Assessment & diagnosis an overview of best practices

Assessment & Diagnosis

An Overview of Best Practices

Assessment & Diagnosis Introduction

• Assessmento Assessment is the process counselors use to measure or ascertain a client’s current state

of being and to develop counseling goals or chart a course of treatment.o Evaluations are a form of assessment however evaluations have a specific purpose - to

report findings, typically to a 3rd party and with little emphasis placed on client well-being.

• Testingo Testing is used along with client interviews as the methodology and tools to assess

clients.o Issues that come up in testing can include testing competence and diversity issues that

influence testing.

• Diagnosiso Diagnoses are defined by the DSM.o Issues that affect diagnosis include a lack of cultural sensitivity in DSM structure, and

insurance company reimbursement policies.

• Client Rightso Clients have a right to be fully informed before these assessment processes begin; and

they have a right to make decisions regarding whether or not they will participate.

Testing Competence

• Education and licensure play a large role in a counselor's ability to test legallyo This varies from state to state.

o Example: LA law delineates between appraisals and testing, an LPC who is privileged can only perform tests that fall under the appraisal definition whereas a psychologist or above can perform testing. State of LA v. Atterberry, 1995.

• Counselors should utilize only those tests they are trained to administero Studies have shown administering and interpreting the MMPI requires more

training than other personality tests

• Testing is vulnerable to abuse; ways to prevent abuse:o Select the appropriate test to administer.o Administer the test appropriately.o Interpret the results correctly.o Multiple areas of criteria should be used before diagnosis, not just the test.

• A counselor requires both statistical and psychological training to properly administer a test

Testing Competence

• Psychological training issues to noteo A test only gives us an idea of how the client performs at the time the test is

administered, not whyo The answer to why requires further knowledge about:

o The client, their environment, and history.o What Intellectual, emotional, and physical issues are revealed

through the counseling process.o Testing Bias based on cultural norms.

o Counselors should select the proper test related to the problem being addressed.

o Aptitude and intellectual tests.o These cognitive tests only measure “Developed Abilities” and reflect a

client’s learning history.o Was the history controlled for in the interpretation of the test results and

the test itself? Administer the test under a controlled setting; i.e. a counselor’s office.

Testing Competence

• Counselor Testing Recommendationso Administer the test under a controlled setting; i.e. a counselor’s office.o Be mindful that interpretation is still needed from the counselor.o Do not rely fully on grading centers.o Be cognizant of counselor testing misuse; reasons include.

o Human desire for a quick answer.o Work pressure, time constraints.o Lack of knowledge.

o Acknowledge and address testing criticism.o Most criticisms deal with how tests are administered and interpreted, not

the test itself.o According to Anastasi (1992) “Tests are essentially tools. Whether

any tool is an instrument of good or harm depends on how the tool is used” (p. 610).

Testing Competence

• Modern Testingo As the profession advances, assessment methodology advances and can be

seen in new test methods like internet testingo The ACA and other governing agencies provide guidelines for proper

use of internet counseling and testingo Also the National Board of Certified Counselors (NBCC),

International Society of Mental Health Online (ISMHO), Association of Counselor Education and Supervision (ACES)

o Areas of concern regarding modern internet testing methods includeo Interpretation of results- Will the client truly understand the

interpretation given over the internet?o Administering of the test- What environment is the client in while

they take the test?

Testing Competence

• Subjectivity Awareness

o Each client is unique. One fallacy of standardized testing tools is the

standardization itself.

o It is important for counselors to be aware of the many issues that might

affect test results such as diversity; the uniqueness of each client should

not be ignored.

o The next few slides highlights this relevance.

Testing Competence

• Recent Nobel Prize (for medicine) winner, Prof. Sir John Gurdon, once scored a 2 out of 50 on a science exam

• He also received poor notes from a teacher, almost causing him to not study his passion, science

Testing Competence

Albert Einstein dropped out of school mid-term after being asked to leave by a teacher who said “He will never amount to anything.”

School class photograph in Munich, 1889. Einstein is in the front row, second from right.

Diversity Issues in Testing

• Testing Competence also requires acknowledgement of diversity issues in testing. The DSM-IV-TR provides counselors with an outline for evaluating clients in different cultural contexts. This minimizes misdiagnosis and heightens awareness of culturally bound disorders. DSM-IV-TR Guidelines:

• The DSM Guidelines are a diversity tool but they do not include everything.

o The DSM does include a glossary of culturally bound syndromes.

o Counselors can supplement the DSM with a "cultralogical" assessment, using psychological and medical testing for diagnosis.

