Chapter 7 – Competence, Assessment, and Diagnosis
Competence as an ethical and legal concept
oAccording to Welfel (2016), competence involves a combination of knowledge,
skill, and diligence.
oSkill building is a complex process that begins in graduate school with applied
courses such as counseling techniques, group work, and practicum and
internship.
oDiligence has been defined by Welfel (2016) as a consistent attentiveness to the
client’s needs that means putting client welfare first and foremost, above all
other concerns.
oThe first standard of the ACA Code of Ethics (2014) reads “The primary
responsibility of counselors is to respect the dignity and to promote the welfare
of clients”.
oNeither is competency a dichotomous concept; there is a continuum of
professional expertise with gross negligence at one end and maximum
effectiveness at the other extreme.
oCompetency is a parallel concept in that external forces require counselors to
demonstrate minimum competency for professionals, whereas an internal force
demands that counselors strive for ideal practice.
oCompetency in counseling involves both ethical and legal considerations. From
an ethical perspective, the most salient moral principle is nonmaleficence: Do no
harm. Incompetence is often a major factor in causing harm to clients.
Counselors rarely intend to harm their clients, but harm can occur if counselors
are not knowledgeable, skillful, and capable.
oThe most basic ethical standard related to competence in the ACA Code of Ethics
(2014) is that counselors “practice only within the boundaries of their
competence”.
oCounselor incompetence is the second most frequently reported area of ethical
complaints (after dual relationships with clients), according to one survey of state
counselor licensure boards (Neukrug, Milliken, & Walden, 2001).
oCompetence is a fluid concept, and achieving competence at one time does not
ensure that one will remain competent over time (Barnett & Johnson, 2015).
Counselor preparation
oCompetence is based on “education, training, supervised experience, state and
national professional credentials, and appropriate professional experience” (ACA,
2014, §C.2.a.).
oTo be competent, counselors are also expected to “gain knowledge, personal
awareness, sensitivity, dispositions, and skills pertinent to being a culturally
competent counselor in working with a diverse client population” (ACA, 2014).
oIt is entirely possible, however, for a student to have strong intellectual abilities
and still not possess the personal characteristics needed to be a therapeutic
person.
oPersonal characteristics such as openness to new ideas, flexibility,
cooperativeness, being open to feedback, awareness of one’s impact on others,
ability to deal with conflict, ability to express feelings, reasoning with higher
levels of cognitive development, and acceptance of personal responsibility have
been identified as necessary for effective performance as a counselor
oAnother approach to ensuring adequacy of preparation programs is regional
accreditation of universities.
oAlthough these approaches to ensuring quality of counselor preparation are both
necessary and helpful, the reality remains that successful graduation from an
accredited program does not guarantee competence (Kitzrow, 2002).
Much depends on the individual student’s motivation and ability to learn,
the quality of instruction, the competencies of the faculty members, the
breadth and extent of supervised counseling experience provided by the
program, and the quality of supervision received.
oCredentialing
Credentialing is a “method of identifying individuals by occupational
group” (Sweeney, 1995, p. 120).
As was discussed in Chapter 2, two important types of credentialing
found in counseling are certification, which takes various forms, and
licensure.
Licensure refers to the most rigorous form of regulation in that only those
who are licensed may practice the profession in a state.
As was explained in depth in Chapter 2, the strict uses of the terms in
governmental regulation of a profession are as follows: (a) Licensure
refers to the most rigorous form of regulation in that only those who are
licensed may practice the profession in a state; (b) certification is the term
used when a title, such as professional counselor, can be used only by
those who are certified, but anyone can practice the profession without
being certified
registration is the form of governmental regulation in which members of
a profession must sign up with the government if they practice the
profession in the state, but anyone may sign the registry without a review
of their credentials
National private organizations, such as the NBCC, offer national
certification, which is a credential that is voluntary (not required by a
government for practice).
