When you meet a patient for the first time, you know very little about her, but you know that there she is suffering. (Note: Throughout this book, I switch genders when discussing theoretical patients rather than resorting to the awkward “him or her.”) While this may seem obvious, this implies something that we often lose sight of. Our job, from the first “hello,” is to ease our patients’ suffering, rather than to make a diagnosis.

Don’t get me wrong—the diagnosis is important. Otherwise, I wouldn’t be subjecting you to yet another edition of this book! But diagnosis is only one step on the path of relieving suffering. And often, you can do plenty to help a patient during the first session without having much of a clue as to the official DSM diagnosis.

Since 2005, when the second edition of this book was published, psychiatry has begun to question its fixation on the value of diagnostic categories. We have come to realize that “major depression” does not imply a specific “disease” but rather a huge range of potential problems. Each of our patients present with their own versions of depression, in other words, and each version requires an individualized treatment approach. A 24-year-old woman floundering around after graduating from college a few years ago is depressed— and the solution may lie in helping her to clarify her goals.
A 45-year-old public relations manager just found out his wife has been having an affair and he is depressed—the solution may be helping him to decide if he can ever trust her enough to engage in couple’s therapy. A 37-year-old woman with three well-adjusted children and a good marriage says her life seems okay but she is depressed—she may need a course of antidepressants.

My point with these examples? Before you dive into the worthy project of becoming a world-class DSM diagnostician, experiment with spending much of your face-to-face patient time thinking about their lives, rather than your diagnosis of their lives. Engage your natural empathy, compassion, and intuition—because these represent the essence of psychological healing. And even as you progress through your career and have logged thousands of patient hours (as I have), always remind yourself of something that a wise colleague, Brian Greenberg, once told me: “I often put the DSM manual aside and tell myself, ‘Brian, how are you going to make this person’s journey easier?’”

The diagnostic interview is really about treatment, not diagnosis. It is important to keep this larger goal in mind during the interview, because if you don’t, your patient may never return for a second visit, and your finely wrought Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis will end up languishing in a chart in a file room.

Studies show that up to 50% of patients drop out before the fourth session of treatment, and many never return after the first appointment (Baekeland and Lundwall 1975). The reasons for treatment dropout are many. Some patients do not return because they formed poor alliances with their clinicians, some because they weren’t really interested in treatment in the first place, and others because the initial interviews alone boosted their morale enough to get them through their stressors (Pekarik 1993). The upshot is that much more than diagnosis should occur during the initial interview: Alliance building, morale boosting, and treatment negotiating are also vital.

The four tasks of the initial interview blend with one another. You establish a therapeutic alliance as you learn about your patient. The very act of inquiry is an alliance builder; we tend to like people who are warmly curious about us. As you ask questions, you formulate possible diagnoses, and thinking through diagnoses leads naturally to the process of negotiating a treatment plan.