What if you worked in an agency that required you to formulate a diagnosis and treatment plan based on your impressions at the time of the initial session? How would this influence your practice? How would you try to maintain your own integrity within this agency?

Such a policy would likely stem from insurance requirements in order to guarantee payment. While navigating such policies could prove tricky, it is possible to proceed with integrity as long as the agency allows modifications to the initial diagnosis.
Categorical definitions of psychological disorders allow physicians to communicate in a shared language with patients, families, and other medical providers regarding treatment and prognosis. At the same time, it is crucial for patients to receive the correct diagnosis in order to receive the appropriate treatment. Without the ability to identify biomarkers, clinicians are forced to rely on the subjective experience of patients and then their own subjective experiences—and then consider how those experiences compare to a population or a subgroup of a population. Certainly there is room for error here, undoubtedly so in diagnoses formed at an initial consultation.
With this in mind, it becomes crucial to have some safeguards in place to influence the care of such patients, such as the following recommendations.
Some mental disorders have overlapping symptoms. Always be willing to re-examine the initial diagnosis in light of conflicting information and to consider alternate diagnoses.
Carefully monitor any treatments provided to a patient under these circumstances. Incorrect treatments could prove detrimental, so frequent checkups should be mandatory in the beginning stages of any new treatments.
Consider delaying the delivery of the official diagnosis to the patient. Sometimes patients subconsciously (or even consciously) create symptoms to match those of any given diagnosis, so in situations where the diagnosis has not been carefully analyzed over time, it could prove counter-intuitive to provide patients with this information.
Remain open to the possibility that a patient does not have a mental disorder and instead has a variant that falls within the ranges of normal human behavior—and be willing to revisit and dismiss the original diagnosis if necessary. One study found that while 25% of the US population is treated for a mental disorder, only 5% have severe symptoms.

"The additional 15–20% have milder and/or more temporary conditions that are placebo responsive and often difficult to distinguish from the expectable problems of everyday life." (Frances)
It becomes paramount, therefore, for the clinician to be certain that only patients who need treatment (especially drug therapies) are receiving treatment. Since this could be incredibly difficult to discern in the initial appointment, great care should be taken to safeguard patients in this area.


Safeguarding one's integrity is crucial, clearly. Always be willing to have difficult conversations about policy. Be the advocate your patients need—and are paying for. If a diagnosis seems questionable, ask for further time or the additional counsel of other clinicians. Keep up with current research regarding diagnoses and have those conversations frequently with the policymakers at the agency. In short, always be sure it is known that you serve the needs of patients first and foremost, and have that conversation in authentic, ongoing ways with involved parties.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683254/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4104191/