Counseling Today, Ethics Update

Permission to refrain from making a diagnosis

David Kaplan August 7, 2006

Editor’s note: American Counseling Association members received the 2005 ACA Code of Ethics bundled with the December 2005 issue of Counseling Today. Completed over a three-year period, this revision of the ethical code is the first in a decade and includes major updates in areas such as confidentiality, dual relationships, the use of technology in counseling, selecting interventions, record keeping, end-of-life issues and cultural sensitivity. 

All ACA members are required to abide by the ACA Code of Ethics, and 21 state licensing boards use it as the basis for adjudicating complaints of ethical violations. As a service to members, Counseling Today is publishing a monthly column focusing on new aspects of the ACA Code of Ethics (the ethics code is also available online at www.counseling.org/ethics).

ACA Chief Professional Officer David Kaplan conducted the following interview with Harriet Glosoff and Michael Kocet, two members of the ACA Ethical Code Revision Task Force.

David Kaplan: Standard E.5.d. of the revised ACA Code of Ethics states, “Counselors may refrain from making and/or reporting a diagnosis if they believe it would cause harm to the client or others.” Would it be safe to say that this is a cutting-edge statement?

Harriet Glosoff: Most definitely! In looking at ethical codes from other mental health professions, I don’t ever remember seeing anything like this.

DK: What was the impetus behind the decision to explicitly give counselors a tool to refrain from making or reporting a diagnosis if it is in the best interest of their client to do so?

Michael Kocet: The Ethical Code Revision Task Force recognized that diagnosis is certainly a piece of what many counselors do but that at the same time we need to acknowledge that information contained in an official file can have long-lasting implications and should not be treated lightly. It goes back to the idea of “do no harm.”

DK: How can diagnosis be harmful?

MK: Recording a formal diagnosis in either a client’s chart or record has the potential to be harmful if that information can be used against the client by a third party. In addition, some counselors lose the fact that they are seeing an individual with their own nuances, their own histories, their own life circumstances and their own family circumstances which might frame a diagnosis.

DK: There are some clinicians who list an “adjustment disorder” for virtually every client under the rationale that it is the most benign diagnosis that is eligible for reimbursement. Is that OK?

HG: That is a direct conflict with Standard E.5., “Diagnosis of Mental Disorders.” The purpose of diagnosis is to inform our treatment. Professional counselors simply do not misdiagnose on purpose. 

DK: Are there any other ways in which diagnosis can be harmful?

HG: Yes, when a diagnosis is made prematurely. In the absence of sufficient data, it is better to refrain from making a diagnosis than to guess and list one that is probably incorrect.

MK: For example, a 9-year-old boy misdiagnosed with ADHD may end up with long-lasting identity and self-concept issues due to that misdiagnosis. The child may interpret normal energetic behaviors as personal deficits and the need to rely on drugs to cure these personal deficits.

DK: Is Standard E.5. “anti-diagnosis”?

HG: No, not at all. The ethical purpose of diagnosis is to help us help clients.

MK: The task force recognized that diagnosis can promote the well-being of a client, especially when the client is involved in the process.

DK: That is interesting. Can you talk a little more about how a diagnosis can be used to promote the well-being of a client? 

MK: I have worked with clients who experienced a sense of relief after receiving their diagnosis. They felt that it was helpful to have a name that went along with their symptoms/

issues and to know that other people have experienced the same thing. It helped these clients to feel that they weren’t crazy. A weight was lifted as they realized their problem

wasn’t a personal failing.

HG: I agree. There are clients who actually are very relieved when they hear a diagnosis, saying, “Oh, thank goodness. That explains why I do what I do.”

DK: What are some scenarios that come to mind when thinking about the new code of ethics standard (E.5.d., “Refraining From Diagnosis”) that permits counselors to refrain from making or reporting a diagnosis?

MK: In some cultures, when a death occurs it is common to have “visions” or to hear the voices of deceased family members. A counselor relying on a Western perspective might diagnose these visions as hallucinations. However, it would be important for the counselor to recognize the cultural issues at play and that classifying the client as having visual and auditory hallucinations might be inappropriate and harmful. This example shows the importance of recognizing historical and social prejudices that have caused the misdiagnosis of individuals.

HG: Another example that comes to mind is when people who have security clearances in the military or high positions in government come in for services. It is possible that the filing of an Axis I diagnosis with a health insurance company will cause these individuals to lose their security clearances. As such, it would be important to highlight the issue of diagnosis and insurance reimbursement during your informed consent process and to refrain from making a diagnosis if it will help the individual keep their security clearances.

DK: What about Axis II?

HG: There are times when I have had a client that fits all of the criteria of a personality disorder, yet I refrained from making the diagnosis. Why? Because I knew that they were going to Google “Borderline Personality Disorder,” read the description and feel doomed to a life of unhealthy relationships. It was not in the best interest of the client to make an Axis II diagnosis.

DK: So the Ethical Code Revision Task Force did not make a distinction between the different DSM (Diagnostic and Statistical Manual of Mental Disorders) axes in terms of the ability to refrain from making a diagnosis?

MK: No. The responsibility to refrain from making a diagnosis when it is in the best interest of the client to do so cuts across all five DSM axes and across any type of diagnosis.

DK: When a decision is made to refrain from making a diagnosis, who makes that decision? Is it the counselor or the client?

HG: The spirit of the ethical code is that the decision is made in collaboration with the client. However, there are times when a client’s request needs to be superseded by clinical judgment.

DK: When a client requests his or her records, does the new standard on refraining from making a diagnosis allow the counselor to say to a client, “I will be glad to share parts of my records with you but not my diagnosis”?

HG: I think so. But counselors only limit a client’s access to records when there is compelling evidence that such access would cause harm. 

DK: What about a supervisor or agency that insists on a diagnosis for every session of every client because that is the only way that they can receive reimbursement?

HG: Standard D.1.g. (“Employer Policies”) of the ACA Code of Ethics states that the acceptance of employment in an agency or institution implies that the counselor is in agreement with the general policies and principles of that agency or institution. Counselors strive to reach agreement with employers as to acceptable standards of conduct that allow for changes in institutional policy conducive to the growth and development of clients.

Standard D.1.h. (“Negative Conditions”) follows up by stating that it is our ethical responsibility as counselors to alert our employers to policies and practices that conflict with the ACA Code of Ethics. In the case of an agency that is asking a counselor to violate Standard E.5.d. and requiring a diagnosis when it is not in the client’s best interest, I would brainstorm alternate forms of funding (such as grants) with supervisors and management so that the agency was not reliant on reimbursement solely from DSM diagnoses.

MK: The example of an employer requiring a diagnosis in order to obtain reimbursement brings the importance of advocacy to the forefront. The counselor can advocate for the client by letting the supervisor, agency or insurance company know why it was in the best interest of the client to refrain from making a diagnosis. The counselor can also assist the client to advocate for themselves.

DK: In some ways having the new Standard E.5.d. in the ACA Code of Ethics makes it easier for the counselor to say to an agency or a supervisor: “Here it is in writing from the American Counseling Association: ‘Counselors may refrain from making and/or reporting a diagnosis if they believe it would cause harm.’”

MK: That is another aspect of advocacy. The ACA Code of Ethics represents the collective values of our profession. It is the responsibility of every counselor to educate agencies, insurance companies and mental health professionals from other disciplines about the concepts within the ethical code.

Next month: New mandates for selecting interventions

Letters to the editor: ct@counseling.org

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