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Testing, Assessment and Diagnosis in Counseling Dessie L. Pierce Student Number 23756056 Liberty University

COUN501_D01_201040 Sub-term D Deadline:12/17/2010 Instructors Name Cassandra Ferreira

ASSESSMENT AND DIAGNOSIS Date of Submission 4/29/13

Abstract Diagnosis is one of the most important tasks performed by every professional counselor. Any weakness of the diagnostic process goes to the very heart of the therapeutic process. Competent testing and proper assessment are crucial to any diagnosis. A study of the history of assessment and its role in diagnosis are informative and helpful for developing a consistent and useful diagnosis process. Also of great importance are the training and techniques of assessment and diagnostic procedures, and the acknowledgement of the historical weaknesses of these processes. The DSM (Diagnostic and Statistical Manual), which is almost universally used, unfortunately reveals that there are problems with gender and ethnic bias which must be addressed. Also explored are the working relationships between diagnosis and the insurance industry, and between the Bible and the DSM.


Testing, Assessment and Diagnosis in Counseling There is almost no universal agreement regarding the practice of diagnosis in the field of counseling, even regarding whether or not it should be performed by counselors at all. The history of diagnosis in the profession of counseling is a long one, however, though often maligned (Hohenshil, 1993a), as its reliability does not have the best track record (Fong, 1995; Hohenshil, 1993b; Dougherty, 2005; McLaughlin, 2002). It is undeniably true, however, that all counselors diagnose, whether they do it formally or informally. Surveyed counselors who were asked how frequently they and other mental health professionals were responsible for assigning diagnoses to their clients, indicated that they were often or always responsible 85% of the time (Mead, Hohenshil & Singh, 1997). Even developmentally oriented counselors must diagnose whether the clients behavior is appropriate for their approach or the client must be referred to a specialist (Hohenshil, 1996). Diagnostic classification has become so widely used, in fact, that it is almost impossible to communicate with colleagues or mental health professionals in other fields without it (Hohenshil, 1996). Virtually all modern counselors, who have to work at the very least with licensing agencies and insurance companies, must know how to formally diagnose mental disorders, and experienced counselors know that doing so leads to more effective treatment methods (Hohenshil 1996; Hamann, 1994). Not only that, but diagnosis performed sloppily and without competence will harm clients (Hamann, 1994), and it is a process with a potential for abuse (Dougherty,

ASSESSMENT AND DIAGNOSIS 2005). Furthermore, empirical research has reached a point where it is possible for a competent counselor to choose specific, empirically verified, therapeutic techniques that are the most effective for each clients issues (Hohenshil 1996, Seligman, 1993). An accurate diagnosis also affects the course of treatment, and provides a benchmark against which the effectiveness of the treatment can be measured. (Hill, 2001; Hohenshil, 1996; Ivey & Ivey, 1999; Mead et al., 1997; Seligman & Moore, 1995).

In fact, the American Counseling Association Code of Ethics states that Counselors take special care to provide proper diagnosis of mental disorders (American Counseling Association, 2005, E.5.a., p. 12). CACREP (Counseling and Related Educational Programs) standards currently require knowledge of the principles and models of biopsychosocial assessments, case conceptualization, theories of human development and concepts of normalcy and psychopathology leading to diagnoses and appropriate counseling plans (Council for Accreditation of Counseling and Related Educational Programs, 2009, .D.5, p. 49), as well as knowledge of the principles of diagnosis and the use of current diagnostic tools, including the current edition of the Diagnostic and Statistical Manual (Council for Accreditation of Counseling and Related Educational Programs, 2009, K.1, p. 22) to be taught in order for a counseling education program to be accredited. Yet until 2001, many counselor education programs did not even require students to complete a DSM course (Dougherty, 2005; Hohenshil, 1993; Mead et al., 1997). Many counselors are uncomfortable with the process of diagnosis, feeling that they are labeling their clients (Hohenshil, 1996; Mead et al., 1997; Seligman, 1999). These labels may follow clients throughout their lives and negatively affect them in many ways, impacting selfesteem, social, job, and educational opportunities, and even eligibility for medical insurance


