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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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potentially beneficial to the client" (Standard A.5.C.). Because counselors generally use diagnosis for both business purposes (e.g., receiving reim- bursement from third parties) and therapeutic purposes, the potential for unethical multiple relationships exists. Only a few articles could be found that explored ethical dilemmas that may arise related to these multiple re- lationships (e.g., Fishman, 2003; Nigro, 2003).

The ethical mandates related to multiple relationships draw attention to the primary purpose of counseling relationships: to meet clients' mental-health- related needs. When a mental health professional enters into any other type of relationship with the client for other purposes (e.g., friendships, relationships at school or church, business relationships outside of the counseling context), these purposes may conflict with meeting the client's therapeutic needs. When the extraneous purpose benefits the mental health professional in some way (e.g., as in a fiduciary relationship), the professional risks losing those benefits if certain decisions are made about the client's care and such feelings of threat may interfere with the professional's ability to consider the cfient's needs as foremost (Galambos, 1999; Ljunggren & Sjoden, 2001). Indeed, almost all counseling relafionships are fiduciary relafionships; thus, this consideration is endemic to almost all counseling. In the case of diagnosis, if giving a diagnosis might be contratherapeufic, the professional may feel conflicted because of the loss of reimbursement for services secondary to not providing a diagnosis.

Ackley (1997) suggested that when practitioners ask for money from third parties, whether insurers, grant sponsors, or employers, they are relinquish- ing control over therapeutic decisions to these third parties. Ackley further underscored the control by managed care companies that exists in the re- quirement that practitioners adhere to the medical model in diagnosis and treatment planning, that they shorten the length of treatment to between four and 10 sessions, and that they submit intimate therapeutic details to insurance companies in treatment plans. From Ackley's perspective, to elimi- nate these potential risks related to diagnosis, mental health professionals would need to stop diagnosing and give up all of the funding sources that depend on diagnosing. According to Ackley, only then, with clients paying out of pocket, might client needs be truly foremost in counseling decisions.

However, as discussed earlier, eliminating third-party payers and diag- nosis does not eliminate the multiple relationships inherent in the fiduciary relationship counselors have with clients. Many of the potential risks of diagnosis that have been stated thus far emerge from the conflicts between a counselor's needs to generate funds for the counseling services and his or her judgments related to the value of rendering a diagnosis (Ljunggren & Sjoden, 2001). Because counselors are invested in receiving money from their clients, the risk of not receiving such financing could hinder their therapeutic judgment or change their therapeutic decisions (Catalano, Libby, Snowden, & Cuellar, 2000; Dewa, 2001; Galambos, 1999).

It might seem that the problem of multiple relationships could be eliminated were the counselor to work in and be paid by a mediating agency (e.g., a

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hospital or a mental health agency). However, in those cases, the need to maintain the relationship with the employer may conflict with one's best therapeutic judgment (Proctor & Morrow-Howell, 1993; Ryan «& Bamber, 2002). Also, employer pressures to maintain billable hours and productivity quotas may also influence counselor decision making related to diagnoses; for instance, a major depression diagnosis may justify more sessions than an adjustment disorder with depressed mood diagnosis. Thus, it may be impossible for counselors to completely eliminate such multiple relation- ships in relation to DSM-IV-TR (APA, 2000) diagnoses.

Refusing to diagnose in order to reduce multiple relationship quandaries related to diagnosis leaves only fee-for-service (i.e., paying out of pocket) options, charity-supported options (e.g., funded by religious organizations), or supportive counseling services, such as school and college counseling, that are financed in other ways and are not limited to remediation and medically necessary treatment. As previously mentioned, this would not eliminate the multiple relationships, merely the multiple relationships that are complicated by issues associated with diagnosis.

Thus, mental health professionals are still left to figure out ways to manage the therapeutic-fiduciary relationship. As with informed consent, counselors might, at a minimum, discuss with clients not only the risks and benefits of diagnosis but also the potential risks of the multiple relationships. Open and honest conversations about these issues may increase clients' abilities to make informed decisions and decrease the chance of exploitation.

Traditional Strategies for Facilitating Ethical Diagnostic Prnctices

Counseling's professional ethical codes suggest that ethical dilemmas may be addressed with adequate training, informed consent, consultation, su- pervision, and documentation, all to ensure that the therapeutic relationship does not suffer (ACA, 2005, Standard C.2.; Bradley & Ladany, 2001; Welfel, 2002). Informed consent has already been discussed, as have the difficulties in determining the extent of information to be offered about the risks and benefits of diagnosis.

With respect to training, many state mental health counselor licensure laws require a course or courses in diagnosis (Saul, 2002). Yet, even if counselors have received what licensure laws and accreditation standards consider adequate training in diagnosis, the question of competency remains because counseling programs generally offer, at most, one class that addresses the content and process of using the DSM-IV-TR (APA, 2000). The information on all of the mental disorders is so extensive that an instructor may not be able to address all of this information and still devote time to addressing DSM-IV-TR ethics-related issues.

Therefore, ongoing consultation and supervision can supplement the basic DSM-IV-TR (APA, 2000) training received in a master's program. Supervi-

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sion and consultation may be used in the following ways: (a) ensure that an accurate diagnosis is rendered, (b) fully determine the ramifications of such a diagnosis, (c) clarify what information to offer clients about the risks and benefits of diagnosis, and (d) decide how best to prevent damage to the client as a result of funding requirements (Galambos, 1999; Proctor & Morrow-Howell, 1993). Consultation also helps counselors ensure that their theoretical procedures fall within the range of typical standards of practice (Daniels, 2001; Fireman, 2002). Those counselors who are unlicensed or who work in hospitals or agencies may have ready access to a supervisor. Other counselors may pay a supervisor for ongoing case-related consultation. However, all counselors should have several more experienced professionals to consult with when diagnosis-related questions and/or ethical dilemmas arise (ACA, 2005, Standards C.2.e. and H.2.d.).

