Psychotherapy Bulletin

Psychotherapy Bulletin

Paging Dr. House

Improving Assessment and Diagnosis

Clinical Impact Statement: Given the high stakes nature of psychological assessment and the implications surrounding proper diagnosis, abiding by ethical codes is paramount. The present article will discuss the importance of ethical practice in assessment and diagnosis, areas of difficulty practitioners commonly encounter with diagnosis, and a discussion of the impact of misdiagnosis.

Primary care physicians and pediatricians are often the first ones to provide a mental health diagnoses and prescribe psychotropic medications. In fact, one study found the proportion of primary care visits at which antidepressants were prescribed, but no psychiatric diagnosis was noted in the record, increased from 59.5% to 72.7% from 1996 to 2007 (Mojtabai & Oflson, 2011). Psychologists have a great deal of value to add to the practice of assessment and diagnosis of psychological disorders. Training in clinical interviewing, personality, cognitive and behavioral assessment, and report-writing allows practitioners to address referral questions regarding diagnostic clarification. Moreover, clients often are seeking an explanation regarding symptomatology and perceived difficulties. Appropriate and accurate diagnosis is critical in providing answers to client questions, as well as providing clients with the appropriate treatment and/or referrals they need.

Given the high stakes nature of psychological assessment and the implications surrounding proper diagnosis, abiding by ethical codes is paramount. The present article will discuss the importance of ethical practice in assessment and diagnosis, areas of difficulty practitioners commonly encounter with diagnosis, and a discussion of the impact of misdiagnosis.

Ethics in Assessment and Diagnosis

Assessment of one of the core foundational competencies of doctoral training in psychology (Belar, 2009). Diagnosis is an inherently imperfect process and requires careful assessment of client symptoms over time (Dougherty, 2005). Complex symptoms can be difficult to assess and diagnose, particularly when a client presents with co-morbid symptoms, has a history of substance use, or there are underlying medical complaints (e.g., traumatic brain injury, organic disorders). Thus, it is unrealistic to expect psychologists to provide an accurate diagnosis in every case. Rather, clinicians should strive to implement the best methodology possible in their assessment process and discuss the potential limitations of their opinion in their written work.

Pope and Vetter (1992) found issues regarding assessment practices to be the most common ethical dilemmas reported by psychologists, citing availability of tests, basing conclusions on inadequate data, or ignoring data as the core themes of ethical complaints. The APA Ethical Principles of Psychologists and Code of Conduct notes, “Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings” (American Psychological Association, 2017). It has been recommended that clinicians should take reasonable care to avoid including data that are beyond the scope of the evaluation and/or referral question(s), even if the information would benefit the client (Michaels, 2006).

A graduate student once remarked her practicum supervisor made her write a diagnosis for everyone. When the student did not find evidence of a disorder, she was encouraged to document an adjustment disorder. This is unethical practice. The most commonly cited reason for misdiagnosis is to facilitate access to services by a third-party payor (Cartwright, Lasser, & Gottlieb, 2017; Kielbasa et al., 2004; Lowe, Pomerantz, & Pettibone, 2007). Research indicates method by which clients pay for psychological services influences the diagnostic decisions made by psychologists. For instance, Kielbasa, Pomerantz, Krohn, and Sullivan (2004) found clients who paid by managed care were more likely to be diagnosed with a DSM-IV-TR (American Psychiatric Association, 1994) disorder and were more likely to receive an adjustment disorder diagnosis. Overdiagnosing for insurance reimbursement violates the APA Code of Ethics. Misdiagnosing clients for insurance reimbursement can also result in civil and criminal prosecution for fraudulent practice. Mead, Hohenshil, and Singh (1997) surveyed 334 mental health counselors about their opinions on, and use of, the DSM diagnostic system. Over 70% of participants reported believing their clients were deliberately underdiagnosed, at least occasionally, and over 60% believed their clients were overdiagnosed. Although psychologists may be well-intentioned by trying to address a social problem (i.e., difficulties in adequate access to care and services), current managed care systems encourage psychologists to provide a diagnosis early in the course of treatment (Dougherty, 2005). An inaccurate or unnecessary diagnosis can cause more harm than good, particularly for children, and should be prevented (Cartwright, Lasser, & Gottlieb, 2017). Also, the impact of inadequate training on a supervisee is worrisome. Graduate students are encouraged to look to their clinical supervisors for guidance on professional practice. In coursework and training programs, students and trainees should be provided space and appropriate mechanisms for seeking consultation on how to address these professional practice concerns with supervision in a professional and ethical manner.

