USING THE DSM-IV-TR LEGALLY AND ETHICALLY: BEST PRACTICES LEARNING OBJECTIVES

This is a post graduate level continuing education ethics course. After completing this course, psychotherapists will be able to gain and apply knowledge about the following topics:

• Ethical diagnosing when using the DSM-IV-TR system • Legal and ethical standards to minimize the risk of malpractice civil suits • The Five Axial System of Diagnosis • Potential harm related to legal and ethical dilemmas when using the DSM • Patient welfare and protection of patients' rights when diagnosing • Accurate billing practices • Accurate use of diagnosis • Avoidance of fraudulent or misleading billing with managed care companies • Awareness of current issues of confidentiality, privilege, and record- keeping, with special regard to diagnosis • Multicultural challenges when using the DSM • Familiarity with ethical decision-making models

AUTHOR DISCLAIMER

The material contained in this course is the professional and personal understanding of the course author’s interpretation of the experts that have been cited throughout the text. Should any person wish to use this material for any purpose other than basic continuing education as it is presented here, that person should seek the original sources for his or her personal understanding.

The authors cited are accepted and published experts in the field of legal and ethical issues in psychology, marriage and family therapy, and social work. Cited herein are current opinions, case law when applicable, state statute. Interpretations of the 2002 APA Ethics Code is primarily gleaned from the fine work of Celia B. Fisher, Ph.D., Chair of the APA Ethics Code Task Force that completed the current revision (Fisher, 2009).

This is IN NO WAY a legal document nor does it offer legal advice or legal interpretations other than those of other experts as cited. This material is not meant as a personal or clinical consultation, nor is it meant to be substituted for contact with an ethics committee, attorney, or professional consultant.

How to Display or Print the Ethical Standards To take this course you will need access to the various ethics codes that apply to your license. The easiest way is to either download and print out the ethics code, or to place it on your desktop, or to use the links throughout the course while taking this course. Links to the Standards are provided at appropriate times during the course, which will also bring up a separate window.

Since this applies to each section of the course, it will only be stated once in this beginning Section A. LEARNING OBJECTIVES FOR INTRODUCTION

• Learn the “four truths” about professional practice • Gain familiarity with various ethical decision making models • Review common strategies to justify unethical behavior • To gain familiarity with ethical decision making models

THE FOUR TRUTHS ABOUT PROFESSIONAL PRACTICE

TRUTH ONE

“You will make mistakes” begins the preface of the Bennett et al. (2006, p. 5) book published by the American Psychological Association Insurance Trust. Psychotherapists are not perfect and in a particularly litigious environment, therapists must be realistic in planning for errors and mistakes. A solid ethical decision making model, as discussed in this section, will give a foundation on which to base decisions and clarify how and why something was done in a specific manner.

Therapists will not be deemed unethical simply for making a mistake “as long as you based your decision on generally acceptable clinical reasoning and knowledge” (Bennett et al., 2006, p. 5). The goal of this course is to prepare therapists to avoid making the big mistakes and to minimize the consequences of smaller mistakes. Licensing boards and ethics committee know therapists to make acceptable, legitimate mistakes and expect them to rectify these by gaining further education and consultation.

TRUTH TWO

“You can’t help everyone” is the second key point made by these authors. Therapists all wish and intend to help a client move forward, ease his or her pain, gather momentum for change and increase the quality of life in as many ways as possible. However, it is not necessarily the fault of the therapist if these things fail to occur within a reasonable amount of time. Knowing when to try another type of treatment rather than the particular theoretical orientation being used currently is part of the process. However, knowing when to refer a client to another helping professional is prudent and ethical. Thus, doing a thorough evaluation prior to agreeing to take a new therapy client is mandatory.

TRUTH THREE

“You won’t know everything” is the third element of these authors risk management and decision making model. It is part of the ethical responsibility to know when to consult, take continuing education courses, and to know one’s limitations.

“You cannot go it alone.” Practicing in isolation exposes a therapist to a higher degree of risk with regard to legal action or ethical complaints. Unfortunately, this is a often a solitary profession where therapists see one client after another without outside contact. Over estimating one’s competence is a mistake that occurs when the therapist fails to recognize his or her need for outside feedback. These authors use the catchy phrase “Outliers risk becoming Outlaws.” By this they are referring to therapists who fail to seek consultation, a second opinion or stay current on best practices.

TRUTH FOUR

“It is helpful to have a proper mix of confidence and humility.” Here Bennett et al., mean therapists must accept their limitations, pool their resources by consultation, and benefit from collective wisdom of colleagues. Using creativity in seeking advice, continuing education and support from other therapists reduces the risk of errors.

QUESTION

Licensing boards and ethics committees expect therapists never to make any mistakes:

A. True B. False

ANSWER: B-True. One will not be deemed “unethical” for making a small, legitimate mistake. However, one must have an appropriate decision making model to fall back on. (see “Introduction” section for review) QUESTION

Licensed psychotherapists can not be expected to help everyone, no matter what the presenting problem:

A. True B. False

ANSWER: A-True. Therapists are not expected to treat everyone just by virtue of having a license. (see “Introduction” section for review)

INTRODUCTION TO ETHICAL DECISION MAKING

Too often therapists fail to approach ethics as a part of everyday planning within their clinical work. Sometimes it is an afterthought to psychological assessment, treatment planning, marketing, planning coursework for classes, and other forensic or consulting work. Fisher (2009) notes that ethical planning should be based upon familiarity with the ethical standards of one’s license, professional guidelines in their specific area of expertise, along with state and federal laws. Additionally, one must base ethical decision making on organizational and institutional policies that re applicable to their work. Ethical decision making should be at the center of any good treatment plan.

Ethical Standards

These are typically known as the “Ethics Codes” by most therapists. Familiarity with the rules of conduct set forth in each licensee’s code is the primary step to preventive measures in the profession. Knowing the particular codes that apply to one’s client and to one’s license helps avoid harm, injustices, and violations of the civil rights of patients that often lead to ethical and licensing complaints

Fisher (2009) give the example of therapists who are aware of and familiar with the ethical standards of confidentiality will take steps to develop an appropriate procedure for protection of confidentiality and privilege. They will also use appropriate and well considered informed consent techniques explaining the limitation of confidentiality. These therapists will also know the proper agencies to contact and the proper steps to take when a breach of confidentiality is necessary to protect the client or society at large.

