Testing, Assessment and Diagnosis in Counseling

Running head: ASSESSMENT AND DIAGNOSIS

Testing, Assessment and Diagnosis in Counseling

Dessie L. Pierce

Student Number 23756056

Liberty University

COUN501_D01_201040Sub-term DDeadline:12/17/2010Instructor’s Name – Cassandra FerreiraDate of Submission 4/11/23

ASSESSMENT AND DIAGNOSIS

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.

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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 client’s 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,

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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 client’s 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 self-

esteem, social, job, and educational opportunities, and even eligibility for medical insurance

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(Dougherty, 2005; Hohenshil, 1993a; Welfel, 2002). A mental health diagnosis can also confirm

a client’s 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 client’s world through understanding what the client’s 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).

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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 individual’s 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

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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,

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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

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(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

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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,

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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

doesn’t 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

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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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Testing, Assessment and Diagnosis in Counseling