. The type of sophisticated understanding that a clinician needs in order to effectively undertake collaborative treatment planning, in the closing phase of the initial interview, will demand a focused attention upon some of the core principles of treatment planning itself.

Before we begin our exploration of the interface between the initial interview and matrix treatment planning, I would like to add a cautionary note to the reader. At times, some of the nuances of matrix treatment planning may appear somewhat complex, perhaps even overwhelming. Truth be told, they are complex. They are also intricate, delicate, and richly practical.

The goal of this chapter is not for the beginning student to understand and be able to immediately utilize all of the principles of matrix treatment planning delineated in the following pages. The goal is to leave the reader with a fascination and a genuine appreciation of the power of matrix treatment planning to heal. If successful, the reader will leave the chapter with a lively motivation to learn how to effectively employ the concept of the human matrix.

As you read, you will develop a sophisticated understanding of how matrix treatment planning principles can be elegantly interwoven into the initial intake. I believe it is important, in a beginning course on interviewing, to immediately see how this integration is gracefully achieved by a skilled interviewer, so as to have a model from which to work from the very beginning of your initiation into clinical interviewing.

As you continue into your more advanced years of training, you will participate in a variety of courses, internships, and clinical rotations that will provide you ample opportunities to learn how to implement the principles described in the following pages. Indeed, it is my hope that in the remaining years of your training (and post-training) you will frequently return to this chapter to help you integrate the many new skills you will be encountering.

Thus, sit back and enjoy the ride. The following pages describing the interface between the initial interview and matrix treatment planning are intended to provide an enticing and practical preview of the process. Nothing more. It will hopefully provide, in the years to come, a goal towards which you can work and a model from which you can more easily achieve that goal.