Chapter 10 Flashcards
The procedures that professionals use to achieve the first goal are collectively called assessment. A wide variety of assessment procedures has been developed, ranging from clinical interviews to standardized tests, behavioral observations, mental status exams, data collection from significant others, and analysis of case records. Ideally, assessment is conducted as a collaborative process between a professional and a client. Competent assessments include judgments about client prognosis, strengths, and social supports, along with determinations of the scope and severity of problems
Assessments can be expressed in a variety of ways, depending on the clinician’s theoretical orientation and use of formal classification systems. The more accurate the assessment of the problems (and the resources a client has to address them), the more likely it is that those problems will be successfully resolved. Assessment is not limited to individual and multiple-person psychotherapy.
Two aspects of assessment are especially vulnerable to abuse: the use of diagnostic categories to describe client problems and the use of psychological and educational tests.
To diagnose means to define in professional terms the nature, limits, and intensity of a problem a client brings to counseling
Differential diagnosis refers to the process of determining which of the possible diagnoses best fit a particular person’s symptoms.
For example, a professional tries to differentiate the normal inclination of a pre-school child to be physically active and inattentive from the early signs of attention deficit hyperactivity disorder
The professional terms used to designate problems are derived from scholarly research and practice and are found in classification systems such as the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization [WHO], 2014) and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) (American Psychiatric Association, 2013).
Diagnosis refers to any organized system for defining client problems in common use by mental health professionals.
Because of its association with naming and specifying problems, diagnosis has been called “labeling” by some professionals, a term that implies that diagnosis is inherently dehumanizing and harmful
The most important is that diagnosing is one of the most influential activities in which a professional engages (Behnke, 2004). Applying a diagnostic name to clients’ problems can powerfully affect many aspects of their functioning—self-esteem, career opportunities, eligibility for insurance, vulnerability to rejection and ridicule by others, and educational placement.
Second, diagnosis has ethical dimensions because it is an inherently imperfect process. Even though behavioral science has advanced substantially over the last century, our knowledge of psychological processes is still limited, and our capacity to reliably assess the functioning of a given individual is also restricted
The imperfections in the diagnostic process are not solely the result of client or insurance impatience, however. Mental health professionals have often made procedural and judgment errors (e.g., Hill & Ridley, 2001; Rabinowitz & Efron, 1997; Smith & Dumont, 2000; Spengler et al., 2009). McLaughlin (2002) refers to these as human information processing errors. Humans use heuristics, experience-based techniques for streamlining problem solving, to assist with processing the vast amount of information that comes to us, and these heuristics can either be very helpful in separating important content from insignificant detail or can erroneously classify the insignificant as important or neglect the relevant.
For example, the human tendency to seek quick answers to dilemmas flaws the diagnostic process (Anastasi, 1992; Groopman, 2007), as does the inclination to emphasize information received early in the interview over data gathered later, called a primacy effect
Client likeability also plays a role; those who are pleasant and easy to work with appear to get more attention from professionals in the diagnostic interview. And those who are unpleasant are more likely to get rushed through the process
Unfortunately, client payment method exerts undue influence over the diagnosis in subtle ways that professionals do not recognize. Kielbasa, Pomerantz, Krohn, and Sullivan (2004) and Lowe, Pomerantz, and Pettibone (2007) reported that psychologists were significantly more likely to use a DSM diagnosis when payment came through managed care than when clients paid out of pocket, even when presented with identical descriptions of client symptoms.
And in Lowe et al. (2007), psychologists were five times more likely to give a DSM diagnosis to a client with a managed care payment, even when the mild social anxiety described in the vignette did not meet the criteria for a DSM diagnosis.
The diagnostic systems currently used are also far from ideal. The research evidence supporting the categories is uneven, and the categories themselves are often overlapping, inconsistent, and vulnerable to gender, racial, and social class bias
These imperfections place a heavy burden on the practitioner trying to use the diagnostic system in a responsible way. Even well-trained professionals do not always arrive at the same diagnosis for identical symptoms when using the DSM, partly because of the overlapping categories
Third, the mere existence of diagnostic identifiers means that mental health professionals may be biased in favor of using them, even when a diagnosis is unjustified.
Rosenhan’s study demonstrates the tendency of mental health professionals to skew the information they receive to fit preexisting categories. This inclination to pathologize normal behavior can also be seen in less dramatic ways when professionals mistake normal feelings of bereavement for depression, or label ordinary adolescent rebellion as conduct disorder.
The practitioner’s first responsibility in assessment is to evaluate evidence objectively, without presupposing that a person in the client role must have a diagnosable disorder. In fact, Section E.5.d of the ACA Code explicitly states that counselors may refrain from giving a diagnosis if, in their judgment, that would be harmful to the client or others.
Fourth, in societies where stigma attaches to mental and emotional disorders, assigning an official diagnostic name to the client’s pain can have powerful psychological effects in itself. Clients may feel ashamed or resist such a designation, and their coping skills may be tested.
Fifth, as Matarazzo (1986) points out, the process of arriving at the diagnosis, of prodding the client for details of his or her experience, is in many ways an invasion of privacy no less severe than a physical examination by a physician or an audit by the Internal Revenue Service. Whenever a professional invades the privacy of another, certain conditions should exist: good reason for the invasion, potential for benefit, competent engagement in the activity itself, and the client’s consent.