Furthermore, documentation may be a means for facilitating ethical be- havior. Much literature related to documentation seems to focus on using documentation to protect mental health professionals in case of a legal suit (Gross, 2001; Scott, 2000; Woody, 2001). In documentation used for this pur- pose, counselors document what they have done related to the diagnosis, provide a rationale as to why they did it, provide some idea of the impact of what they did, and indicate what was discussed with clients prior to gaining their consent to act. Should the client later sue the mental health professional, the professional has a record of all activities and events to use in her or his defense. If the counselor's rationale makes sense, if the client consented, and if what was done conforms with standards of professional counseling practice and standards, then the counselor is less likely to lose the case (Carelock & Innerarity, 2001; Scheflin, 2000).

However, ethical pracfice extends beyond this sort of legal risk management. For example, documentafion should assist counselors in remembering client- related details, issues that are raised during counseling, counseling procedures that have been used, and client responses to these procedures (Cameron & Turtle-Song, 2002; Prieto & Scheel, 2002). Thoroughly documenting the ratio- nale for the client's ascribed diagnoses (or lack of diagnoses) rrüght support the counselors' actions. Taking adequate time to document their work with clients may also provide counselors with the necessary reflection time for internally processing the best ways to conceptualize and work with a client (Cameron & Turtle-Song, 2002; Prieto & Scheel, 2002). A diagnosfic process that is carefully documented in this manner might help counselors in their decision making related to multiple relationships. Counselors would, in this way, be taking the time necessary to assess whether a multiple relationship has the potenfial for harm, and, if so, how they might preclude such harm.

Emerging Strategies for Enliancing Ethicai Diagnostic Practice

Emerging strategies also exist for enhancing ethical diagnostic practice. These might include developing more egalitarian relationships with clients.

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openly discussing the values undergirding treatment choices, and infusing ethical dilemma discussions throughout counselor training programs and agency supervision. For instance, the ethical dilemmas described in this article might be resolved by adopting a dialogical, egalitarian, and tentative approach with clients, checking out client perceptions about the developing counseling process, posing ideas gently, and encouraging clients to partici- pate fully in the choice-making process, not only about counseling goals and behaviors to be changed but also about diagnosis and about the counseling process itself (Bilsbury & Richman, 2002; Fitzsimons & Fuller, 2002). Such open discussions could be initiated by the counselor when choice points emerged and revisited if client concerns developed.

In the process of such open discussions, counselors might give clients a chance to examine the values inherent in various counseling and diagnostic procedures (Gambrill, 2003; Nelson & Neufeldt, 1996) and to decide how the procedures mesh with client values. Counselors who are open to their clients' input in making decisions accept that there are many ways of mak- ing meaning, that none are sufficient explanations of human behavior, and that the medical model expressed in the DSM-IV-TR (APA, 2000) is merely one way of making meaning (e.g., for insurance purposes, for research, and for certain aspects of practice) that can be combined with other models and systems (Bracken & Thomas, 2001; Brown, 2002; Raingruber, 2003; Sperry, 2002; Zalaquett et al., 2008). Additionally, counselors can temper their use of DSM-IV-TR diagnoses by helping clients become more cognizant of their personal strengths and challenges (Zalaquett et al., 2008).

Infusing diagnostic dilemma discussions throughout the counselor-training curriculum might also facilitate ethical diagnostic practices. Few of the ethi- cal dilemmas that arise from the previously discussed concepts are explored adequately in counselor education (Eriksen & Kress, 2005). Instead, during the diagnosis course, counselors-in-training typically read and perhaps memorize the DSM-IV-TR (APA, 2000), read a text on psychopathoiogy, watch videos or read cases about people with various diagnoses, practice diagnostic discernment, and consider what treatments might be most useful for people with various diagnoses (White, 2001). As mentioned earlier, it is unusual for students to as- similate such a tremendous amount of material during one course, much less to have time to consider the complexity of various diagnostic ethical dilemmas that may arise in their future work. Discussing possible dilemmas intention- ally throughout the training program may ensure better diagnostic strategies with clients, particularly those with less power in our society (Caplan, 1995; Duffy, Gillig, Tureen, & Ybarra, 2002; Kurpius & Gross, 1996). Infusing these discussions may also assist counselors to better integrate the DSM-IV-TR model with the traditional counseling model (Eriksen & Kress, 2006; Hansen, 2003). After graduation, infusion of these discussions into agency staff meetings and trainings may create opportunities for thoughtful discussions and may prevent problematic ethical and legal issues from developing.

The DSM-IV-TR (APA, 2000) system of diagnosis is a reality of current mental health practice (Eriksen & Kress, 2005). At present, and in addition to

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the ideas already suggested, perhaps the best solution to the ethical dilem- mas presented in this article is an awareness of the issues, combined with thoughtful, contextually sensitive practices. Increased conversations about how mental health diagnosis can be done in the most ethical fashion and how practitioners can deal with ethical dilemmas may increase counselors' understanding of these issues and how to best manage them (Eriksen & Kress, 2005).

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