Ethical Dimensions of Diagnosing: Considerations tor Ciinicai Mentai Health Counselors

Victoria E. Kress, Rachel M. Hoffman, and Karen Eriksen

There are numerous ethicai considerations inherent within the process of assigning a Diagnostic and Statistical Manual of Mental Disorders (^4\h ed., text rev.; DSM-IV-TR: American Psychiatric Association, 2000) diagnosis, in this article, general ethics considerations such as informed consent and confidentiaiity, accuracy of diagnosis, and multiple reiationships are examined as they reiate to ciinicai mentai heaith counseiors’ use of the DSM-IV-TR. The articie concludes with the authors’ suggestions for ethicaiiy sensitive diagnostic practices.

T he Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2009) requires that all counselor trainees receive instruction in the application of ethics principles (CACREP, 2009, Stan-

dard II.G.l.j.). Additionally, CACREP standards require that clinical mental health counselors and addictions counselors receive training in the use of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000; CACREP, 2009, Section III, Clinical Mental Health Counseling, K.I.; Section III, Addiction Counseling, K.I.). Despite codes of ethics and accreditation standards re- lated to ethics and diagnosis, little has been written in the literature about the intersection of ethics and diagnosis. In other words, how clinical mental health counselors might ethically use the DSM-IV-TR is rarely discussed in the literature (Eriksen & Kress, 2005).

The lack of literature related to the DSM-IV-TR (APA, 2000) and ethics is particularly problematic when one considers the discormect between the DSM-IV-TR’s static, mental-illness-oriented approach to understanding client problems and professional counseling’s focus as codified in the ACA Code of Ethics (American Counseling Association [ACA], 2005, Section A), which addresses developmental growth toward mental Wellness. Applying a DSM-IV-TR diagnosis may directly contradict counseling’s humanistic and developmental origins (Hohenshil, 1993). The DSM-IV-TR diagnostic system also forces a dichotomy by requiring clinical mental health coun- selors to decide on the presence or absence of a category of pathology on the basis of the presentation of enough of the relevant symptoms. Although

Victoria E. Kress, Department of Counseling and Special Education, Youngstown State University; Rachel M. Hoffman, Counseling and Human Development Services Program, Kent State University; Küren Eriksen, We’re Gonna Change the World, Delray Beach, Florida. Rachel M. Hoffman is now at Meridian Services, Youngstown, Ohio. Correspondence concerning this article should be addressed to Victoria E. Kress, Department of Counseling and Special Education, Youngstoxun State University, Rayen Avenue, Beeghly Hall, Room 3312, Youngstozon, OH 44555 (e-mail: victoriaekress@gmail.com).

© 2010 by the American Counseling Association. All rights reserved.

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the DSM-IV-TR’s expanded multiaxial format promotes evaluation that includes the broader context of a person’s life, emphasis is still placed on medical problems and life Stressors rather than on a more strength-based approach (e.g., how a person is well and what assets he or she possesses; Saleebey, 2001; White, 2001). Many clinical mental health counselors regard the ascription of DSM-IV-TR diagnoses as an imperfect process (Welfel, 2002). Thus, the mental illness orientation of the DSM-IV-TR may chal- lenge mental-health-oriented counselors to think carefully about their use of DSM-IV-TR diagnoses. Despite some of the limitations of the DSM-IV- TR system, DSM-IV-TR diagnoses are used daily by most clinical mental health counselors (Eriksen & Kress, 2006). In fact, DSM-IV-TR diagnoses are required for almost all third-party reimbursements for counseling services (Eriksen & Kress, 2005). If clinical mental health counselors are seeking payment for the services they provide, they are generally required to diagnose their clients using DSM-IV-TR diagnoses, and the DSM-IV-TR system is the most researched and detailed system available for diagnosing clients’ mental disorders (Eriksen & Kress, 2005).

Culturally sensitive diagnostic practices are a requirement for ethical pracfice and are necessary to ensure effective mental health treatment (Kress, Eriksen, Dixon Rayle, & Ford, 2005). Kress et al. (2005) suggested that counselors should conduct a thorough assessment of their clients’ cultural realities and develop an appreciation of the layered contextual issues associated with their use of the DSM-IV-TR (APA, 2000). Pipes, Blevins, and Kluck (2008) suggested that whenever addressing ethical issues such as confidentiality, clients’ cultural considerations are especially important. A discussion of the cultural and ethical issues associated with using the DSM-IV-TR is complex and is beyond the scope of the present article. For more information regarding the intersection of culture, ethics, and the DSM-IV-TR, readers are directed to Kress et al.’s and Eriksen and Kress’s (2005) publications on the topic.

