1. Assessment & Diagnosis
An Overview of Best Practices

2. Assessment & Diagnosis Introduction
• Assessment
o Assessment is the process counselors use to measure or ascertain a client’s current state
of being and to develop counseling goals or chart a course of treatment.
o Evaluations are a form of assessment however evaluations have a specific purpose - to
report findings, typically to a 3rd party and with little emphasis placed on client well-
being.
• Testing
o Testing is used along with client interviews as the methodology and tools to assess
clients.
o Issues that come up in testing can include testing competence and diversity issues that
influence testing.
• Diagnosis
o Diagnoses are defined by the DSM.
o Issues that affect diagnosis include a lack of cultural sensitivity in DSM structure, and
insurance company reimbursement policies.
• Client Rights
o Clients have a right to be fully informed before these assessment processes begin; and
they have a right to make decisions regarding whether or not they will participate.

3. Testing Competence
• Education and licensure play a large role in a counselor's ability to test
legally
o This varies from state to state.
o Example: LA law delineates between appraisals and testing, an LPC
who is privileged can only perform tests that fall under the appraisal
definition whereas a psychologist or above can perform testing. State of
LA v. Atterberry, 1995.
• Counselors should utilize only those tests they are trained to administer
o Studies have shown administering and interpreting the MMPI requires more
training than other personality tests
• Testing is vulnerable to abuse; ways to prevent abuse:
o Select the appropriate test to administer.
o Administer the test appropriately.
o Interpret the results correctly.
o Multiple areas of criteria should be used before diagnosis, not just the test.
• A counselor requires both statistical and psychological training to properly
administer a test

4. Testing Competence
• Psychological training issues to note
o A test only gives us an idea of how the client performs at the time the test is
administered, not why
o The answer to why requires further knowledge about:
o The client, their environment, and history.
o What Intellectual, emotional, and physical issues are revealed
through the counseling process.
o Testing Bias based on cultural norms.
o Counselors should select the proper test related to the problem being
addressed.
o Aptitude and intellectual tests.
o These cognitive tests only measure “Developed Abilities” and reflect a
client’s learning history.
o Was the history controlled for in the interpretation of the test results and
the test itself? Administer the test under a controlled setting; i.e. a
counselor’s office.

5. Testing Competence
• Counselor Testing Recommendations
o Administer the test under a controlled setting; i.e. a counselor’s office.
o Be mindful that interpretation is still needed from the counselor.
o Do not rely fully on grading centers.
o Be cognizant of counselor testing misuse; reasons include.
o Human desire for a quick answer.
o Work pressure, time constraints.
o Lack of knowledge.
o Acknowledge and address testing criticism.
o Most criticisms deal with how tests are administered and interpreted, not
the test itself.
o According to Anastasi (1992) “Tests are essentially tools. Whether
any tool is an instrument of good or harm depends on how the tool is
used” (p. 610).

6. Testing Competence
• Modern Testing
o As the profession advances, assessment methodology advances and can be
seen in new test methods like internet testing
o The ACA and other governing agencies provide guidelines for proper
use of internet counseling and testing
o Also the National Board of Certified Counselors (NBCC),
International Society of Mental Health Online (ISMHO), Association
of Counselor Education and Supervision (ACES)
o Areas of concern regarding modern internet testing methods include
o Interpretation of results- Will the client truly understand the
interpretation given over the internet?
o Administering of the test- What environment is the client in while
they take the test?

7. Testing Competence
• Subjectivity Awareness
o Each client is unique. One fallacy of standardized testing tools is the
standardization itself.
o It is important for counselors to be aware of the many issues that might
affect test results such as diversity; the uniqueness of each client should
not be ignored.
o The next few slides highlights this relevance.

8. Testing Competence
• Recent Nobel Prize (for medicine) winner, Prof. Sir John Gurdon,
once scored a 2 out of 50 on a science exam
• He also received poor notes from a teacher, almost causing him to
not study his passion, science

9. Testing Competence
Albert Einstein dropped out of school mid-term after being asked to
leave by a teacher who said “He will never amount to anything.”