Review cultural background & possible cultural explanations of client issues.

Assess identity and cultural information relevant to the client

Review possible cultural factors of clients' psychosocial states

Assess any cultural meaning of the client's problems

Review competencies affecting counselor client relationship

Assess the impact of family, work, and community regarding any client issues


• Diversity issues can affect diagnosis. Some common diagnosis problems that might be rooted in a lack of muticultural competence include:

o Underdiagnosing: i.e. all elderly people are sad- that is normal. They aren't depressed they are just boring.

o Overdiagnosing: i.e. commonly medicating children with ADHD/ADD

o Misdiagnosing: i.e. people who are diagnosed with bipolar disorder may actually have borderline personality disorders with impulse control issues.

• The definition of normal and acceptable test results in testing might lack cultural sensitivity given historical accounts

o Behavior that is not deemed ok now, but was deemed ok then: White Christians came to America and slaughtered many native Americans because they thought that they were superior.

o White Americans believed in the idea of "drapetomania" (slavery) and any desire to escape captivity was considered maladaptive.

• The DSM standards are rooted in research conducted by medical and psychiatric professionals and likely members of the dominant culture; normal standards might disregard a culturally diverse population


• Counselors should be aware of cultural influences that might affect the outcomes of testing. Some observations might include:

o Cultural schemas in each client.

o Framework of their identity.

o Cultural explanation of problems.

o Cultural attitude/perception of help seeking.

o Cultural adaptive functioning.

o Ethnocentric views.

o A closer look at ethnocentric views (real life scenario): Michael is a 25 year old African American male in east USA. He is going up for a promotion at work. He sees a counselor stating "I feel anxious/concerned with people always watching me." He also is always cautious when he sees a cop.

o Michael's test results indicate a high level of paranoia.

o Could Michael's ethnocentric view regarding authoritative figures have influenced his results?


• Counselors should be aware of the power they have as a tester and remain cognizant of the lasting effects cultural incompetence plays regarding test results

o The following clip highlights such power in an academic setting: http://youtu.be/wwCFAnSuL7c. Highlights:

o The principal makes a discriminating remark about the students five times - students with a different cultural background.

o Only one statement was made in defense of the minority group while multiple offensive remarks were made.

o "Some of them are just out of juvenile hall, and some of them might be wearing ankle cuffs to monitor their whereabouts.”

o "Those are lovely pearls. I wouldn't wear them to class."

• Counselors should monitor testing tools and reframe from the use of content bias testing tools where items on a test refer to experience familiar to only certain people

• Counselors must be cautious when using tests with culturally diverse clients

http://youtu.be/wwCFAnSuL7c

Diagnosis & DSM Controversy

• Testing typically results in using the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose clients

• The DSM system is based on the medical model of health, but mental health counselors prefer the wellness model (Remley & Herlihy, 2010).

o Although counselors align themselves with the medical model, they are expected to abide by the medical model to diagnose clients and for insurance reimbursement.

• There is controversy surrounding the DSM and the process of diagnosis within the industry

o Conflict exists between the DSM system & wellness orientation of counselors (Remley & Herlihy, 2010).

o Should counselors diagnose clients using the medical model-oriented DSM system?


• Conflict between the two models: Medical Model vs. Wellness Model

Medical Model

oFocuses on symptoms of the individuals.

oPhysicians and mental health workers use it to identify an illness instead of problems areas of functioning.

oIndividuals are viewed as the illness and are cured by physicians.

Wellness Model

oPeople are more than their illness.

oFocuses on clients' strengths rather than symptoms.

o“Used to help people resolve personal and emotional problems rather than focused on the illness” (p. 26).

oFocuses on determining which factors in the clients lives are interfering with the goal of reaching their full potential

oFocuses on how to improve clients’ functioning rather than curing them of an illness


• Common Issues with the DSM

o The DSM promotes sex role stereotypes and bias.

o It is rooted in the dominant North American culture in its diagnosis assumptions and is not culturally sensitive in composition.

o It lacks empirical evidence that diagnosis criteria enhances implementation of treatment.

• Common Issues with the DSM and Managed Healthcare Companies

o Managed mental health care determine which services are reimbursable (Braun & Cox, 2005).

o Even if counselors oppose diagnosis, they must assign a DSM diagnosis in order for them to be financially reimbursed (Braun & Cox, 2005; Remley & Herlihy, 2010).

o Counselors are challenged when particular diagnosis are not considered for insurance reimbursement (Braun & Cox, 2005).

o Counselors are presented with the ethical challenge of intentionally misdiagnosing clients in order to obtain reimbursement.