Counselors and therapists often lose sight of the threat that diagnosis represents to clients. In a now classic publication, Raimy (1975) suggests that people who voluntarily enter counseling have two underlying worries in addition to their presenting problems. First, they fear that professionals will confirm their worst fear—that they are truly crazy. Second, clients worry that the problems they have
Sixth, knowledge of diagnostic language can lead to casual diagnosis, the application of diagnostic terms to people with whom one does not have a professional relationship. For example, mental health professionals may be tempted to use their diagnostic skills to interpret the behaviors of politicians, disfavored colleagues, troublesome students, or others in their personal lives
The need for Standard 9.01b first became apparent in 1964, when Barry Goldwater was a candidate for the U.S. presidency. At that time, there were a number of mental health professionals who publicly questioned his mental stability and fitness for office but who had never interviewed or evaluated the candidate. Their willingness to make such bold statements in the absence of any direct professional contact led the American Psychiatric Association to initiate what came to be termed as the Goldwater rule, which prohibits diagnosis in the absence of an examination
A related ethical issue that has taken the forefront in the psychiatric profession is the influence of the pharmaceutical industry on how psychiatric diagnoses are constructed (Moncrieff, 2009). Moncrieff notes the correlation between the development of new psychopharmacological medications and the creation of new diagnoses and/or the dramatic increase in the incidence of a disorder for which medication becomes available. Other mental health professionals need to be alert as well to unintentional influences of this industry on diagnoses.
Diagnosis can also be used to discredit people who are already objects of discrimination and disfavor in the society. As Szasz (1971) noted, diagnosis can serve as a form of social control. He gives the example of labeling slaves who ran away from slaveholders as mentally disordered, with a diagnosis of drapetomania.
For example, African Americans and Latinos have been more likely to receive diagnoses of schizophrenia than their European American counterparts
The now famous research by Broverman and her colleagues (Broverman, Broverman, Clarkson, Rosencrantz, & Vogel, 1970) first highlighted how professionals show gender bias in their professional judgments. They found that mental health professionals used discrepant definitions of a healthy male and a healthy female, but the same professionals used nearly identical adjectives to describe healthy males and healthy adults. Using this logic, a female adult could not be judged both a healthy adult and a healthy woman
This research also shows that defining a behavior as functional or dysfunctional does not take place in a social or cultural vacuum. As Marecek (1993) notes, all definitions of abnormal behavior are rooted in a culture’s conception of what an ideal life is. Behaviors that appear bizarre in one society are viewed as normal and desirable in another.
Thus, professionals who fail to take into account the social and cultural context of current definitions of health and disorder may erroneously designate a normal behavior as pathological (Kress, Hoffman, & Eriksen, 2010). Marsella and Kaplan (2002) propose that assessment of client problems should include culturalogical interviewing, a procedure that systematically explores the client’s life context and perceptions of health and abnormality.
Finally, a diagnosis can become a “self-fulfilling prophecy” for a client. For instance, a person with an erroneous diagnosis of major depression may begin to interpret his or her normal variations in mood as problematic and may overreact to them. Others may begin to treat that person differently. In time, the focus on low mood can change behavior and thinking, and that person’s ordinary adjustment problems may grow into the depressive disorder they have been labeled.
A boy erroneously diagnosed with an attention deficit may stop attempts to concentrate on school work since he believes that he is not capable of focus, given the diagnosis.
In summary, diagnosis is a powerful tool that professionals must learn to use responsibly so that it helps rather than harms the client. Its misuse stems from a variety of causes, but underlying them all is insensitivity to the implications of diagnosis, insufficient skill with diagnosis, inadequate informed consent, or ignorance of the scientific and practical limitations of current diagnostic systems.
For all these reasons, the ACA Code obliges counselors to be especially careful to obtain a proper diagnosis, with explicit attention to cultural considerations and awareness of the profession’s flawed history of misdiagnosis deriving from cultural bias (Sections E.5.a–c).
The fundamental ethical directives for test developers are
(a)
to prepare instruments with sufficient evidence to support their validity and reliability, with appropriate test norms, and with a comprehensive (and up-to-date) test manual and
(b)
to keep the welfare of the consumer as a higher priority than profit.
According to this standard, an acceptable test manual elaborates research evidence, describes appropriate applications, and honestly conveys strengths and weaknesses of the test.
In addition, test manuals should offer detailed information about norms, and describe the appropriateness of the test for groups of different racial, ethnic, and linguistic backgrounds. Current standards also encourage developers to provide data that help users to avoid common misinterpretations of results.
Another major responsibility of test developers is to revise test content and procedures as research and environmental circumstances dictate. Even a measure that is well designed, uses an appropriate norm group, and shows sufficient evidence of validity and reliability at its creation can devolve into a test that fails to provide meaningful results because of changing evidence and circumstances.
The Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1943), developed just before World War II, represents an example of a measure that needed revision over time because of changing demographics, outdated language, and content that became inappropriate by the 1990s; hence the publication of the MMPI-2 and the MMPI-A.
For any professionals subject to HIPAA regulation (a category that includes virtually all who provide clinical mental health services), the regulations require that clients be allowed to view their treatment records, including test results that are part of the personal record (HIPAA Privacy Rule, U.S. Department of Health and Human Services [DHHS], 1996). In parallel fashion, some state legislatures have enacted open-records legislation that also affirms the right of clients to access all information about them in a medical or mental health record.
In response to such questions, ethics committees of the professional associations have devoted much attention to strategies to address this conflict and provide professionals with better guidance. Ultimately, these issues may require legal resolution in the courts or legislatures, but the professional associations have offered the following standards and recommendations for professionals caught in similar situations. The APA has taken the lead on this matter and has helped professionals by clarifying what constitutes test data that are part of the client’s record and what assessment information belongs exclusively to the publisher. In Standard 9.07, APA clarifies that clients have a right to all data about their performance (assuming of course, that data will not cause them harm), but they do not have a right to the test materials that belong to the publisher of the test