(Dougherty, 2005; Hohenshil, 1993a; Welfel, 2002). A mental health diagnosis can also confirm a clients fear of being crazy, leading them to feel embarrassed or even hopeless (Dougherty, 2005; Welfel, 2002). Some counselors also feel that labels can cause them to dehumanize clients, which would lead them to devalue clients, discredit their concerns, and disengage from them in the therapeutic process (Hohenshil, 1996; Benson, Long, & Sporakowski, 1992, as cited in Hohenshil, 1996). Diagnosis can have a positive effect, however, like providing clients with a name for their suffering, making them more likely to seek help (Dougherty, 2005; Welfel, 2002). It can also help counselors enter the clients world through understanding what the clients symptoms mean (Hohenshil, 1993a). Some counselors have tried to help with the labeling problem by referring to their clients as people with a diagnosis, for example, a person with schizophrenia rather than a schizophrenic (Hohenshil, 1993b). By far the most commonly used system for diagnosis in the counseling profession is the Diagnostic and Statistical Manual, in its various editions (Hohenshil, 1996; Mead et al., 1997; Seligman, 1999). The first edition, the DSM-I, was published in 1952, and it had 108 different categories under eight major headings (American Psychiatric Association, 1952; Hohenshil, 1993b). The DSM-II contained 185 categories (American Psychiatric Association, 1968; Hohenshil, 1993b). Both of these editions came under attack because of ambiguous criteria that resulted in low interrater reliability (Hohenshil, 1993b). The DSM-III contained 256 mental disorders and a new multiaxial system of classification (American Psychiatric Association, 1980; Hohenshil, 1993a).

ASSESSMENT AND DIAGNOSIS Research indicates that counselors use the DSM for billing insurance, case and treatment planning, communication with other professionals, education, evaluation, meeting requirements of employers and other entities such as courts and governmental agencies (Mead et al., 1997). Many counselors believe that the DSM follows a rigid medical model (Crews & Hill,

2005; Dougherty, 2005), even though the vast majority of the disorders listed are not attributable to known or presumed organic causes (Sue, Sue, & Sue, 1990, as cited in Crews & Hill, 2005). The authors of the DSM-III-R purposely avoided identifying a specific school of thought, such as medical or behavioral, but intended it to be atheoretical and purely descriptive (Cook, Warnke, & Dupuy, 1993; Crews & Hill, 2005; Fong, 1995; Hohenshil, 1993b). Other criticisms of the DSM system state that it is biased, difficult to use (Mead et al., 1997), pseudoscientific (Rabinowitz & Efron, 1997), difficult to apply to families and groups (Mead et al., 1997), and one study went so far as to say, To use the DSM-IV to diagnose relationships is tantamount to using a tape measure to determine an individuals weight, i.e. not impossible but certainly less than accurate. (Crews & Hill, 2005, p. 65). Others have countered by claiming that the limitations of the DSM system to deal with relationships are not inherent in the system itself, but in how it is used. It can be used to conceptualize systems and interactions, not just individual people (Sporakowski, 1995). It has also been pointed out that when clinicians fail to follow the DSM criteria when making diagnoses, the system can hardly be blamed for the mistakes that follow (Hohenshil, 1993b; McLaughlin, 2002; Rabinowitz & Efron, 1997). When used properly, in fact, the DSM system can be one of the many important sources of information about a client (Seligman, 1999), provide a list of characteristic behaviors and attitudes for each diagnostic category (Ivey & Ivey, 1999), enhance the selection of effective treatment procedures (Hohenshil, 1993a), provide a

ASSESSMENT AND DIAGNOSIS common language among mental health professionals (Hohenshil, 1993a), and aid in case conceptualization, treatment planning, and educating clients (Mead et al., 1997).

Beginning with DSM-III (American Psychiatric Association, 1980), the diagnosis process involved creating a comprehensive picture of the client by evaluating them according to five axes (Seligman, 1999), each axis describing a different aspect of functioning (Fong, 1995). The diagnosis was made using a menu approach, using lists of criteria which were made up of symptoms, emotions, behaviors or beliefs, and which have a required threshold number. For example, a diagnosis might be indicated by four or more of the criteria on the list (Fong, 1995). Axis I issues are egodystonic, that is, they are not perceived by the client to be a part of the self. Axis II issues are egosyntonic, perceived as an integral part of the self (Fong, 1995). The other axes describe medical problems, psychosocial problems and adaptation. Counselors should determine a full five-axial diagnosis on all clients (Fong, 1993). Although the words testing and assessment are often used interchangeably, standardized tests and self-report inventories are only a few of the many types of assessment done by competent counselors. Assessment is anything performed in the process of collecting information for use in diagnosis (Hohenshil, 1996). Assessment involves a variety of formal and informal methods, including personal interviews, questionnaires, checklists, behavioral observations, analysis of case records, information gleaned from significant others, as well as consultation with other professionals (Dougherty, 2005; Fong, 1995; Hill & Ridley, 2001; Hohenshil, 1993a; Welfel, 2002). The ACA Code of Ethics and Standards of Practice states that assessment techniques including the personal interview should be carefully selected and properly utilized to promote client well-being while diminishing potential harm to clients (American Counseling Association,