• Diagnosis and Ethical Violations

o Counselors who do not feel comfortable labeling their clients may participate in downcoding- under diagnosing clients for reimbursement.

o Counselors who feel pressured to obtain reimbursement from insurance companies might take part in upcoding- overdiagnosing clients for reimbursement.

o Upcoding can have serious consequences for the client as it can cause stigmatization by society.

o “Diagnosing for dollars” or intentional misdiagnosing, violates ethical codes and legal statutes (Braun & Cox, 2005).

• Ethical Standards and Violations

o Standard A.1.a of the ACA Code of Ethics (2005)-The primary responsibility of counselors is to respect the dignity and to promote the welfare of clients.

o Standard E.5.a. of the ACA Code of Ethics (2005)-Counselors take special care to provide proper diagnosis of mental disorders.

o These codes are violated when clients are intentionally misdiagnosed, especially when diagnoses decisions are collaborated with clients.


• Diagnosis and Legal Violations

o Counselors participate in fraud when they “misrepresent to health

care companies facts regarding their services” (Remley & Herlihy,

2010).

o Clients also participate in fraud when they collaborate with

counselors in intentional misdiagnosis (Braun & Cox, 2005).

o This behavior leads to court actions by the government.

o The government uses the Health Insurance Portability and

Accountability Act of 1996 as well as the 1986 False Claims Act to

investigate individuals who might be participating in insurance fraud

(Braun & Cox, 2005).


• An Informal Investigation of Future Counselors' and Current Counselors' Opinion regarding Diagnosis and the DSM

o Investigation Highlight: 100% surveyed believe it is unethical to intentional misdiagnose clients in order to receive insurance reimbursement

Survey No. 1 Survey No. 2

Current Masters-Level Counseling Students

Current Doctoral-Level Counseling Graduate Students/Professional Counselors

Four Questions Asked Five Questions Asked


Question 1: Would you feel comfortable diagnosing your clients with a mental disorder using the DSM?

Question 2: Would you ever consider overdiagnosing a client for insurance reimbursement?

Question 3: Do you think it is unethical for a counselor to incorrectly diagnose a client intentionally?

Question 4: Do you agree with Managed Care’s policy that your clients must meet certain criteria in order for you to be reimbursed?

Yes- 75%NoDepends- 25%Prefer not to answer

YesNo- 100%UnsurePrefer not to answer

Yes- 100%NoUnsureDepends on the reasonPrefer not to answer

Yes- 12%No- 38%Unsure- 50%Prefer not to answer

• Survey No. 1


Question 1: Do you feel comfortable diagnosing your clients with a mental disorder using the DSM?

Question 2: Would you ever consider overdiagnosing a client for insurance reimbursement?

Question 3: Have you ever under- or overdiagnosed a client, for any reason?

Question 4: Do you think it is unethical for a counselor to incorrectly diagnose a client intentionally?

Question 5: Do you agree with Managed Care’s policy that your clients must meet certain criteria in order for you to be reimbursed?

Yes- 40%No- 60%DependsPrefer not to answer

YesNo- 80%DependsUnsure- 20%Prefer not to answer

YesNo- 100%Prefer not to answer

Yes- 100%No UnsureDepends on the reasonPrefer not to answer

Yes- 60NoUnsure- 40%Prefer not to answer

• Survey No. 2

Client Rights Regarding Assessment & Diagnosis

Despite the different assessment and diagnosis processes and controversy, clients have rights that should not be overlooked.

• Clients have a right to be evaluated by a mental health service provider who is culturally competent and who is knowledgeable about the subject being evaluated

o The ACA Code of Ethics, 2005 E.2.a mandates that counselors only use assessment tools that they are trained to use.

•Counselors have a responsibility to ensure that tasks are clearly defined and assigned when working with other service providers

o Counselors sometimes work with testing specialists, i.e. psychologists, who conduct client assessments for their use; role expectations should be outlined up front. Discussions regarding roles might include:o Results feedback expectations, i.e. who will deliver results to the cliento A client's potential desire to switch counselors.o Which service provider will provide feedback to the client.o Handling the need for immediate intervention (i.e. threat of client harm

to self or others).o ACA Standard E.6.b requires counselors provide detailed information

about the client when referring assessment to other professionals.


• There is a difference between assessment tools used in counseling and evaluation.

• Counselors are responsible for explaining the difference between the two of these tools to clients prior to conducting evaluations. The ACA Code of Ethics Standard E.13.a instructs counselors to not only explain the difference but to obtain written consent from clients before conducting evaluations.