Licensure
oLicensure is related to counselor competency in that it is the most powerful type
of credentialing and is established by state law.
oLegislators agree to license a professional group only when it can be shown that
members of the public (a) do not have the ability to determine who is competent
to practice within a particular profession and (b) could be harmed by
incompetent practitioners.
oEconomists oppose counselor licensure, arguing that licensing of professions is
self-serving, restricts entry into professions, and causes fees for services to rise
unreasonably (Rottenberg, 1980). Organizations whose purpose it is to limit the
role of government in citizens’ lives also oppose licensure statutes.
oThe U.S. Constitution requires that individuals who were practicing counseling in
a state when a licensure statute is passed be automatically licensed. This process
has been referred to as grandparenting.
oAccording to Harris (1997) and ACA (2014), licensing statutes for counselors
range from a low of 30 required graduate credits to a high of 60 credits.
oIn addition, the numbers of required post–master’s degree supervised hours
range from 2,250 to 4,000. Some statutes specify a significant number of
required courses; others require fewer specific courses.
oA limitation to licensure is that the possession of a license does not ensure that
practitioners will competently do what their license permits them to do.
oClearly, licensing of counselors is an attempt to ensure competent practice.
oIn reality, the standards set for licensure are often the result of political
compromises rather than of standards set by the profession for minimum
competency.
oCertification
In addition to becoming licensed, counselors can offer evidence that
supports their competence by becoming certified.
National Certified Counselors (NCC), like licensed counselors, have
received preparation in specific content areas and clinical instruction,
have had supervised counseling experience, and have passed an
examination.
oSpecialties
In addition to generic certification as an NCC, NBCC offers two specialty
certifications: Certified Clinical Mental Health Counselor (CCMHC) and
National Certified School Counselor (NCSC; NBCC, 2018).
An additional certification, Master Addictions Counselor (MAC), was
under review as of mid-May 2018.
An affiliate of NBCC, the Center for Credentialing and Education (CCE),
offers a specialty credential in supervision (CCE, 2018).
Specialty certifications are another means of establishing a counselor’s
competence to work with certain types of clients, in certain settings, or in
specialized areas of counseling.
A host of other, narrower specialty certifications are offered by various
groups in such areas as hypnotherapy, biofeedback, or sex therapy.
Currently, however, the prevailing school of thought is that counselors
who have proven their minimal preparation and are licensed can decide
for themselves the boundaries of their competence and may practice in
areas considered specialties without holding any specialty certifications.
Maintaining competence
oThe Code of Ethics underscores this responsibility, stating that “Counselors
continually monitor their effectiveness as professionals and take steps to improve
when necessary” (ACA, 2014, §C.2.d.).
oOne of the indicators of a profession, which distinguishes it from a
semiprofession or a nonprofession, is that the members of the profession
practice autonomously.
oIn return for this privilege of independence, professionals must limit themselves
to practicing within the areas in which they are competent. Professionals
individually determine the limits of their competence and practice accordingly.
oContinuing education
Counselors must keep up with new knowledge related to emerging issues;
for instance, there is a growing body of literature on counseling clients
who are involved in self-injurious behaviors and crisis (Werner, 2014) or
disaster counseling
The ACA Code of Ethics (2014) states that counselors recognize the need
for continuing education to acquire and maintain awareness of current
scientific and professional information, and most counselor licensure and
certification boards have established continuing education requirements
for maintaining one’s license.
As Herlihy and Corey (2015a) have noted, however, there are limits to
what continuing education requirements can accomplish. “It is difficult to
monitor the quality of continuing education offerings or their relevance to
a particular counselor’s needs. The number of clock hours obtained may
have little relation to how much the counselor has actually learned and
integrated into practice” (p. 185).
The focus should be on maintaining competence rather than on simply
accumulating the continuing education credits required to maintain a
license or certification
Peer review/peer consultation
oPeer review is a convenient and cost-effective approach to monitoring
competence that can be very effective
oPeer review is a system by which mental health professionals assess one
another’s services.
oThese benefits include enhanced self-awareness and a deeper understanding of
the complexities of counseling (Granello et al., 2008); opportunities to discuss a
wide variety of answers to clinical and professional questions (Barnett & Johnson,
2015); mutual support; objective feedback in dealing with countertransference
issues; information on therapeutic techniques, new research, and referral
sources; and help in dealing with difficult cases, stress, and the isolation often
experienced by private practitioners.
oTechnology
The counseling profession has established a solid presence on the
Internet. This offers opportunities to access virtual libraries for
researching the latest information on client problems and effective
counseling techniques, as well as to collaborate and consult with other
professionals around the world.
oMaking referrals
The ACA Code of Ethics (2014) states that counselors avoid entering into a
therapeutic relationship when they lack the competence to counsel a
prospective client.
If a counseling relationship has already begun, counselors discontinue
working with the client and suggest alternative resources that are
culturally and clinical appropriate (ACA, 2014).