Appropriate, comprehensive psychological assessment can help inform diagnostic decision-making. Psychologists are tasked with selecting and administering measures that are appropriate for their clients, and discussing the strengths and limitations of test results in their interpretations. While there are many assessment tools available to address numerous clinical problems, these tests are not without flaws. It is important for psychologists to examine the psychometric properties of these measures, as well as evaluate the population the test was normed on. The Code of Conduct reads, “Psychologists who offer assessment or scoring services to other professionals accurately describe the purpose, norm, validity, reliability, and applications of the procedures and any special qualifications applicable to their use” (American Psychological Association, 2017). It is important to recognize the limitations of psychological assessment measures, particularly when clients do not fit within the normative sample. Additionally, this is an important call for researchers and test developers to examine the reliability and ecological or cross-cultural validity of measures through replication studies.

Finally, there have been discussions on whether to share diagnoses with clients. Many psychologists have discussed the importance of covering the implications of diagnosis with clients (Kress, Hoffman, Adamson, & Eriksen, 2013; Phillips, 2013). Kress and colleagues (2013) note clients “should have the opportunity to freely determine whether they will agree to receive a diagnosis” (p. 18). While knowing a diagnosis provides some clarity and insight for many clients, there may be some unintended consequences. Diagnosis can affect several aspects of a client’s life, including future insurance coverage, child custody disputes, and employment opportunities (Phillips, 2013). Ultimately, it is important for psychologists to take reasonable steps to discuss the potential implications of assessment and diagnosis on clients.

Areas of Need and Impact

In general, children and adolescents are difficult to diagnosis. Given variability in symptom presentation and short duration and history to assess their symptoms, it can be difficult to determine what symptoms are simply a function of normative adolescent development (Cartwright, Lasser, & Gottlieb, 2017). Psychologists should use extreme caution to avoid misdiagnosing adolescents, as the label can have negative consequences (Michaels, 2006). Labeling has major implications for individuals and diagnoses and treatment recommendations can contribute to the iatrogenic consequences. Diagnoses can be stigmatizing. For instance, if a child is evaluated for a threat or risk assessment in school, administered the Hare Psychopathy Checklist: Youth Version (PCL:YV), and has a score in the clinical range, how do we report those results? What are the implications of those results? I have witnessed reports in which evaluators label this pre-teen explicitly as a psychopath.

Neuropsychological testing and testing for neurocognitive complaints and traumatic brain injuries is often underutilized. However, availability of trained neuropsychologists in certain areas may be limited. Psychologists must take the appropriate course of action to discuss the limitations of available assessment approaches in providing a diagnosis. Also, psychologists want to be mindful of their own competence to assess for these diagnoses if they do not have the appropriate training and experience. Medical causes for symptoms may also be an area of consideration for appropriate diagnosis. For instance, medical evaluations (including updated physical examinations) may be warranted to rule out medical causes of psychological symptoms or those caused by side effects of certain medications.

Use of skilled interpretors is important for assessment of clients for whom English is not the primary language. Selecting culturally appropriate assessment measures, as well as conducting clinical and diagnostic interviews with the assistance of an interpreter is recommended. The Code of Conduct notes, “Psychologists use assessment methods that are appropriate to an individual’s language preference and competence, unless the use of an alternative language is relevant to the assessment issues” (American Psychological Association, 2017). Some states require interpreters to have advanced training to work in mental health settings; therefore, it is important for psychologists to be aware of legal requirements in the states in which they practice (Boness, 2016). For example, given language problems present among many in the Deaf community, a qualified and culturally competent interpreter is necessary in providing ethical treatment (Boness, 2016). This interpreter would need to be aware of the unique mental health concerns among members of the Deaf community. Lack of knowledge in Deaf culture, understanding of systemic oppression, and appropriate training in cultural and linguistic issues relevant to Deaf and hearing impaired individuals has resulted in mistrust of mental health professionals. Continued training in cultural competence in assessment is also recommended in order for professionals to maintain and enhance their skill sets in these important areas of practice.

Lastly, access to resources could become a barrier in providing comprehensive assessment to inform diagnostic considerations. What if you don’t have an access to an Arabic translator? What if the nearest pediatric psychologist works two hours away? What if there is limited access to training in assessment for individuals with autism spectrum disorders? Practicing within the boundaries of competence is particularly important in these high stakes contexts, including educational assessments and civil and criminal forensic evaluations (Sackett, Borneman, & Connelly, 2008; Sackett, Schmitt, Ellingson, & Kabin, 2001). Further, as a field we must continue to address these important barriers to access for clients.


Psychological assessment has much to offer in the way of developing diagnostic formulations for clients. Appropriate and accurate diagnosis is needed to prevent labeling and provide proper treatment to clients in need of services. Unethical practice in assessment and diagnosis has major, long-term negative consequences. Therefore, psychologists must be mindful of the strengths and limitations of assessment and diagnostic opinions in their practice and written work.

Cite This Article

Alexander, A. (2018). Paging Dr. House: Improving assessment and diagnosis. Psychotherapy Bulletin, 53(4), 67-71.


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