Guidelines

Therapists who have awareness of proper guidelines in working with difficult or dangerous clients are at decreased risk for ethical or licensing complaints. Knowledge of the current literature, standard of care, and expert opinion is mandatory in working professionally. Lack of familiarity with current standards when working with, for example, Post Traumatic Stress Disorder, leaves one vulnerable to a complaint should the client fail to improve or their symptoms worsen.

Laws, Regulations and Policies and Standard of Care

Therapists are required to remain abreast of current laws and case laws with regard to client care. Generally, the standard of care is defined by state statute (i.e., Penal Code 11166, child abuse report law) and the current ethics code of the profession. Another factor that establishes the standard of care in a profession is something called “case law”. Case law is a ”collection of reported cases that form the body of jurisprudence within a given jurisdiction” (Black’s Law Dictionary, 1996, p. 84). This means that when judges adjudicate a case in an appeals court, it becomes precedent, and must be followed thereafter. Case law is just as powerful as statute and must be followed just as closely as law that has progressed through the legislative process. Failure to gain awareness of case law that currently dictates protocol is considered unprofessional practice

Regulations are different from laws or case laws in that they dictate what is required specifically by the licensed therapist. They are “rules or orders having legal force issued by an administrative agency or a local government” (Black’s Law Dictionary, 1996, p. 532).

Familiarity with legal and organizational rules is essential for informed ethical decision making.

Reduce but not Eliminate

Experts in ethical decision making (Barnett, Rosenthal, Behnke & Koocher, 2007; Fisher, 2009) note that well-informed ethical planning will reduce but cannot possibly eliminate ethical challenges emerging out of clinical work as therapists. There are consistently unexpected events that are unique to every case.

Ethical decision making requires flexibility and sensitivity to the individuals involved, the complexities of each case, the zeitgeist of the times, and the context in which the events take place. Each therapist must take the time to reflect, remain informed and be willing to consult on a regular basis.

ETHICAL DECISION MAKING MODELS

FISHER’S DECISION MAKING MODEL Fisher (2009, p. 43-44) draws upon numerous ethical decision making models in order to compile the following eight step in her ethical decision making model.

1. Develop and sustain a professional commitment to what is right.

This is a statement that is pivotal in the practice of psychology. Making this choice requires a dedication to seek help, stay current, and reflect the highest ideals of the profession.

2. Acquire sufficient familiarity with the ethical code [that dictates your license] to be able to anticipate situations that require ethical planning and to identify unanticipated situations that require ethical decision making.

Here, Fisher refers to maintaining a working knowledge of the ethical code and standards, not simply reading them. It is a constant challenge to apply the ethical codes to situations as they occur in practice.

3. Gather additional facts relevant to the specific ethical situation from professional guidelines, state and federal laws, and organizational policies.

4. Make efforts to understand the perspective of different stakeholders who will be affected by the decision and consult with colleagues.

Stakeholders are those whose rights might be violated or ignored during the ethical decision making process or during the therapy relationship. Discussions with stakeholders can clarify the multifaceted nature of an ethical problem while illuminating specific principles are areas that require further education. Understanding the concerns of stakeholders such as family members, students, clients, employers, and research participants is prominent in any ethical decision making model.

This element of the decision making model includes consulting with colleagues. Knowing our limitations and blind spots is part of one’s professional responsibility.

Consultation is the standard of care that is used to reduce counter-transference, burnout and to support a treatment plan with dangerous patients.

In the case of Roberts-Henry v. Richter (1989) in which Dr. Richter, a Colorado psychiatrist had sexual relations with his patient ten days after terminating therapy for the specific purpose of having a sexual affair (both parties were married and the patient had sought therapy due to guilt over having had a post- marital affair), several precedents were set. At the time in Colorado, it was not illegal to have sex with a patient ten days post termination, nor to terminate solely for the purpose of having a sexual relationship. During the trial, the attorney’s for the plaintiff, who knew the defendant had personal problems at the time of the sexual affair with the plaintiff, Roberts-Henry, asked the psychiatrist “Did you return to personal therapy at the time? Did you seek consultation with another professional in Colorado? How many psychiatrists do you know in Colorado? Why didn’t you seek consultation with another psychiatrist before having sex with a patient?” Even here, it became an important part of the case against the defendant that he failed to seek consultation. The 3-man, 3-woman jury found Plaintiff Roberts-Henry 18% responsible for her own damages, and Defendant Richter 82% responsible for her damages of Post-Traumatic Stress Disorder. Several precedents were set in this case:

1. Plaintiff Roberts-Henry later addressed the Colorado legislature drafting a bill to limit the ability of the defendant’s attorney to investigate the plaintiff’s sexual history

2. The Plaintiff addressed the Colorado legislature drafting a bill to make sex with a patient illegal after which six other states (1989) followed suit. NOTE: Each psychotherapist is mandated to know his or her state’s laws regarding sex with current and former patients.

Why and when seek consultation? (Clayton & Bongar, 1994)

• To document the psychotherapist was practicing the standard of care by seeking consultation • To get ongoing one-on-one consultation • To obtain a second opinion • To deal with counter-transference or burnout issues • To avoid impaired judgment • For any “red flag” issues

Danger to self or other

Abuse issues

• Uncertainty about diagnosis • When treating special populations

Cultural issues

AID/HIV

• Any legal or ethical consideration • Lack of momentum or improvement in the treatment • When using new techniques with no established standard of care 5. Apply steps 1-4 to generate ethical alternatives and evaluate each alternative in terms of moral theories, general principles and ethical standards.

6. Select and implement an ethical course of action.

7. Monitor and evaluate the effectiveness of the course of action.

This step requires the therapist to continually check in with his or her own sense of what is correct, consult with other colleagues, and keep track of outcomes.

8. Modify and continue to evaluate the ethical plan if necessary.

QUESTION

Why is it important to acquire sufficient knowledge of the ethics code of one’s license in advance of client treatment?

a. To satisfy the ethics committee should they ask in a complaint b. to be able to anticipate situations that require ethical planning and to identify unanticipated situations c. To be able to defend oneself in court

ANSWER: B-To be able to anticipate situations that require ethical planning and to identify unanticipated situations. This is one of the key reasons for obtaining advance knowledge of one’s ethical standards. Armed with knowledge in advance will guide the treatment and protect both the client and the therapist. (see #2 under Fisher’s Decision Making Model for review)

QUESTION

Who are other “stakeholders” that must be considered when making ethical decisions about a client? a. All clients in therapy b. Society in general c. Those whose rights might be violated or ignored during the ethical decision making process or during the therapy relationship.