• ACA Standard E.2.c calls for counselors to have significant knowledge of an area's assessment process when decisions will be made based on results.

Assessments Used in Counseling Evaluation

Client well being is considered Client well being is not the focus

Results are used to develop counseling goals in collaboration with the client

Results are used to guide decisions concerning the client

Results are normally confidential Results are normally deliberately reported to 3rd parties


• Clients have a right to choose whether or not they will participate in testing

o Counselors should ensure that clients make informed decisions by disclosing as much information about the processes as possible beforehand – this includes discussing the test itself and what factors might contribute to favorable results.

• Clients should understand and be aware of how their test results will be used

o If data will be reported to a 3rd party, i.e. an evaluation, counselors should inform the client before conducting the assessment. An explanation explaining the purpose of the assessment and any results' intended use, should be discussed with the client at his or her level of understanding.

• Counselors have a responsibility to only release assessment records to those individuals who can accurately interpret the results

o The ACA Code of Ethics, 2005 E.3.b instructs counselors to include their interpretation of results when releasing results to qualified professionals. Counselors are also advised to be responsible when transmitting records.


• Clients have a right to test review.

o The ACA Code of Ethics mandates that counselors review test results with clients and offer clients feedback regarding assessment results.

o Counselors should go over results with clients face to face and observe the client’s reaction because that observation is an assessment tool within itself and can give the counselor additional insight.

o Service providers should know that a face to face review might expose gray areas where the testing instrument might not have been clear to the client.

o Review is a check and balance that might also highlight test fallibility; fallibility would be included in the discussion as required by ACA Standard E.9.a.

o Counselors should take care when presenting results to clients recalling that data can be interpreted differently based on how it was presented.

• Clients have a right to question.

o Counselors should welcome questions and respect each client's right to exercise his or her rights during the assessment and diagnosis process.

Assessment & Diagnosis Best Practices Summary

• Counselors should utilize only those tests they are trained to administer.

• Education, licensure and training are important to properly administer a test.

• Client subjectivity, test biases and limitations, result meanings and testing fallacies are important to consider in the testing process.

• Cultural competence is important and counselors should be aware of diversity issues in testing and ethically address any issues they might face.

• There is conflict between the DSM and it's medical model orientation and counselors' use of the wellness model; counselors should use the ACA Code of Ethics guidelines to supplement the DSM and address any conflicts or gray areas.

• DSM diagnoses are typically required by managed healthcare companies for client reimbursement; counselors should avoid misdiagnosing in order to obtain reimbursement.

• Counselors should collaborate closely when working with other mental health professionals to conduct assessments; roles and expectations should discussed up front.

• Counselors should disclose as much information about the assessment and diagnosis processes as possible to clients beforehand; written consent should be obtained up front.

• Testing methods, results and the use of any results should be discussed with the client.

• Counselors should release test results and their interpretations only to qualified individuals..

• Counselors should be aware that clients have a right to refuse participation in the assessment and diagnosis process.

References

Anastasi, A. (1992). Test and Assessment: What Counselors Should Know About the Use and Interpretationof Psychological Tests. Journal of Counseling & Development, 70, 610-615.

Braun, S. A., & Cox, J. A. (2005). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling and Development, 83(4), 425-433.Davidson, M. (2012). A poor school report is no barrier to success - just look at Prof Sir John Gurdon. Retrieved from http://www.telegraph.co.uk/science/9596616/A-poor-school-report-is-no-barrier-to-success-just-look-at-Prof-Sir-John-Gurdon.htmlHennessey, E.F. (1989). The Family, the courts, and Mental Health Professionals.American Psychologist, 44(9), 1233-1224.Lpc.org. (2009). Louisiana Licensed Professional Counselors Board of Examiners Position Statement onAppraisal Activities Clarification of the Distinction between Appraisals and Psychological Tests. Retrieved from http://www.lpcboard.org/Position_Statement_Appraisal_Activities.htm

Remley, T. P., & Herlihy, B. (2010). Ethical, legal, and professional issues in counseling. (3rd ed.). Upper Saddle River, NJ: Pearson Prentice HallWetter, M.W., & Corrigan, S.K. (1995). Providing Information to Clients About Psychological Tests: ASurvey and Law Students’ Attitudes.Professional Psychology: Research and Practice, 26(5), 474-477.

http://www.telegraph.co.uk/science/9596616/A-poor-school-report-is-no-barrier-to-success-just-look-at-Prof-Sir-John-Gurdon.html



Assessment & Diagnosis An Overview of Best Practices

Jessica Krzyzanowski

Brianna Harvey

Jennifer Barron

Myia Bennett•