10. Diversity Issues in Testing
• Testing Competence also requires acknowledgement of diversity issues in
testing. The DSM-IV-TR provides counselors with an outline for evaluating
clients in different cultural contexts. This minimizes misdiagnosis and
heightens awareness of culturally bound disorders. DSM-IV-TR Guidelines:
• The DSM Guidelines are a diversity tool but they do not include everything.
o The DSM does include a glossary of culturally bound syndromes.
Review cultural background &
possible cultural explanations of
client issues.
Assess identity and cultural
information relevant to the client
Review possible cultural factors
of clients' psychosocial states
Assess any cultural meaning of
the client's problems
Review competencies affecting
counselor client relationship
Assess the impact of family,
work, and community regarding
any client issues

11. Diversity Issues in Testing
• Diversity issues can affect diagnosis. Some common diagnosis problems that
might be rooted in a lack of muticultural competence include:
o Underdiagnosing: i.e. all elderly people are sad- that is normal. They aren't
depressed they are just boring.
o Overdiagnosing: i.e. commonly medicating children with ADHD/ADD
o Misdiagnosing: i.e. people who are diagnosed with bipolar disorder may
actually have borderline personality disorders with impulse control issues.
• The definition of normal and acceptable test results in testing might lack
cultural sensitivity given historical accounts
o Behavior that is not deemed ok now, but was deemed ok then: White
Christians came to America and slaughtered many native Americans because
they thought that they were superior.
o White Americans believed in the idea of "drapetomania" (slavery) and any
desire to escape captivity was considered maladaptive.
• The DSM standards are rooted in research conducted by medical and
psychiatric professionals and likely members of the dominant culture; normal
standards might disregard a culturally diverse population

12. Diversity Issues in Testing
• Counselors should be aware of cultural influences that might affect the
outcomes of testing. Some observations might include:
o Cultural schemas in each client.
o Framework of their identity.
o Cultural explanation of problems.
o Cultural attitude/perception of help seeking.
o Cultural adaptive functioning.
o Ethnocentric views.
o A closer look at ethnocentric views (real life scenario): Michael is a 25
year old African American male in east USA. He is going up for a
promotion at work. He sees a counselor stating "I feel
anxious/concerned with people always watching me." He also is always
cautious when he sees a cop.
o Michael's test results indicate a high level of paranoia.
o Could Michael's ethnocentric view regarding authoritative figures have
influenced his results?

13. Diversity Issues in Testing
• Counselors should be aware of the power they have as a tester and remain
cognizant of the lasting effects cultural incompetence plays regarding test
results
o The following clip highlights such power in an academic setting:
http://youtu.be/wwCFAnSuL7c. Highlights:
o The principal makes a discriminating remark about the students five times
- students with a different cultural background.
o Only one statement was made in defense of the minority group while
multiple offensive remarks were made.
o "Some of them are just out of juvenile hall, and some of them might be
wearing ankle cuffs to monitor their whereabouts.”
o "Those are lovely pearls. I wouldn't wear them to class."
• Counselors should monitor testing tools and reframe from the use of content
bias testing tools where items on a test refer to experience familiar to only
certain people
• Counselors must be cautious when using tests with culturally diverse clients

14. Diagnosis & DSM Controversy
• Testing typically results in using the Diagnostic and Statistical Manual of
Mental Disorders (DSM) to diagnose clients
• The DSM system is based on the medical model of health, but mental health
counselors prefer the wellness model (Remley & Herlihy, 2010).
o Although counselors align themselves with the medical model, they are
expected to abide by the medical model to diagnose clients and for insurance
reimbursement.
• There is controversy surrounding the DSM and the process of diagnosis
within the industry
o Conflict exists between the DSM system & wellness orientation of
counselors (Remley & Herlihy, 2010).
o Should counselors diagnose clients using the medical model-oriented DSM
system?

15. Diagnosis & DSM Controversy
• Conflict between the two models: Medical Model vs. Wellness Model
Medical Model
oFocuses on symptoms of the
individuals.
oPhysicians and mental health workers
use it to identify an illness instead of
problems areas of functioning.
oIndividuals are viewed as the illness and
are cured by physicians.
Wellness Model
oPeople are more than their illness.
oFocuses on clients' strengths rather than
symptoms.
o“Used to help people resolve personal
and emotional problems rather than
focused on the illness” (p. 26).
oFocuses on determining which factors in
the clients lives are interfering with the
goal of reaching their full potential
oFocuses on how to improve clients’
functioning rather than curing them of an
illness

16. Diagnosis & DSM Controversy
• Common Issues with the DSM
o The DSM promotes sex role stereotypes and bias.
o It is rooted in the dominant North American culture in its diagnosis
assumptions and is not culturally sensitive in composition.
o It lacks empirical evidence that diagnosis criteria enhances implementation
of treatment.
• Common Issues with the DSM and Managed Healthcare Companies
o Managed mental health care determine which services are reimbursable
(Braun & Cox, 2005).
o Even if counselors oppose diagnosis, they must assign a DSM diagnosis in
order for them to be financially reimbursed (Braun & Cox, 2005; Remley &
Herlihy, 2010).
o Counselors are challenged when particular diagnosis are not considered for
insurance reimbursement (Braun & Cox, 2005).
o Counselors are presented with the ethical challenge of intentionally
misdiagnosing clients in order to obtain reimbursement.