ANSWER: C – those whose rights might be violated or ignored during the ethical decision making process or during the therapy relationship. It is critical to consider the rights and consequences of all those who might be affected by the therapist’s decision. These include significant others, children, employers, and others. (see #4 under Fisher’s Decision Making Model for review)

REMLEY AND HERLIHY’S DECISION MAKING MODEL

Remley and Herlihy (2010) considered numerous ethical decision making models incorporating research and input from various authors (Cottone, 2001; Welfel, 2008) to present the following ethical decision making model:

1. Identify and define the problem. Take time to reflect and gather information about the situation. Most therapists feel a sense of urgency when faced with ethical challenges; however, acting impulsively or without fully examining the ethical situation can lead to simplistic solutions rather than well considered decision making.

2. Consider the moral principles. How do the moral principles apply to the particular problem at hand? Remley refers to moral principles as one’s personal belief system and how this affects interactions with other people in society. In other words, how does one’s own moral stance in the world impact judgment in deciphering how to handle a specific ethical issue in clinical practice?

One way to handle the process in considering moral principles is to rank order the moral principles in order of their priority to the decision maker and then see how they interact and compete with each other.

3. Tune in to your feelings. It is well known that emotion affects our ability to make clear decisions. When making an ethical decision about client care, consider what emotions are being experienced as the issues are being contemplated. To what extent do the following emotions impact judgment: a. fear b. self doubt c. overwhelming sense of responsibility d. anger e. anxiety f. overwhelm

4. Consult with colleagues or experts. As discussed in the Fisher model of ethical decision making, this is a key feature of properly making informed decisions. Decisions made in isolation are often unsound and uninformed. Consultation serves as an important element of any defense in court should one’s decision be challenged.

5. Involve your client in the decision making process. Remley believes this should occur throughout the process, rather than making this a separate step in the decision making model. Including clients in the decision making process can have the ability to empower the client and enrich the relationship. Engaging the client as an active partner is considered a culturally relevant element in the process as well. “Counselors should avoid making decisions for the client when those decisions can be made with the client” (Remley, 2005, p. 13).

6. Identify desired outcomes. Generally, in the decision making process, there is not just one desired outcome, but several. Depending upon the situation, there may be an essential outcome that is required to occur. However, there are often offshoots of that essential outcome that are desirable but not critical. For example, deciding whether or not to attend the wedding of a client has one essential outcome: whether or not to attend or accept the invitation. However, other important outcomes would include maintenance of the therapeutic alliance, disappointing the client, and breach of confidentiality should one decide to attend.

7. Consider possible actions. It may be useful to make a list of desired actions and pair them up with the desired outcomes. How can facilitation and achievement of the goals of the decision making occur? Ponder the implications and consequences of each option for the client, for all others involved and for yourself.

8. Choose and act on your choice. Once an action has been selected, or a series of actions, pay attention to how you feel about the choice made. It takes courage to follow through with the decision.

QUESTION

Why is it important to consider one’s own moral stance when working with a decision making model?

a. To decrease impairment in judgment b. To improve the course of the treatment c. To properly document your work

ANSWER: A – To decrease impairment in judgment. One’s own moral stance is critical to determine the proper course in making an ethical decision. Failure to be aware of how a therapist views the world can impinge upon properly considering the issues. (see #2 under Remley and Herlihy’s Decision Making Model for review) POPE AND VASQUEZ STEPS IN ETHICAL DECISION MAKING

Pope and Vasquez (2007) have listed eighteen steps in decision making, not all of which can possibly be considered in each case. These authors provide steps they know to be helpful in thinking through how to respond to ethical dilemmas, taking action, and assuming personal responsibility for what is decided in the final stage. They emphasize that not every step is relevant to each and every situation and that therapists will need to adapt the steps to fit their particular situation.

The beauty and usefulness of this model is that it encompasses the previous discussion of ethical decision making and includes all the steps previously discussed in one eighteen step model for consideration:

1. Identify the situation the requires ethical consideration and decision making. These authors ask the therapist to find the clearest and most concise way to formulate his or her question. What other valid ways are there to define and delineate the question at hand? Does the manner in which the question is formulated hide or distort the critical aspects that need consideration?

2. Anticipate who will be affected by your decision. Here, the authors give the example of a client attending a session in a state of inebriation. How does this affect other individuals in the scenario? How does the therapist define his or her responsibility with regard to public safety, family members, the client’s best interests? The choices made by the therapist can affect the safety and well-being of other people who might be on the road, should the therapist allow the client to drive home.

A second example they posit is when a managed care organization refuses to award further sessions to a client the therapist believes requires more mental health care. How does the therapist formulate this with regard to the anticipated affect on the client and others?

3. Figure out who, if anyone, is the client. Try to remove any ambiguity, confusion or conflict with regard to who the actual therapy client is. For example, if a client has someone else paying the therapist’s fee, how is this person related to the original client? What rights do they have, or think they have with regard to the records, consultations with the therapist, or are they considered part of the “treatment team?” Does the therapist have divided loyalty in family or couples counseling that could influence decision making?

4. Assess our relevant areas of competence and of missing knowledge, skills, experience, or expertise in regard to the relevant aspects of this particular situation. How prepared is the therapist to handle this situation in terms of continuing education, literature review, or supervision or consultation. What steps can the therapist take to ensure that he or she can be as effective as possible in the situation? Given all of the relevant factors, should the therapist get a professional consultation, refer the client, or speak with an attorney or malpractice insurance carrier?

5. Review relevant formal ethical standards. The ethical standards are written in a general fashion in order for them to be applicable to a myriad of situations that can occur in the course of professional work. Is there a specific code that applies to the situation at hand? Since the ethical standards are ambiguous in some cases, how can the therapist interpret how to use the standards that apply in a useful manner? In some cases, the ethical standards will seen irrelevant and, misinterpreted, can lead to an inappropriate decision.

6. Review relevant legal standards. As discussed previously, relevant state and federal statutes must be considered in any formal decision making plan. However, case law is more difficult to interpret and it is more difficult to gather information about interpretation of case law. Therefore, it is mandatory for the therapist to endeavor to see if the case law works against or blocks the most ethical response. Remember, there are situations in which ethics and law collide; making a decision in these situations is particularly challenging.