Ethical counselors recognize that they will need to refer a client when
accepting or continuing to work with that client would exceed their
boundaries of competence.
An issue that has become the focus of much controversy is the distinction
between competence-based referrals and values-based referrals.
oDiversity considerations
When you think of your own future practice, keep in mind that if you are
not trained and competent to work with culturally diverse clients, you are
at risk of practicing unethically if you attempt to provide services to such
clients.
Counselors who work in urban and suburban settings typically have
numerous referral resources available to them. Counselors who practice
in rural areas, however, do not enjoy this luxury and often practice as
generalists out of sheer necessity (Welfel, 2016).
Erosion of competence: burnout and impairment
oCounselors, as partners in the therapeutic journey, can be deeply affected by the
pain of their clients (Corey et al., 2019).
oOf counselors surveyed by Farber and Heifetz (1982), 74% saw lack of
therapeutic success as the most stressful aspect of their work, and 55% felt
depleted by the unreciprocated attentiveness, giving, and responsibility that the
therapeutic relationship demands.
oStress can lead to distress which can, over time, lead to burnout and impairment
oDistressed counselors may experience irritability, anxious and depressed moods,
somatic complaints, lowered self-esteem, and feelings of helplessness, but they
are not necessarily impaired in their professional functioning.
oThey know at some subjective level that something is wrong and that distress is
usually a transitory and temporary condition.
oWhen distress remains unalleviated, however, it can lead to burnout, which has
been described as “a state of physical, emotional, intellectual, and spiritual
depletion characterized by feelings of helplessness and hopelessness”
oAccording to Zur (2011a), signs of burnout include emotional depletion, an
unrelieved sense of worry, loss of perspective, helplessness, inefficiency, and an
inability to leave clients’ concerns at the office.
oImpaired counselors, by contrast, are unable to transcend periods of stress
oTheir therapeutic skills have diminished or deteriorated to the point that they are
unable to perform their responsibilities appropriately
oThe medical profession has described impairment as “the inability to deliver
competent patient care”
oWhy do some counselors become impaired, whereas others manage to bounce
back from periods of distress or burnout? Sometimes environmental factors can
play a key role.
oHuman-created tragedies such as mass shootings and natural disasters such as
hurricanes and widespread flooding are examples of events that can put
counselors at risk of experiencing vicarious traumatization, also known as
compassion fatigue or secondary traumatic stress disorder
oCounselors who fail to recognize the warning signs of vicarious traumatization in
themselves may become less skilled and less able to be emotionally present with
clients who have been traumatized.
oPersonal difficulties that have led some counselors to enter the profession may
be exacerbated by the practice of the profession. The practice of counseling can
reactivate early experiences, open old wounds, and reawaken unresolved issues.
oGlickhauf-Hughes and Mehlman (1996) contended that certain personality
characteristics make counselors more vulnerable to impairment. These
characteristics include parentification (a willingness to take responsibility for
others), perfectionism, imposter feelings and self-doubt, and audience sensitivity
(strong awareness of others’ feelings and responsiveness to them).
oCertain kinds of clients and client problems can promote counselor distress
(Stadler, 2001).
Working with suicidal clients has been shown to take an emotional toll.
For counselors who work with clients with substance abuse problems, the
high relapse rate among these clients can lead to counselor
discouragement and cynicism about the sincerity of clients’ desires to
change.
oLawson and Myers (2011) surveyed more than 500 ACA members and found that
counselors scored higher on the measure of wellness (Professional Quality of
Life; ProQOL) than did populations previously studied, and they had lower scores
on compassion fatigue and burnout.
oIf they determine they are impaired, counselors must limit, suspend, or
terminate their professional responsibilities until they can safely resume their
work and seek assistance to address their problems (ACA, 2014).
oWARNING SIGNS OF PROFESSIONAL IMPAIRMENT IN FIGURE 7-1
oMany resources and strategies are available to counselors when they recognize
that they need to make changes in their lives if they are to remain competent
practitioners (Kottler & Schofield, 2001).