ASSESSMENT AND DIAGNOSIS 2005, E.5.a). Licensing and certification standards also require some knowledge of tests and assessment. Of course, these are minimum standards and do not fulfill the degree of proficiency that should be the goal of every counselor (Zytowski, 1994). For personal interviews, many counselor educators strongly encourage the use of a semistructured interview guide, to avoid subjective impressions and judgments based on only a few symptoms (Fong, 1995; Morey & Ochoa, 1989, as cited in Fong, 1995). While it seems obvious that assessment is important at the start of the therapeutic

relationship, it is also important in every stage. First, the counselor uses assessment techniques to gather information for at least a tentative diagnosis and treatment plan. During treatment, assessment data collected will provide information about progress made, and assist in making the decision of when to terminate the therapeutic relationship. Follow-up assessment might include client self-reports, behavioral observation, and/or reports by significant others, for the purpose of determining the lasting effects of treatment (Hohenshil, 1993b; Sporakowski, 1995). Diagnosis is the interpretation of the information gathered through assessment, using a diagnostic classification system (Hohenshil, 1996). There are many ways to improve the accuracy of diagnosis, but the most efficient way is through effective training. The Council for Accreditation of Counseling and Related Educational Programs (CACREP) and state licensure agencies now require knowledge of psychopathology and diagnostic skills for program approval and licensure (Hohenshil, 1996; Mead et al., 1997), and at least 90% of counselor education programs offer some training in the diagnosis of mental and emotional disorders (Hamann, 1994; Hohenshil, 1992; Seligman, 1999), mostly in the DSM system (Hohenshil, 1996; Mead et al., 1997), although some have called for a an even more aggressive approach (Hamann, 1994). In fact, it has been suggested that the low interrater reliability rate obtained by some DSM-III-R

ASSESSMENT AND DIAGNOSIS (APA, 1987) studies reflects poor diagnostic training (Hohenshil, 1996), as good to excellent interrater reliability has been found for even the most difficult diagnoses when clinicians were studied who were well trained in the use of systematic interviewing procedures and were able to apply the DSM-III-R diagnostic criteria correctly.

While some find the DSM system to be too distant from their professional value of caring (Ivey & Ivey, 1999), most call for counselor educators and supervisors to train new counselors to use it in a way that maximizes its benefits while minimizing its drawbacks (Mead et al., 1997). Although much focus has gone into improving the DSM system and other tools for diagnosis, this has not resulted in an increased diagnostic accuracy (Rabinowitz & Efron, 1997). Accuracy will only improve with better training in the use of these tools as well as the best diagnostic techniques. Some suggestions in the literature for improving the process of diagnosis include delaying diagnosis to improve accuracy (Dougherty, 2005; Fong, 1993; Hill & Crews, 2005; Hill & Ridley, 2001; McLaughlin, 2002; Rabinowitz & Efron, 1997), thinking of diagnosis as an ongoing process rather than a rigid one (Dougherty, 2005; Hohenshil, 1993a; Hohenshil, 1996), basing diagnostic decisions on more than one assessment instrument (McLaughlin, 2002), assuring that all the DSM criteria for a particular disorder have been considered (McLaughlin, 2002), considering all of the pros and cons of a particular diagnosis to guard against confirmatory bias (McLaughlin, 2002), writing down expectations about clients to make them explicit and thereby reducing the likelihood of self-fulfilling prophecies (McLaughlin, 2002), focusing on the atypical aspects of a case (McLaughlin, 2002), gathering counterevidence (Rabinowitz & Efron, 1997), consulting with peers (McLaughlin, 2002), keeping in mind that the DSM favors some groups over others (McLaughlin, 2002; Garb, 1998, as cited in McLaughlin, 2002), and taking

ASSESSMENT AND DIAGNOSIS advantage of all opportunities for training in diagnosis and the use of the DSM system (McLaughlin, 2002).