7. Review the relevant research and theory. All ethical guidelines require therapists to remain current on the recent findings in the area in which the client needs assistance. Since there are numerous diverse approaches with respect to theoretical orientation and treatment methods, the therapist is charged with studying and choosing which method is the most effective according to the relevant and current research. These authors name the following options for consideration: cognitive, psychodynamic, behavioral, feminist, psychobiosocial, family, multicultural, existential, and EMDR to name only a few.

8. Consider how, if at all, your personal feelings, biases, or self-interest might affect your ethical judgment and reasoning. As mentioned in other decision making models, it is important to gauge the influence one’s own counter transference and history have on the situation. Some therapists feel as if the ethics committee or licensing board is sitting on one’s shoulder waiting to pounce upon an error. This can lead to a lack of creativity and intuition.

Indeed, Pope and Vasquez note that therapists have to consider if doing the right thing cost time, money, reputation, referrals, prestige, a promotion, one’s job, or threaten one’s income? 9. Consider what effects, if any, that social, cultural, religious, or similar factors may have on the situation and on identifying ethical responses. The same decision may take on a very different meaning in varied societies, cultures, religions or age groups. What is ethical given a particular culture may be considered rude, disrespectful or inappropriate in another environment. It is critical to consider all aspects of the individual’s world in ethical decision making.

10. Consider consultation. Who might lend a different perspective or orientation to the situation? Do not choose a consultant based upon what one wishes to hear reflected back. A consultant is chosen for his or her expertise and ability to lend an objective point of view to the decision making process.

11. Develop alternative courses of action. Once again, making a list of the various choices that apply to the situation will help lay out the possibilities, clarify the choices to be made, and help the therapist to consider alternatives that may be hidden in the material. In other words, a better response may occur during the process of looking at the alternatives.

12. Evaluate the alternative courses of action. What impact is each possible choice likely to have upon the client, the therapist, and other people involved? How can the best possible choice be made given the needs of all people involved? Imagine how each person in the scenario will be affected by your decision and the immediate and long term consequences. What are the implications for all members of the group? Always consider the risks and benefits of each decision and any unintended consequences. Therapists can never know in advance what all the consequences of a decision may be; however, relying on a good consultation and the relevant literature, one is less likely to suffer adverse consequences with a licensing board or ethics committee.

13. Try to adopt the perspective of each person who will be affected. These authors posit that this will help in understanding each consequence and aid in making the decision. This step reduces distortion, clarifies possibilities and consequences, and opens new avenues.

14. Decide what to do, and then review or reconsider it. If time permits and it is not an emergency situation, rethink the decision that has been chosen. Making a decision to choose one option has the tendency to exclude all others. Taking a second look helps insure a better decision.

15. Act on and assume personal responsibility. This is generally the easier part as all of the other steps led up to making this decision. Figuring out how to reconcile the dilemma or ethical conflict is harder than acting upon the decision once it is made. It is a natural response to blur the issue or evade making a decision when the issue is difficult and threatening.

16. Evaluate the results. At this point, the therapist is ready to actually evaluate the results of the decision made; in other words, what happened after the decision was put into action? Here is where one would consider if the same course of action would be taken should this arise again, and would the same decision have been made given the outcome.

17. Assume personal responsibility for the consequences of your action. To what extent did the decision rectify the problem, or bring about the expected consequences? Here is where unforeseen issues are evaluated and dealt with. One must ask what else needs to be handled at this point and are there any new ethical challenges give the results.

18. Consider implications for preparation, planning, and prevention. Here is a chance to reflect upon the possibility of further preparation and prevention given what is known at this point. What practical steps can the therapist take to head off future problems or enable others to address the issues more effectively.

Conclusion

Psychotherapists are confronted on a regular basis with a very wide range of ethical dilemmas, concerns and challenges. From those who are the most seasoned to intern therapists, all are plagued with the same ethical issues and can become unsure how to proceed.

The ethics codes do not hold all the answers, although it is a vitally important and excellent starting place. No code addresses all the dilemmas that therapists are faced with on a daily basis as the standards are written broadly in order to cover numerous situations.

Experts have suggested that ethics codes be used to ask the following questions:

1. Will doing this be helpful to my client? 2. Will this action likely harm anyone? 3. To whom do I own an obligation or allegiance in this situation? 4. Will this action likely promote dependence on me by my client? 5. Are my actions consistent with how other psychotherapists treat their clients? 6. Have I allowed my judgment to become impaired as a result of inadequate attention to my own care or needs? Barnett et al. (2007a) suggest that asking these questions honestly and sincerely will be helpful in augmenting the guidance provided by the ethics codes.

Colleagues who have a specific area of competence should be sought because they have a particular area of expertise such as ethics, multicultural issues, or expertise in the specific dilemma.

Finally, it is difficult to decide if the chosen path is the correct one. However, experts suggest the decision making has been successful if:

1. The therapist has maintained personal and professional honesty 2. The therapist has promoted the client’s best interests 3. The therapist has acted without malice or personal gain 4. The therapist can justify the actions as the best actions based upon the current standard of care

THE ROLE OF ETHICS CODES (Herlihy & Corey, 1997)

1. To protect the public 2. To Educate members of the profession about what constitutes ethical, sound and appropriate conduct 3. To provide a means to ensure accountability by enforcing the standards of the profession 4. To serve as a catalyst for improving professional practice 5. To protect the profession from governmental intrusion by allowing the profession to regulate itself and function with autonomy 6. To help control internal disagreement while promoting stability within the profession 7. To protect clinicians and practitioners. a. If professionals practice in accordance with established guidelines, then their behavior is more likely to be judged to be in compliance with universally accepted professional standards when being applied to a malpractice suit or a licensing or ethics complaint

Power and Ethics

By nature of the relationship set up between clients and their therapists, there is generally an unequal distribution of power between the two parties (Haug, 1999). Therapists possess knowledge, education, and skills beyond the ordinary citizen which may extend certain privileges and power to such individuals. The general public may not know if a therapist is treating the client professionally, ethically and with appropriate methods and techniques. Many people seeking psychotherapy are unfamiliar with the counseling process.

The primary goal of psychotherapy is to increase patient welfare. Because clients can be vulnerable, they may need to view the therapist as powerful, all- knowing and strong. Thus, an unscrupulous person could take advantage of the client by overcharging for services, borrowing money from clients, or engaging in inappropriate behaviors such as sexual or social relationships with clients which clearly is not in the best interests of the client.

Thus, psychotherapists have an obligation to maintain their own mental health, seek counseling and consultation when necessary, and to stay abreast of current literature and methods. Ethics codes and state licensing boards require psychotherapists practice in an ethical and legal manner. These agencies have the authority to bar an unethical clinician from practicing (Remley & Herlihy, 2010).