Some of these are (a) seeking counseling for themselves; (b) seeking
supervision, especially of their work with clients who are difficult and
tend to drain their personal resources; (c) taking a break or vacation from
practice; (d) joining a peer support group; (e) getting regular exercise,
meditating, and taking time to enjoy hobbies; and (f) seeking support
from family and friends.
oYour questions might include whether you ask supervisors or peers for help when
you need it, whether you are willing to seek personal counseling if you think you
need it (Cheng, Wang, McDermott, Kridel, & Rislin, 2018; Mullen & Crowe, 2017),
whether you engage in self-care practices, whether you are engaged in life
outside of work, and whether you are staying connected to family members and
friends.
oDiversity considerations in burnout prevention
Cause for concern in differences was found along cultural variables,
however. Female students scored higher than male students on the
measure of Gender Identity, and non-Caucasian students scored higher
than Caucasian students on the measure of Cultural Identity. The
researchers suggested that these findings may reflect greater awareness
of gender and cultural issues on the part of persons who belong to
historically oppressed groups in U.S. society.
Assessment and diagnosis
oEvaluation and assessment
Competence in evaluation
Despite arguments to the contrary made by psychologists and
some other mental health providers, counselors have the
education and skills necessary to conduct certain types of
evaluations.
According to the ACA Code of Ethics (2014), counselors utilize only
those testing and assessment services for which they have been
trained and are competent.
Counselors commonly conduct evaluations for a number of
purposes. To give some examples, counselors evaluate:
oWhat type of custody arrangement would be in the best
interests of a child (Patel & Choate, 2014)
oThe extent of an individual’s disability and the potential for
future employment
oWhether an individual has a substance abuse problem and,
if so, the type of treatment that is needed
oWhether a person is at risk for abusing children in the
future
oWhether a person is at risk for harming others
oWhether a person is at risk for suicide or other self-
injurious behavior
oWhether a person has a diagnosable mental disorder
oWhether a person would perform well in a particular job
Formal evaluations
Evaluations completed by a counselor might include a personal
interview, but interviews in which persons are being evaluated
have a different purpose than counseling interviews.
When a counselor who is also going to treat the client completes
an evaluation, the sole purpose should be to gain information to
allow the counselor and client to understand the problems and
establish appropriate counseling goals.
Before counselors begin an evaluation interview, it is essential that
they fully describe the difference between being counseled and
being evaluated. Counselors must ensure that the individual
understands that this is not a counseling relationship, and the
counselor may use any information gathered in the interview as
the basis of a report and opinion that will be given to a third party.
When an assessment or evaluation is completed, the assessment
itself is the end product. A counselor or any number of other
individuals might then use the assessment report for purposes
other than for counseling.
Clients who are being assessed need to understand that the
process is different from counseling, what the process entails,
what the final product will be, and how and by whom the
assessment is intended to be used.
According to the ACA Code of Ethics (2014), the client’s written
informed consent should be secured before beginning a forensic
evaluation (ACA, 2014). Before counselors conduct any type of
assessment, they must explain its nature and purposes in
language that the client can understand (ACA, 2014).
The counselor as expert witness
If your job requires that you conduct evaluations or if you
complete evaluations in your private practice, you must be
prepared to testify in court as an expert witness. There is a good
chance that eventually you will be subpoenaed and ordered to
explain and defend your conclusions and recommendations.
The attorney will do this in one or more of the following ways: (a)
object to the expert’s credentials, arguing that the counselor is
not expert enough to give an opinion in court; (b) attack the
process the counselor used in completing the evaluation, claiming
that it was not adequate; (c) attempt to get the counselor to
contradict statements, hoping that the judge or jury will give less
credibility to a witness who is not consistent; and (d) offer another
expert witness’s testimony that contradicts the counselor’s
conclusions and recommendations, hoping the judge or jury will
give more credibility to the other expert’s testimony.
Counselors who plan to serve as expert witnesses should take
courses to prepare themselves, observe other experts testifying
over a period of time, and read written materials
Assessment within the counseling relationship
oIn its broadest sense, assessment is the process of gathering information about a
client.
oCounselors use assessment to ascertain information about clients such as the
nature of their problem; the severity and impact of the problem; the interplay
between family, relationships, and past experiences with respect to the problem;
the impact of environmental conditions on the problem; the client’s challenges,
strengths, and readiness for counseling; and whether counseling can be
beneficial to the client
oAssessment is a collaborative process to which both the counselor and the client
contribute with the aim of gaining a better understanding of the client’s
problems.
oAn accurate assessment of the problems, in turn, increases the likelihood that
the problems will be resolved successfully in counseling.
oThe most commonly used method for gathering this initial information is the
unstructured clinical interview.
oThe most commonly used forms of assessment are tests of various types and
diagnosis
oTesting
Counselors use tests in various ways. Occasionally they may be involved in
developing new tests, but more often they select existing tests,
administer them, and interpret them for their clients.
oCompetence to test
The preparation that master’s-level counselors receive in testing usually
includes the following: (a) a three-credit assessment course, (b) some
testing principles in a research class, (c) testing information in courses
such as career counseling and diagnosis of mental disorders, and (d)
supervised practice of the use of tests in practicum and internship.