17. Diagnosis & DSM Controversy
• Diagnosis and Ethical Violations
o Counselors who do not feel comfortable labeling their clients may participate
in downcoding- under diagnosing clients for reimbursement.
o Counselors who feel pressured to obtain reimbursement from insurance
companies might take part in upcoding- overdiagnosing clients for
reimbursement.
o Upcoding can have serious consequences for the client as it can cause
stigmatization by society.
o “Diagnosing for dollars” or intentional misdiagnosing, violates ethical codes
and legal statutes (Braun & Cox, 2005).
• Ethical Standards and Violations
o Standard A.1.a of the ACA Code of Ethics (2005)-The primary responsibility
of counselors is to respect the dignity and to promote the welfare of clients.
o Standard E.5.a. of the ACA Code of Ethics (2005)-Counselors take special
care to provide proper diagnosis of mental disorders.
o These codes are violated when clients are intentionally misdiagnosed,
especially when diagnoses decisions are collaborated with clients.

18. Diagnosis & DSM Controversy
• Diagnosis and Legal Violations
o Counselors participate in fraud when they “misrepresent to health
care companies facts regarding their services” (Remley & Herlihy,
2010).
o Clients also participate in fraud when they collaborate with
counselors in intentional misdiagnosis (Braun & Cox, 2005).
o This behavior leads to court actions by the government.
o The government uses the Health Insurance Portability and
Accountability Act of 1996 as well as the 1986 False Claims Act to
investigate individuals who might be participating in insurance fraud
(Braun & Cox, 2005).

19. Diagnosis & DSM Controversy
• An Informal Investigation of Future Counselors' and Current Counselors'
Opinion regarding Diagnosis and the DSM
o Investigation Highlight: 100% surveyed believe it is unethical to intentional
misdiagnose clients in order to receive insurance reimbursement
Survey No. 1 Survey No. 2
Current Masters-Level Counseling
Students
Current Doctoral-Level Counseling
Graduate Students/Professional
Counselors
Four Questions Asked Five Questions Asked

20. Diagnosis & DSM Controversy
Question 1: Would you feel comfortable
diagnosing your clients with a mental
disorder using the DSM?
Question 2: Would you ever consider
overdiagnosing a client for insurance
reimbursement?
Question 3: Do you think it is unethical
for a counselor to incorrectly diagnose a
client intentionally?
Question 4: Do you agree with Managed
Care’s policy that your clients must meet
certain criteria in order for you to be
reimbursed?
Yes- 75%
No
Depends- 25%
Prefer not to answer
Yes
No- 100%
Unsure
Prefer not to answer
Yes- 100%
No
Unsure
Depends on the reason
Prefer not to answer
Yes- 12%
No- 38%
Unsure- 50%
Prefer not to answer
• Survey No. 1

21. Diagnosis & DSM Controversy
Question 1: Do you feel comfortable
diagnosing your clients with a mental
disorder using the DSM?
Question 2: Would you ever consider
overdiagnosing a client for insurance
reimbursement?
Question 3: Have you ever under- or
overdiagnosed a client, for any
reason?
Question 4: Do you think it is unethical for a
counselor to incorrectly diagnose a client
intentionally?
Question 5: Do you agree
with Managed Care’s
policy that your clients
must meet certain criteria in
order for you to be
reimbursed?
Yes- 40%
No- 60%
Depends
Prefer not to answer
Yes
No- 80%
Depends
Unsure- 20%
Prefer not to answer
Yes
No- 100%
Prefer not to answer
Yes- 100%
No
Unsure
Depends on the reason
Prefer not to answer
Yes- 60
No
Unsure- 40%
Prefer not to answer
• Survey No. 2

22. Client Rights Regarding Assessment & Diagnosis
Despite the different assessment and diagnosis processes and controversy, clients have
rights that should not be overlooked.
• Clients have a right to be evaluated by a mental health service provider who is
culturally competent and who is knowledgeable about the subject being evaluated
o The ACA Code of Ethics, 2005 E.2.a mandates that counselors only use
assessment tools that they are trained to use.
•Counselors have a responsibility to ensure that tasks are clearly defined and
assigned when working with other service providers
o Counselors sometimes work with testing specialists, i.e. psychologists, who
conduct client assessments for their use; role expectations should be outlined
up front. Discussions regarding roles might include:
o Results feedback expectations, i.e. who will deliver results to the client
o A client's potential desire to switch counselors.
o Which service provider will provide feedback to the client.
o Handling the need for immediate intervention (i.e. threat of client harm
to self or others).
o ACA Standard E.6.b requires counselors provide detailed information
about the client when referring assessment to other professionals.