In this article, we review relevant literature related to the ethical use of DSM- IV-TR (APA, 2000) diagnoses. More specifically, we discuss how clinical mental heath counselors might apply informed consent, confidentiality, accuracy, and multiple relationship considerations to the process of diagnosis. These topics were selected because they have been the most often addressed in the profes- sional literature with regard to the DSM-IV-TR and ethics. Suggestions for ethi- cally sensitive DSM-IV-TR diagnostic practices are also provided. This article is groimded in the assumption that ethical behavior requires the search for best practices and an inclination or motivation toward behaving with professional integrity (Mezzich, 1999). Therefore, the discussion that follows assumes that reflection on the relationship between ethics and the practice of diagnosis may improve clinical mental heath coimselors’ ability to diagnose clients with integrity.

Informed Consent and Confidentiality

Ethical practice requires that counseling professionals obtain informed con- sent from their clients and maintain their clients’ confidentiality (ACA, 2005,

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Standards A.2., A.6., B.I., B.6.). Both obligations contribute to the develop- ment of trust in the counseling relationship. That is, informed consent and confidentiality offer the assurance that counselors will keep clients apprised of important information related to the counseling process and will keep the counseling experience private.

Informed Consent

Informed consent as it relates to diagnosis means that counselors offer enough information about diagnosis for clients to responsibly consent to diagnosis and to treatment that is based on that diagnosis. At a minimum, counselors inform clients at the beginning of counseling that they may receive a diag- nosis and subsequently inform them about what actual diagnosis is given (Welfel, 2002). However, Grover (2005) suggested that informed consent may not be truly informed in that the full implications of having the diagnosis and of having it communicated to others may not be adequately understood by the client at the time consent is granted.

In general, informed consent also requires sharing with clients the benefits and risks of possible treatment procedures before the client consents to participate in the procedures. Counselors may find themselves challenged by the task of realistically portraying the diagnostic process, including sharing the risks of DSM-IV-TR (APA, 2000) diagnosis without unnecessarily deterring clients from pursuing needed help. For example, one of the risks of a DSM-IV-TR diagnosis is the potential for client disempowerment. Dentón (1989) claimed that diagnosis may deny individual uniqueness by reducing individuals’ total- ity to a single word (i.e., a disorder). Thus, diagnosis may lead some clients to a false resignafion about who they are, with subsequent despair or falling victim to self-fulfilling prophesies. In addition, diagnosis may distract clients and counselors from acknowledging the client’s aspirations and positive characteristics, thus contrasting with the basic wellness-oriented approach that serves as the foundation for the counseling profession (Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). Given these considerations, DSM-IV-TR diagnosis may present ethical challenges to the practice of informed consent.

Confidentiality and Diagnosis

Counselors may also struggle with whether to disclose the risks related to the confidentiality of a diagnosis because of the possible negative cli- ent reactions secondary to learning of this diagnosis (Welfel, 2002). For example, a potential risk may present should a client become involved in legal proceedings. In some jurisdictions, a judge may deem the client’s records necessary to serving justice, and subpoenaed records may include a diagnosis. If records are revealed during court proceedings, the client’s diagnosis becomes known to people who were not intended to be involved in the counseling process. The client’s diagnosis may also then become part of the public record.

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Another risk of DSM-IV-TR (APA, 2000) diagnosis may occur for individuals who anticipate applying for health or life insurance (Welfel, 2002). Diagnostic codes are routinely reported to a central data bank that insurance companies check before issuing insurance plans; clients can be denied future coverage on the basis of having received certain diagnoses. Clearly, risks from situ- ations such as this may not always exist, and counselors should use their judgment to determine when risks would be more likely. However, it may not be possible to predict all situations in which the client could be harmed by the release of diagnostic information. Knowing and reflecting on the possibilities, however, may help counselors to make responsible diagnostic and informed consent choices.

Accuracy Versus Misrepresentation

Counselors are required by ethical standards to provide accurate diagnoses of client difficulties and to avoid misrepresenting their work to clients, to the public, or to others, such as insurance companies (ACA, 2005, Standards A.2.b. and E.5.). However, research that examined the actual practices of counselors has indicated that counselors may not always abide by these requirements (Danzinger & Welfel, 2001).