The literature provides some insight into the sorts of errors that contribute most heavily to misdiagnosis. These are referred to as information processing errors (McLaughlin, 2002; Rabinowitz & Efron, 1997) and contribute to such flawed thinking as stereotyping, which is making a decision based on only a few common features or symptoms (McLaughlin, 2002; Rabinowitz & Efron, 1997), self-fulfilling prophecy, which is acting on an expectation in a way that confirms it (McLaughlin, 2002), data availability and vividness, which is the practice of categorizing something on the basis of its familiarity, ease of recall, or clarity (McLaughlin, 2002), self-confirmatory bias, which is categorizing something only based on confirming evidence (McLaughlin, 2002), ignoring data in favor of personal experience, (McLaughlin, 2002), giving precedence to anecdotal information over systematic information (McLaughlin, 2002), relying on intuition and first impressions (McLaughlin, 2002; Rabinowitz & Efron, 1997), and assuming in the first stage of diagnosis that pathology is present, thus diagnosing pathology even when it is not there (McLaughlin, 2002; Rabinowitz & Efron, 1997). Being aware of these errors helps counselors guard against falling into them. Charges of gender and racial bias have been aimed at the DSM system, claiming that it operates from a Eurocentric male point of view (Cook, Warnke, & Dupuy, 1993; Dougherty, 2005; Ivey & Ivey, 1999), that it tends to overdiagnose women and underdiagnose men (Cook, Warnke, & Dupuy, 1993), and that both men and women in less traditional roles are more likely to be diagnosed with pathology than are those in traditional gender roles (Cook, Warnke, & Dupuy, 1993). Proponents of the system, while admitting that such a bias unquestionably exists, tend to blame it on the mind-set of the clinicians (Cook, Warnke, & Dupuy, 1993; Crews & Hill,

ASSESSMENT AND DIAGNOSIS 2005; Fong, 1993), rather than on the system itself, and reiterate that gender bias is minimized


when the DSM system is used in a competent manner by well-trained clinicians who follow the diagnostic criteria. Some counselors have even suggested the addition of a Global Assessment of Culture, Age, and Gender Scale, which would enrich understanding and use of Axis V, which would be a genuinely productive contribution of the ACA to a truly culture-centered, contextually aware DSM-IV (Hinkle, 1999, as cited in Ivey & Ivey, 1999; Ivey & Ivey, 1999). But the strongest criticism of the DSM system comes from marriage and family and group therapists who complain that the DSM is oriented to the diagnosis of individuals and doesnt lend itself to the diagnosis of systems and groups (Crews & Hill, 2005; Hill & Crews, 2005; Hohenshil, 1996; Ivey & Ivey, 1999; Sporakowski, 1995). The only codes related to relational diagnoses are the so-called V codes (Crews & Hill, 2005; Sporakowski, 1995) still referred to as such even though they are no longer called V codes in the latest revision (American Psychiatric Association, 2000). Unfortunately, the V codes are not eligible for reimbursement from third party payers (Crews & Hill, 2005; Hamann, 1994), which brings up further issues for family and group counselors. A DSM diagnosis is usually required for reimbursement (Crews & Hill, 2005; Hohenshil, 1996), in fact some studies have found that marriage and family counselors primary use of the DSM is to diagnose clients for insurance purposes (Dougherty, 2005; Hamann, 1994; Hohenshil, 1996; Mead et al., 1997). They are forced to choose between billing the correct diagnosis, even when a family may not be able to afford to pay for the unreimbursed therapy, or billing the third party payer with a somewhat misleading individual diagnosis, a practice that is apparently not at all rare, even though it is unethical and fraudulent (Crews & Hill, 2005; Dougherty, 2005; Hamann, 1994; Mead, Hohenshil, & Singh, 1997; Welfel, 2002). Keep in mind that such a

ASSESSMENT AND DIAGNOSIS diagnosis can also follow a client for years, with possible negative consequences (Dougherty,


2005; Hohenshil, 1993a; Welfel, 2002). It is no wonder that some feel that the use of the DSM is primarily for financial gain. As in every area of life, the Bible has some guidance for us on this important topic. Even though the process of diagnosis performed by a counselor can be used by God to begin a very powerful life-changing process in a client, it is a difficult process, and also has great potential to cause harm. The Bible guides us to be humble (2 Samuel 22: 28, Psalm 25:9, Ephesians 4:2, James 4:10, to name but a few), to not think of ourselves as better than others (Philippians 2:3), to not judge others in such a way that we would be judged the same way (Matthew 7:1), and to do all things in love (1 Corinthians 16:14, John 13:35). We can never go wrong if we treat others the way we would want to be treated if we were in their situation. Irvin D. Yalom (2002) asks an eloquent question in his book The Gift of Therapy, If you were in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?" (p. 5, as cited in Dougherty, 2005).

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