23. Client Rights Regarding Assessment & Diagnosis
• There is a difference between assessment tools used in counseling and
evaluation.
• Counselors are responsible for explaining the difference between the two of
these tools to clients prior to conducting evaluations. The ACA Code of
Ethics Standard E.13.a instructs counselors to not only explain the difference
but to obtain written consent from clients before conducting evaluations.
Assessments Used in Counseling Evaluation
Client well being is considered Client well being is not the focus
Results are used to develop counseling goals in
collaboration with the client
Results are used to guide decisions concerning
the client
Results are normally confidential Results are normally deliberately reported to
3rd parties

24. Client Rights Regarding Assessment & Diagnosis
• Clients have a right to choose whether or not they will participate in testing
o Counselors should ensure that clients make informed decisions by disclosing
as much information about the processes as possible beforehand – this
includes discussing the test itself and what factors might contribute to
favorable results.
• Clients should understand and be aware of how their test results will be used
o If data will be reported to a 3rd party, i.e. an evaluation, counselors should
inform the client before conducting the assessment. An explanation
explaining the purpose of the assessment and any results' intended use,
should be discussed with the client at his or her level of understanding.
• Counselors have a responsibility to only release assessment records to those
individuals who can accurately interpret the results
o The ACA Code of Ethics, 2005 E.3.b instructs counselors to include their
interpretation of results when releasing results to qualified professionals.
Counselors are also advised to be responsible when transmitting records.

25. Client Rights Regarding Assessment & Diagnosis
• Clients have a right to test review.
o The ACA Code of Ethics mandates that counselors review test results with
clients and offer clients feedback regarding assessment results.
o Counselors should go over results with clients face to face and observe the
client’s reaction because that observation is an assessment tool within itself
and can give the counselor additional insight.
o Service providers should know that a face to face review might expose gray
areas where the testing instrument might not have been clear to the client.
o Review is a check and balance that might also highlight test fallibility;
fallibility would be included in the discussion as required by ACA Standard
E.9.a.
o Counselors should take care when presenting results to clients recalling that
data can be interpreted differently based on how it was presented.
• Clients have a right to question.
o Counselors should welcome questions and respect each client's right to
exercise his or her rights during the assessment and diagnosis process.

26. Assessment & Diagnosis Best Practices Summary
• Counselors should utilize only those tests they are trained to administer.
• Education, licensure and training are important to properly administer a test.
• Client subjectivity, test biases and limitations, result meanings and testing fallacies are
important to consider in the testing process.
• Cultural competence is important and counselors should be aware of diversity issues in
testing and ethically address any issues they might face.
• There is conflict between the DSM and it's medical model orientation and counselors' use of
the wellness model; counselors should use the ACA Code of Ethics guidelines to supplement
the DSM and address any conflicts or gray areas.
• DSM diagnoses are typically required by managed healthcare companies for client
reimbursement; counselors should avoid misdiagnosing in order to obtain reimbursement.
• Counselors should collaborate closely when working with other mental health professionals
to conduct assessments; roles and expectations should discussed up front.
• Counselors should disclose as much information about the assessment and diagnosis
processes as possible to clients beforehand; written consent should be obtained up front.
• Testing methods, results and the use of any results should be discussed with the client.
• Counselors should release test results and their interpretations only to qualified individuals..
• Counselors should be aware that clients have a right to refuse participation in the assessment
and diagnosis process.

27. References
Anastasi, A. (1992). Test and Assessment: What Counselors Should Know About the Use and Interpretation
of Psychological Tests. Journal of Counseling & Development, 70, 610-615.
Braun, S. A., & Cox, J. A. (2005). Managed mental health care: Intentional misdiagnosis of mental
disorders. Journal of Counseling and Development, 83(4), 425-433.
Davidson, M. (2012). A poor school report is no barrier to success - just look at Prof Sir John Gurdon.
Retrieved from
http://www.telegraph.co.uk/science/9596616/A-poor-school-report-is-no-barrier-to-success-just-look
-at-Prof-Sir-John-Gurdon.html
Hennessey, E.F. (1989). The Family, the courts, and Mental Health Professionals.American Psychologist,
44(9), 1233-1224.
Lpc.org. (2009). Louisiana Licensed Professional Counselors Board of Examiners Position Statement on
Appraisal Activities Clarification of the Distinction between Appraisals and Psychological Tests.
Retrieved from http://www.lpcboard.org/Position_Statement_Appraisal_Activities.htm
Remley, T. P., & Herlihy, B. (2010). Ethical, legal, and professional issues in counseling. (3rd
ed.). Upper Saddle
River, NJ: Pearson Prentice Hall
Wetter, M.W., & Corrigan, S.K. (1995). Providing Information to Clients About Psychological Tests: A
Survey and Law Students’Attitudes.Professional Psychology: Research and Practice, 26(5),
474-477.

28. Assessment & Diagnosis
An Overview of Best Practices
Jessica Krzyzanowski
Brianna Harvey
Jennifer Barron
Myia Bennett
•