In reality, however, considerable knowledge and professional judgment
are needed to select the right test for the intended purpose and clientele,
administer the test properly, and interpret the findings to the client.
Leppma and Jones (2013) have reminded counselors of their ethical
responsibility to use multiple methods of assessment. This means that
counselors should never use a test as the sole criterion for making clinical
or educational decisions.
Competence to use a test always depends on the individual counselor’s
training and experience with the particular test.
If licensed counselors exceed their statutory authority to test, they could
be accused and found guilty of practicing psychology without a license.
This happened to an LPC in Louisiana (State of Louisiana v. Atterberry,
1995).
Two particularly useful documents are the Code of Fair Testing Practices
in Education and the Responsibilities of Users of Standardized Tests.
oDeveloping and publishing test
Test producers must produce and market tests that have demonstrated
validity and reliability and appropriate norms, as well as provide a manual
that clearly explains how to use the test, specify the clientele for whom it
is and is not suitable, and explain its strengths and limitations.
Test security
oCounselors have both ethical and legal obligations to protect the security of tests
from improper usage, copying, or dissemination (ACA, 2014, Code of Ethics,
§E.10.).
oA problem related to test security occurs when counselors and other
professionals break the law by violating copyrights of tests held by test authors
and publishers.
oOnce a test has been created, the author (or publisher, if the author transfers the
rights) owns the test for 75 years from the date of first publication or 100 years
from its date of creation, whichever date expires first (Henn, 1991).
oRelease of testing records
Counselors should not release test data to anyone who is not qualified to
receive the information.
The ACA Code of Ethics (2014) states that counselors should release test
data only to persons recognized by counselors as competent to interpret
the data.
Counselors also have an ethical obligation to ensure that testing records
are transferred in a secure manner.
oProviding explanations to clients
Clients have the right to make an informed choice about whether they
want to participate or refuse to engage in testing procedures. They can
also expect to receive an explanation of the results of any test they take.
Before counselors test, they must explain the nature and purposes of
assessment and the specific use of the results in language that the client
can understand. It is particularly important that clients understand what
uses will be made of their test results.
They have a right to know in advance if tests will be used as a factor in
employment decisions, as a criterion for placement in a special
educational program, as a device for screening potential members of a
psychotherapy group, or as a means of making other decisions that will
affect their lives (ACA, 2014, §E.3.a.).
After clients have participated in testing procedures, they have a right to
receive feedback about the results (ACA, 2014, §E.1.b.).
Counselors appreciate commercial services that score and interpret
psychological tests because the services save time and relieve them of the
task of scoring the tests, but they should avoid overreliance on them.
They do not take into account the individual characteristics of the test
taker and may not generate sufficient alternative explanations of results
A face-to-face conversation with the client regarding test results can serve
additional purposes.
Counselors need to educate clients about the limitations of tests
and to keep these limitations prominent in their own thinking.
This will help them avoid any tendency to present results in
absolute language. In addition, a dialog with the client can shed
light on any unclear or unexpected test results.
For many counselors, the pressures of time-limited counseling
relationships imposed by managed care are also a factor.
Welfel (2016) has suggested that the criteria for deciding how much time
to devote to test interpretation should include the following: (a) clients’
satisfaction that they understand the meaning and implications of the
results, (b) the counselor’s assessment that feedback has clarified any
confusion or unclear results, (c) a mutual agreement about ways the test
results should influence the counseling process, and (d) implications of
releasing the findings to others if the client has agreed to such a release.
oDiversity issues in testing
They must select tests carefully to avoid inappropriate testing that may
lack appropriate psychometric properties for a particular client
population (ACA, 2014, §E.8).
Because many tests have been validated on mostly middle-class people of
European extraction, special populations may not be represented in the
norm group on which a test was standardized.