Counselors may choose inaccurate diagnoses for a nimiber of reasons. For example, because of the philosophical discrepancies underlying the DSM-IV- TR (APA, 2000) and the counseling profession, some counselors may invest only marginally in the diagnostic process. They may view diagnosis as a necessary evil that is required to receive insurance reimbursement or other forms of financial reimbursement. Counselors may, therefore, report a diag- nosis that they know will be reimbursed (e.g.. Axis I diagnoses; APA, 2000), rather than one that will not (e.g.. Axis II diagnoses; APA, 2000), despite the greater accuracy of the unreimbursable diagnosis (Danzinger & Welfel, 2001; Glosoff, 1999; Mead, Hohenshil, & Singh, 1997). In other words, counselors may be tempted to “upcode” (Cooper & Gottlieb, 2000, p. 199), giving an acute problem a more severe diagnosis than presenting symptoms warrant for a presenting problem, or to “downcode” (p. 199) to an Axis I diagnosis when the client presents with just an unreimbursable diagnosis (e.g., an Axis II diagnosis; APA, 2000). In the process, such coimselors misrepresent their work to third parties (Braun & Cox, 2005; Danzinger & Welfel, 2001; Kanapaux, 2003). Danzinger and Welfel (2001) found that 44% of counselors responding to a survey “indicated that they had changed or would change a client’s di- agnosis in order to receive additional managed care reimbursement” (p. 146). Conversely, counselors may also choose inaccurate diagnoses as a means of protecting clients from the stigma of certain diagnoses (Dentón, 1989). They may ascribe less stigmatizing diagnoses, even though the full criteria for an- other diagnosis exist and the criteria for the diagnosis ascribed do not exist.

When clients are able to pay out of pocket, counselors may feel less bound to the DSM-IV-TR (APA, 2000) diagnosis in situations where the diagnosis

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does not seem therapeutically relevant. For example, Lowe, Pomerantz, and Pettibone (2007) found that practitioners were more likely to assign a DSM-IV-TR diagnosis to a client paying via managed care compared with an identical client paying out of pocket. However, without the assistance of third-party reimbursement (which requires a diagnosis), middle or lower socioeconomic status clients will unlikely be able to afford counselors’ rates, and counselors are unlikely to be able to continue to practice on the basis of what such clients could afford to pay (Cohen, 2003; Danzinger & Welfel, 2001). Therefore, it is not always practical for clients or counselors to shift to a client self-pay system so as to avoid the problems of diagnosis.

Counselors who engage in deliberate misdiagnosis may justify these behav- iors by claiming that they are countering a system that is inherently flawed (Mead et al., 1997). Still other counselors may be cynically responding to the market demand to provide a reimbursable diagnosis; that is, counselors may assume that clients will be able to find another professional who will assign the diagnosis necessary for insurance reimbursement (Dentón, 1989). However, it is critically important that counselors recognize that misrep- resentation may harm clients also. If a clinician chooses to upcode a child from the unreimbursable parent-child relational problem to a potentially reimbursable diagnosis such as oppositional defiant disorder, the potential harms of labeling and stigma exist for the child even if the client’s parent willingly agrees to the misrepresentation. Deliberately misdiagnosing is fraudulent (Hamann, 1994), and counselors could be held liable in both civil litigation and criminal prosecution for deliberately assigning an incorrect diagnosis (Dougherty, 2005).

Informed consent about misrepresentation may thus be as ethically nec- essary as informed consent about an accurate diagnosis (Eriksen & Kress, 2005). In other words, clients need to be aware of the potential ramifications of the misdiagnosis. Expanding on the aforementioned example, the parents of a minor child may have agreed to upcoding from parent-child relational problem to oppositional defiant disorder in order to obtain insurance reim- bursement for their child’s counseling sessions (which is an obvious benefit). Counselors should also consider informing the parents of the potential risks of claiming the upcoded diagnosis, such as the potential for the incorrect diagnosis to be used by other entities (e.g., schools, estranged spouses suing for custody, and other insurance companies). Counselors also need to inform the family of the potential legal ramifications of intentional misdiagnosis (e.g., loss of insurance coverage).

Multiple Relationships: The Therapeutic-Fiduciary Reiationship Tension

The ACA Code of Ethics (ACA, 2005) stresses that “Counselor-client nonpro- fessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is

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