REFERENCES

Barnett, J. E., Behnke, S. H., Rosenthal, S. L., & Koocher, A. (2007a). In Case of Ethical Dilemma Break Glass: Commentary on Ethical Decision Making in Practice. Professional Psychology: Research and Practice, 38, 7-12.

Barnett, J., Lazarus, A., Vasquez, M, Moorehead-Slaughter, O., & Johnson, W. (2007b). Boundary issues and multiple relationships: Fantasy and reality. Professional Psychology: Research and Practice, 38I, 401-410.

Bennett, B., Bryant, B., VandenBos, G., & Greenwood, A. (1990). Professional Liability and Risk Management. Washington, DC: APA.

Bongar, B., Maris, R., Berman, A., & Litman, R. (1998). Outpatient standards of care and the suicidal patient. In B. Bongar, A.L. Berman, R.W. Maris, M.M. Silverman, E.A. Harris, & W.L. Packman (Eds.), Risk management with suicidal patients (pp. 4-13). NY: Guilford.

Clayton, S., & Bongar, B. (1994). The use of consultation in psychological practice: Ethical, legal & clinical considerations. Ethics & Behavior, 4, 43-57.

Cottone, R. (2001). A social constructivism model of ethical decision making in counseling, Journal of Counseling and Development, 79, 39-45.

Fisher, C. (2009). Decoding the Ethics Code: A Practical Guide for Psychologists. Thousand Oaks, CA: Sage.

Gardner, B. (Ed) (1996). Black’s Law Dictionary. St. Paul, Minn: West Publishing Co.

Haug, I. (1999). Boundaries and the use and misuse of power and authority: Ethical complexities for clergy psychotherapists. Journal of Counseling and Development, 77, 411-418. Herlihy, B., & Corey, G. (1997). Codes of ethics as catalysts for improving practice. In Ethics in therapy (pp. 37-56). NY: Hatherleigh.

Hill, M., Glazer, K., & Harden, J. (1995). A feminist model for ethical decision making. In E. J. Rave & C. C. Larsen (Eds.)., Ethical decision making in therapy: Feminist perspectives (pp. 18-37). NY: Guilford Press.

Pope, K., & Vasquez, M. (2007). Ethics in Psychotherapy & Counseling: A Practical Guide (3rd Ed.). San Francisco, CA: Jossey-Bass.

Welfel, E. (2006). Ethics in counseling and psychotherapy: Standards, research, and emerging issues (3rd ed,.). Pacific Grove, CA: Brooks/Cole. LEARNING OBJECTIVES FOR SECTION A

• To understand the basic elements of professional malpractice • To become familiar with the 2002 APA Ethics Code

INTRODUCTION TO COURSE

California psychologists are required to take four hours of law and ethics continuing education for each licensing renewal period, so we thank you for taking this course from the many courses you have from which to choose! This will be a chance to combine both use of the DSM-IV-TR (hereon referred to as the DSM) and legal and ethical clinical practice in one course. Something new!

You will be asked from time to time to take brief quizzes throughout the course which are aimed at helping you learn and retain the material for the final evaluation of your learning at the conclusion of the course.

References for material will be given throughout the text in red, with a reference list at the end of each section. INTRODUCTION TO APA ETHICS CODE

The complete title of the document is Principles of Psychologists & Code of Conduct (APA, 2002). The need for an ethics code arose after World War II when psychologists developed group tests to help the armed services quickly evaluate draft eligibility and to provide mental health services to returning soldiers. After numerous task force revisions and draft approval by membership, the first code was adopted by APA in 1952 and published in 1953.

The purposes of the current ethics code were many, including establishing the integrity of the profession, provision of a guide for proper and expectable professional behavior, securing public trust, self-monitoring, and the ability to adjudicate (APA, 2002; Please see Fisher, 2009 for most recent interpretation of 2002 code).

There are five important reasons for having an ethics code:

• To prevent government intrusion • To aid professional autonomy • To avoid undue interference from outside parties • To assert self regulation • To protect the profession from internal discord

In other words, psychologists, without an ethics code, would be vulnerable to outside regulators who might use their powers of adjudication in cases of ethics violations. Or worse still, outside regulators might use inappropriate standards to adjudicate when those standards are not applicable to psychologists.

The current code was adopted in 2002 and took effect in June, 2003. We will use the current code in this course. BASICS OF THE APA ETHICS CODE

There are two primary sections:

ASPIRATIONAL – ENFORCEABLE UNENFORCEABLE Introduction Numbered Codes Preamble Ethical Standards General Principles: 1.01 to 10.10 A – E 82 Numbered Codes

Aspirational & Unenforceable

The Introduction section discusses the intent and organization of the code and provides guidance only. IT IS NOT A LEGAL DOCUMENT. Even though some states adopted the 1992 Code as legal and binding, the creators did not have this in mind. It looks at “reasonable” prevailing judgment and considers the dictates of one’s own conscience strongly encouraging professional consultation with colleagues.

The Preamble section discusses psychologists’ commitment to science in the improvement of the lives of others. Psychologists have a lifelong effort to act ethically.

The General Principles A-E guide and inspire psychologists to act with the very highest ideals considering patient welfare as primary.

Enforceable

The 82 numbered standards are the only enforceable part of the Code. These can be used in any state or APA ethics committee adjudication proceedings, and have been used in malpractice suits and licensing board violations.

NOTE: See Section A – Introduction and Basics to APA Ethics Code for review of answer material below:

Question 1

The APA Code of Ethics varies from state to state.

a. TRUE b. FALSE

Question 2

The APA Code of Ethics is a legal document:

a. TRUE b. FALSE

Question 3

The Aspirational (unenforceable) section of the code contains:

a. Aspirations, guidelines, introduction b. Introduction, guidelines, aspirations c. Introduction, preamble, general principles A-E

ANSWERS – The answer to question one is (a) false. There is only one APA Code that applies to all psychologists in all fifty states. The answer to question two is false (b) false, as mentioned earlier, the document is NOT to be used as a legal document, but as a guideline and set of standards. Question three answer is (c) as explained earlier in this section.

ELEMENTS OF MALPRACTICE

There are four elements of a malpractice suit and all four have to be believed to be met by an attorney in a court of law. In some cases, the difficulties of proving a suit, or defending against a complaint, get reflected in out of court settlements.