Especially when working with culturally diverse clients, test results must
be placed in perspective with other relevant factors (ACA, 2014).
There is evidence that these tests tend to discriminate against African
American and Hispanic children (Walsh & Betz, 1995).
When some items in a test refer to experiences that are not familiar to
certain populations, the test is content biased. For example, an item on a
test that refers to milking cows may make no sense to an urban child who
lives in an impoverished socioeconomic environment.
Counselors must be alert to the passage of laws that affect testing
practices. Two examples are the Education for All Handicapped Children
Act (1975) and the Americans with Disabilities Act (1990).
The Education for All Handicapped Children Act requires that tests
be in a child’s language and be appropriate for the intended use.
Ethical practice requires counselors both to understand how clients’
cultures and world views can influence their performance on
standardized tests and to place test results in perspective with other
factors in evaluating these clients.
Diagnosis
oDiagnoses usually are made using the DSM-5 (American Psychiatric Association,
2013), which is the world’s most widely used system for identifying and
describing mental disorders (Gray, 2011).
oThis system of diagnosis is based on the medical model of mental illness.
oIn contrast to the medical model, counselors espouse a wellness model that
focuses on client strengths (Slaiba & Barden, 2017) rather than on simply
ameliorating symptoms
oThe CACREP standards (2014) specify that counseling students must acquire the
competencies needed to effectively use the DSM-5 in their work, and many state
counselor licensure boards require applicants to demonstrate formal training in
diagnosis.
oSome counselors may try to diagnose most or even all of their clients as having
an adjustment disorder, which is the mildest and least stigmatizing type of
disorder. Some might assign a more serious diagnosis than is clinically warranted
so that a client can qualify for health insurance reimbursement.
These practices of under-diagnosing, or downcoding, and over-
diagnosing, or upcoding, are dishonest, inaccurate, andunethical
oEven more serious is the practice of deliberately changing a diagnosis for
insurance reimbursement purposes. Some research has indicated that
approximately 35% to 44% of mental health practitioners may be engaging in this
behavior
oA first step is to clarify your own stance toward diagnosis.
oThe primary purpose of diagnosis is to facilitate effective treatment.
oDiagnosis should point the way to treatment planning and to the selection of
effective treatment strategies for identified disorders
oDiagnosis serves other important functions.
First, an accurate diagnosis can help counselors make a prognosis or
predict the course of a disorder.
Second, the diagnostic system in mental health care was developed to
facilitate communication among professionals (Kutchins & Kirk, 1987) and
provides a common language and shared frame of reference for mental
health professionals.
Third, it helps counselors identify conditions that may require the
attention of a physician, such as organic disorders or medical conditions
that are contributing to psychological problems, so that a referral can be
made.
Finally, the diagnostic system provides a framework for research.
oRisk involved in diagnosis
It can be comforting for clients to learn that their condition has a name,
that they are not alone in what they are experiencing, and that they are
not going crazy. On the other hand, clients may feel embarrassed or
ashamed of their diagnosis or feel stigmatized by a diagnostic label and
refuse treatment rather than have the diagnosis become part of their
record.
It is also possible that a diagnosis can lead to a self-fulfilling prophecy; for
instance, a client who is diagnosed with depression may become even
more deeply depressed.
Diagnoses can significantly affect not only clients’ feelings and self-
concepts but also their lives. Severe diagnoses can have harmful effects
far into a client’s future, including difficulty obtaining certain kinds of
employment or having their diagnosis used negatively in child custody
proceedings.
oCarrola and Corbin-Burdick (2015) expressed the concern that a myopic focus on
symptoms and diagnosis can further stigmatize certain clients (for example,
assessing for PTSD when counseling military veterans and thus failing to consider
their unique experiences and needs).
oInformed consent
Consulting with physicians
oCounselors are wise to determine the physical condition of their clients when
they begin the counseling process. Intake forms or interview protocols must ask
clients whether they have any negative health conditions and, if so, the details
regarding their treatment.
oCounselors must also know whether their clients are taking any medications and,
if so, the purpose of the medications and the effects and side effects that the
medications produce.
oWhen clients have physical complaints that obviously might be related to medical
problems (such as headaches, dizziness, or chest pains), counselors must insist
that these clients have physical examinations as a condition to their continued
mental health treatment.
oMental health professionals who overlook or ignore the obvious need for a
referral to a physician could be held negligent if a client’s supposed mental
condition later turned out to be caused by a physical problem.
oThe symptoms of some mental disorders can be alleviated by psychotropic
medications.
oQualifications to diagnose
In some states, licensed counselors have been challenged and accused of
practicing outside their scope of authority when they have diagnosed
emotional and mental disorders.