A civil suit for malpractice is defined as a lawsuit between two citizens where the issue is whether or not the psychologist has breached the standard of care (Black’s Law Dictionary, 1996). (We will define standard of care below.)

Duty of Care: A Duty of Care arises when there has been an agreement between the psychologist and the client that they will work together in a therapeutic relationship. In most cases, a therapist-patient relationship should be established within the first few sessions because a patient begins to develop an assumption he or she has begun treatment. It is important to be completely clear from the start under what circumstances the patient is being seen. Is it merely a two-time evaluation for longer term therapy? Was something said to the patient that indicated long-term therapy had begun? Or is the relationship based upon a brief 6-week behavior model of treatment? If the parties have not decided whether or not they wish to work together by the third session or so, the court may decide for them if a civil suit should occur that a “duty” of care has been established. Exchange of money alone does not establish a duty; however, if there is nothing else for the court to consider, it may look at any financial matters in an attempt to establish responsibility.

Standard of Care: This refers to the level of proficiency against which any other psychologist’s work will be measured or compared. In other words, what any other trained psychologist would do with reasonable experience or the minimum below which a psychologist must not fall (Stromberg, et al, 1988; Caudill & Pope, 1994). Generally, the standard of care is defined by state statute (i.e., Penal Code 11166, child abuse report law) and the current ethics code of the profession. Another factor that establishes the standard of care in a profession is something called “case law”. Case law is a ”collection of reported cases that form the body of jurisprudence within a given jurisdiction” (Black’s Law Dictionary, 1996, p. 84). This means that when judges adjudicate a case in an appeals court, it becomes precedent, and must be followed thereafter. Case law is just as powerful as statute and must be followed just as closely as law that has progressed through the legislative process.

Caudill & Pope (1995) define standard of care as “the minimum standard below which a practitioner cannot fall. It is based on the average competent professional, not the best or the brightest” (p. 564). These authors go on to explain that competent treatment can lead to unsuccessful results without meaning that the treatment was negligent. “Errors in judgment are not necessarily malpractice… instead if the requisite degree of skill and care is used, a judgment call that proves wrong is not actionable” (p. 564).

Demonstrable Harm: Can harm be shown to have occurred to the “victim”? Was anyone hurt or harmed? If so, what are their damages? The idea is to return a harmed individual to the condition in which they existed prior to the harm. This is done in only one way in a civil suit: throw money at the damage! In many cases of demonstrable harm with psychologist defendants, the damage claimed is psychological in nature. Therefore, it is much harder to prove and harder to approximate the financial award.

Proximate Cause: Proving that the psychologist’s wrongful conduct caused the damage and that it was the direct or proximate cause of the harm of the plaintiff’s injury is probably the most difficult element to establish. However, attorneys will try to impose liability upon the psychologist for their acts that “caused” the damage to the client. The question is: would the client have been damaged if the psychologist had done anything differently? Where injury is alleged to have occurred the client must still prove that the alleged injury is caused by the psychologist’s breach of the standard of care. In 1991, the California Supreme Court adopted a definition of proximate cause easily understandable to lay people: the “substantial factor” element. Was the therapist’s action a “substantial factor” in causing the patient’s injury? (Caudill & Pope, 1995).

BRENDA VIGNETTE

Brenda has been Dr. Brown’s client for five months. She calls Dr. Smith saying she is suicidal because her boyfriend just broke up with her and wants him to meet her at his office or else she might drive her car off a cliff. Dr. Smith is newly licensed and is fearful that Brenda might hurt herself if he does not do as she says, so he goes into the office at 11PM on Saturday night.

When they get to the office, Brenda gets upset and tries to kiss Dr. Smith. He gets flustered and kisses her back. Soon they are making love.

Later that week, Brenda tries to get Dr. Smith to return her phone calls, but he is terrified of what he has done, and refuses her calls, either socially or professionally. Brenda has a serious suicide attempt and winds up in the hospital. Later, she contacts her lawyer who helps her to file a civil suit against Dr. Smith. Is there a case considering the four elements of malpractice?

NOTE: See Section A – Elements of Malpractice for review of answer material below:

Question 1

Since Brenda and Dr. Smith had been seeing each other in a therapeutic environment for five months, the first element of a malpractice suit has been met because:

a. Duty of Care established b. A Breach of the Standard of Care c. Demonstrable Harm evident d. Proximate Cause shown

Question 2

Dr. Smith was probably not adhering to the current Ethics Code for Psychologists, the statutes of his state, nor the recent case law. Therefore he probably:

a. Did not create a Duty of Care b. Breached the Standard of Care c. Demonstrated Demonstrable Harm d. Provided Proximate Cause

Question 3

Since Brenda wound up in the hospital after treatment with Dr. Smith, this is probably evidence of:

a. Duty of Care b. Breach of Standard of Care c. Demonstrable Harm d. Proximate Cause

Question 4

If Brenda would have been fine if her psychologist, Dr. Smith, had treated her in a more appropriate manner, this is proof of:

a. Duty of Care b. Breach of Standard of Care c. Demonstrable Harm d. Proximate Cause

Questions 1-4 in order: (1) answer is a - duty of care gets established when a client-therapist relationship is developed or created. When Dr. Smith failed to follow the ethics code of his profession, he was (2) answer is b - breaching the standard of care of his profession. (3) answer is c- demonstrable harm. Since his patient wound up in the hospital, harm was able to be demonstrated. If it could be proven (very difficult to do) that the patient would not have suffered damages (or they would not have been as serious, had Dr. Smith done anything differently, then (4) answer is d - proximate cause can be claimed by the attorney of the patient.

REFERENCES

American Psychiatric Association. (2002). Diagnostic and Statistical Manual of Mental Disorders, fourth edition – Text Revision. APA: Author.

Gardner, B. (Ed.) (1996). Black’s Law Dictionary, (1996). St. Paul, MN: West Publishing Co.

Caudill, B., & Pope, K. (1995). Law and Mental Health Professionals. Washington, DC: APA

Fisher, C. (2009). Decoding the Ethics Code: A Practical Guide for Psychologists. Thousand Oaks, CA: Sage.

Stromberg, C. (et al.) (1988). The Psychologist’s Legal Handbook. Washington, DC: The Council for the National Register of Health Care Providers in Psychology. LEARNING OBJECTIVES FOR SECTION B

• To gain familiarity with the basic DSM multiaxial system • To gain knowledge of the history and timeline of the DSM • To become familiar with the DSM-V update due 2012 • To review the five axes of the multiaxial system DSM TIMELINE

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000) was a long time getting here. Below is a brief history of the DSM process and advances (Dziegielewski, 2002):

DSM-I Published in 1952 This 1952 version focused upon a psychobiological point of view.