The following quotation from the DSM-5 clearly states that it is applicable
in a wide diversity of contexts and
is of value to all professionals associated with various aspects of
mental health care, including psychiatrists, other physicians,
psychologists, social workers, nurses, counselors, forensic and
legal specialists, occupational and rehabilitation therapists,
counselors, and other health professionals. (American Psychiatric
Association, 2013, DSM-5, preface, p. xii).
Accusing counselors of practicing outside their scope of authority when
diagnosing emotional and mental disorders is an example of a turf issue
that can pit counselors against other mental health professionals such as
psychiatrists, psychologists, and social workers, who have traditionally
endorsed the medical model.
The issue is very important because if mental health professionals are
unable to render diagnoses of emotional and mental disorders, some
agencies may refuse to employ them, and health insurance companies
may not reimburse their clients for mental health services that counselors
provide.
Counselors have responded to this problem by introducing legislation that
amends the scope of practice in their state licensure statutes (Kassirer et
al., 2013). The amendments specifically indicate that licensed counselors
may diagnose and treat emotional and mental disorders.
oDiversity considerations in diagnosis
It is important to keep in mind when dealing with diagnosis that mental
disorders are defined in a cultural context.
Clients’ socio-economic and cultural experiences are considered when
diagnosing mental disorders.” Behaviors that may seem bizarre in one
culture may be considered perfectly normal in another.
A section on cultural formation has been expanded to include cultural
syndromes, idioms, and explanations. Nonetheless, this cultural
formulation fails to fully address the concerns of wellness-oriented
counselors because it focuses on pathology rather than on client
strengths.
Concern has been expressed recently that the DSM-5 may not be
appropriate when working with traumatized populations such as refugees
Assessment and treatment based on a Eurocentric diagnostic system may
pathologize cultural expressions of distress. When refugees have been
exposed to historical or intergenerational trauma that has been passed
from generation to generation, it is even more imperative that
comprehensive and ongoing trauma assessments be made, rather than
relying solely on the DSM-5.
Several studies have demonstrated gender bias against women among
mental health professionals, including mental health counselors.
Herlihy and Watson (2003) identified three ethical problems in the use of
the DSM system with diverse clients.
First, the DSM is based on the medical model of mental illness
that defines problems as residing within the individual. Failure to
consider social, political, economic, and cultural factors in clients’
lives does a disservice to clients whose problems originate in or
are exacerbated by oppression, marginalization, and
discrimination.
Second, the DSM system tends to pathologize the problems of
racial and ethnic minority clients as well as women. A number of
studies have demonstrated that members of minority groups tend
to receive more severe diagnoses than members of the majority
culture for the same symptoms.
Third, the DSM system tends to perpetuate a paternalistic
approach to mental health care and thus to reinforce the societal
oppression of women and minority clients. The medical,
pharmaceutical, and psychotherapy industries profit
tremendously from the treatment of mental disorders.
Standard E.5.c. states that counselors recognize these prejudices
that have led to the misdiagnosing and pathologizing of certain
individuals and groups and strive to become aware of and address
such biases in themselves or others (ACA, 2014).
Counselors must be careful to maintain their wellness and holistic
orientation and to avoid equating clients with their disorders
through diagnostic labeling. For example, a client is never referred
to as a schizophrenic but, rather, is described as an individual who
suffers from schizophrenia.
Legal issues in diagnosis
oInappropriate use of a diagnostic category to obtain insurance reimbursement is
the type of financial misconduct that is frequently brought before ethics
committees, licensing boards, and courts.
oA client could bring a civil malpractice suit against the counselor, and a
prosecutor could bring criminal charges against the counselor based on the
fraud.
oA client who was assigned a false diagnosis would have an excellent foundation
for a successful malpractice suit against the counselor if the client later lost a job,
was denied a license, or was denied a security clearance because of the false
diagnosis.
oIf it could be shown that a mental health professional knew or should have
known that a client had a serious disorder but recorded a less serious disorder,
and that the client received inadequate treatment that led to harm, or was
denied health insurance reimbursement because of the false diagnosis, the
mental health professional could be found to have committed malpractice.