DSM-II Published in 1968 This DSM had no particular point of view; DSM-I and DSM-II were criticized for being unscientific and for encouraging negative labeling of patients.

DSM-III Published in 1980 This version attempted to calm controversy by claiming to be unbiased and based more upon science. Ongoing problems were overshadowed by increasing demand for diagnoses that could get insurance reimbursement

DSM-III-R Published in 1987 This 1987 revision utilized field trial data that developers claimed validated the system on scientific grounds. Questions about reliability, misuse, misdiagnosis, and ethics of use continued to persist.

DSM-IV Published in 1994 The DSM-IV attempted to dispel earlier criticisms of the DSM system. This version added cultural information, diagnostic tests, and lab findings and was based on 500 field trials

DSM-IV-TR Published in 2000 This current version did not change codes or criteria from the 1994 previous version; However, it did supplement the current categories with additional information based on research studies along with field trials in every area.

THE FUTURE OF DSM-V

According to the website www.psych.org, the DSM-V timeline is as follows:

1999 – 2001 Research and planning 2001 – 2005 Research initiatives 2006 – 2007 Development workshops 2008 – 2012 Field trials -- proposed criteria 2013 Final review and publication

The process for revising the Diagnostic and Statistical Manual of Mental Disorders began with a brief discussion between Steven Hyman, MD, (then dirctor of the National Institute of Mental Health), Steven Ml Mirin, MD, (then medical director of the American Psychiatric Association) and David J. Kupfer, MD (then chair of the American Psychiatric Association Committee on Psychiatric Diagnosis and Assessment) at the Nationnal Institute of Mental Health (NIMH) in 1999l They believed it was important for the American psychiatric Association (APA) and NIHM to work together on an agenda to expand the scientific basis for psychiatric diagnosis and classification (www.psych.org, downloaded 1/15/10).

Each work group meets regularly, in person and on conference calls. They betin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are first developed and then investigated through literature reviews and analyses of existing data. They will also develop research plans, which can be further tested in DSM-V field trials involving direct data collection. In order to invite comments from the wider research, clinical, and consumer communities, the APA launched a DSM-V Prelude Web site in 2004, where these groups could submit questions, comments, and research findings to be distributed to the relevant work groups (www.psych.org, downloaded 1/15/10).

Based on this comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups will develop draft DSM-V diagnostic criteria. A period of comment will follow, and the work groups will review submitted questions, comments, and concerns. The diagnostic criteria will be revised and the final draft of DSM-V will be submitted to the APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. A release of the final, approved DSM-V is expected in May 2013 (www.psych.org, downloaded 1/15/10).

Therefore, look for the DSM-V to appear sometime in or after 2013. If you wish to have input, watch the professional publications for offers to give feedback to the relevant task force of your choice.

DSM-V EXPERT REPRESENTATION

Degree Representation

AB, ScB 1 1% Ph.D. 50 31% M.D. 110 67% RN, Ph.D. 2 1% Total 163 100%

Sex

Female 49 30% Male 114 70% Total 163 100%

Diversity

Australia 2 1% Brazil 1 1% Canada 8 5% China 2 1% Denmark 1 1% France 1 1% Germany 4 2% Italy 1 1% Mexico 1 1% Netherlands 6 4% Puerto Rico 1 1% South Africa 1 1% Sweden 1 1% Switzerland 1 1% UK 8 5% USA 124 76% Total 163 100%

Summary of Diversity Status

It is clear that the majority of contributors to the DSM-V are both males and medical doctors from the United States of America. The American Psychiatric Association continues to participate with the World Health Organization in a “DSM/ICD/Harmonization Coordination Group” according to the current activities report of the American Psychiatric Association (APA, 2008).

To try to ensure that the revision process represents diverse perspectives, disciplines and the many areas of expertise in the profession, the Task Force and work groups represent a variety of clinical and scientific disciplines, patient and family groups, women and minority and under-represented groups. Each group has tried to include at least one international member.

Integration of DSM-V and International Classification of Diseases-11 (ICD-11)

According to the Current Activities Report (September, 2008), “the aim of this group is to facilitate the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioral disorders and DSM-V” (p. 2). Below are the functions of this group:

1. To identify effective mechanisms to share information on developmental processes of the DSM-V and the ICD-11 2. To find strategies to narrow the differences between the DSM-V and the ICD-11 3. To coordinate efforts towards harmonization of the two diagnostic systems by making specific recommendations to the respective decision making bodies 4. To provide a forum in which difficult issues around harmonization can be discussed and common approaches identified (p. 2). DSM-II AND DSM-IV-TR COMPARISON

The DSM and its multiaxial system for assessment has clearly become the most common language of communication with regard to client problems. It reduces very complex information into a sort of “shorthand” that makes the material about a patient more manageable (Seligman, Walker, & Rosenhan, 2001). Graduate school students are required to acknowledge the importance of the DSM system and often must take courses in using the system properly (Commission on Accreditation for Marriage and Family Therapy Education, 1997; Council for the Accreditation of coumseling and Related Educational Programs, 2001; American Psychological Association, 2002).

Challengers of the DSM System wonder whether the necessity of using the manual is less for understanding and helping to diagnose mental health patients has been overwhelmed by the market value of the manual. Is the primary use of the DSM to sustain practitioners’ livelihood in which case one might “invent” justifications for its use and for broadening its scope (Schwartz & Wiggins, 2002).

Glancing at the comparison figures below, it is easy to see that the DSM has increased significantly in amount of categories and pages from its first publication in 1968 to the current 2000 version. Throughout this course, the reader will find a number of citations to experts who question the motivation behind this proliferation of diagnoses. There are numerous opinions that will be presented with respect to their application to ethics and diagnosis.

DSM-II 1968 DSM-IV-TR 2000

182 categories of disorders 400 categories of disorders 119 pages 943 pages

INTRODUCTION TO THE DSM DIAGNOSTIC SYSTEM

NOTE: Relevant page numbers corresponding to the DSM-IV-TR will be listed where pertinent.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. It has a primary duty to provide diagnostic criteria for the wide range of mental disorders. Used in the United States and other countries around the world to varying degrees, it stands as the most widely used method of diagnosing mental illness (Wikipedia). It is used by insurance companies, clinicians, researchers, psychiatric drug regulation agencies, pharmaceutical companies, and policy makers.

The manual has attracted much controversy and criticism along with its share of praise and complements. As mentioned previously, there have been five revisions since it was first published in 1952. The Diagnostic and Statistical Manual of Mental Disorders gradually included increasingly more diagnoses and disorders; however, some have been removed and eliminated throughout the various revisions while some are no longer considered mental disorders (homosexuality).

The DSM evolved initially from a system of collecting census and psychiatric hospital statistics, and also from a manual created by the United States Army. The largest and major revision occurred in 1994 which was the fourth edition known as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 1994). A “text revision” to the 1994 version was published in 2000 in order to aid in research, clarify changes, and keep users updated on the latest findings, statistics and other important elements of psychopathology. However, much of the manual was unchanged.

Due to major criticism over the length of the manual and the proliferation of diagnoses in the DSM-IV-TR (2000), David Kupfer, who is shepherding the current DSM-V revision said to an interviewer recently, “One of the raps against psychiatry is that you and I are the only two people in the United States without a psychiatric diagnosis” (Grossman, 2008).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is currently in the consultation, planning and preparation stages and is due for publication sometime in 2013. An early draft should be released in 2010 for public comment.

The DSM is set up such that there are five “axes” on which a person should be diagnosed. A multiaxial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome… the multiaxial system facilitates comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem. (APA, 2000, p. 27)

Ethically, a clinician must strive to know as much as possible about the patient he or she is treating in order to formulate an appropriate diagnosis and corresponding treatment plan. The DSM instructs the diagnostician to attempt to capture all of the complexity of the clinical situation and to aid in describing the complete clinical picture.

One goal of the multiaxial system, was to present a biopsychosocial model of the client in order for the clinician to gather as full a picture of the client as possible. Biopsychosocial refers to:

• Bio – Considerations of any and all general medical conditions that could be relevant in the treatment of the client. Additionally, one should always consider if the any general medical condition or use of a mind altering substance could be the source of the symptoms rather than the source being psychological or functional.

• Psycho – Considerations of any and all psychological or mental conditions that are relevant to the treatment of the client. The question to be asked here is: What are the psychological aspect of the clients difficulties as opposed to the general medical conditions or external elements.

• Social – Considerations of any and all social situations and issues that are relevant to the treatment of the client. Here, issues such as culture, family, sexual orientation, background, opportunities, finances and a host of other social features should be considered.

In recent years experts have come to recognize the need for an integrative Biopsychosocial viewpoint that acknowledges that biological, psychological, and sociocultural factors all interact and play a role in psychopathology and its treatment. QUESTION 1

What is the proper name of the current DSM?

a. Diagnostic and Statistical Manual of Disorders of the Mind b. Diagnostic and Statistical Manual of Clinical Disorders c. Diagnostic and Statistical Manual of Mental Disorders

QUESTION 2

What year is the DSM-V scheduled for publication if all goes well?

a. 2011 b. 2012 c. 2013

QUESTION 3

What is the primary purpose of the “multiaxial” system of diagnosing?

a. To get a more comprehensive picture of the patient b. To help insurance companies evaluate clients c. To help in treatment planning

Questions 1-3 in order: (1) answer is (c) – Diagnostic and Statistical Manual of Mental Disorders; (2) answer is (c) – 2013; (3) answer is (a) - To get a more comprehensive picture of the patient.

DETAILED DISCUSSION OF THE MULTIAXIAL SYSTEM

AXIS I – CLINICAL DISORDERS & OTHER CONDITIONS AS FOCUS OF TREATMENT

This first Axis is for reporting most of the primary diagnoses in the DSM with the exception of the ten Personality Disorders and Mental Retardation (coded on Axis II). Also reported on Axis I is Other Conditions That May Be a Focus of Clinical Attention (V-Codes). This axis records the particular clinical syndromes or other conditions that may be a focus of clinical attention. This would include schizophrenia, generalized anxiety disorder, major depression, and substance dependence, among other things. Axis I conditions are often compared to the various illnesses and diseases recognized in general medicine.

When there is more than one Axis I diagnosis that is currently being treated, the disorders should be listed in the order in which they are being treated. For example:

Axis I 291.81 Alcohol Withdrawal 300.4 Dysthymic Disorder

In the above example, the Alcohol Withdrawal is the primary diagnosis being treated first. Dysthymic Disorder is also a primary diagnosis, but it is the secondary diagnosis and is being considered for treatment secondary to the Alcohol Withdrawal. If and when this changes, the two diagnoses should be reversed in their order on Axis I.

When there is an Axis I and an Axis II disorder and the Axis II disorder is the primary diagnosis being treated at this time, “Principle Diagnosis” (for inpatient population) or “Reason for Visit” (for outpatient population) should be placed in parentheses next to the Axis II diagnosis. This method indicates to the insurance company and others on the treatment team that the Axis II diagnosis is the primary focus of current treatment (see Section C below for more detailed discussion).

For example (p 27-28): Axis I 300.4 Dysthymic Disorder Axis II 301.0 Paranoid Personality Disorder (Principle Diagnosis)

AXIS I

1. Clinical Disorders (p. 28) Disorders usually first diagnosed in infancy, childhood, or adolescence Delirium, dementia, and amnestic and other cognitive disorders Mental disorders due to a general medical condition Substance-Related disorders Schizophrenia and other psychotic disorders Mood disorders Somatoform Disorders Factitious disorders Sexual and Gender Identity Disorders Eating disorders Impulse-Control disorders not elsewhere classified Adjustment disorders

2. Other Conditions That May Be a Focus of Clinical Attention (V-Codes) Problems Related to Abuse and Neglect (3) Additional Conditions That May Be a Focus of Clinical Attention (13) Relational Problems (5)

V-Codes are conditions that can be treated therapeutically but are NOT considered mental disorders. V-Codes are seldom reimbursed by insurance companies (more later). The method for coding V-Code diagnoses is as follows: Example:

Axis I V61.1 Partner Relational Problem

QUESTION

What two elements get coded on Axis I?

a. Personality Disorders and Mental Retardation b. Partner Relational Problem and Major Clinical Disorders c. Major Clinical Disorders and V-Codes

Answer: The answer to this question is (c) Major Clinical Disorders and V- Codes.

AXIS II – PERSONALITY DISORDERS & MENTAL RETARDATION

Axis II is for reporting the ten Personality Disorders and Mental Retardation which are separated from all of the other clinical disorders coded on Axis I. Personality Disorders encompass a variety of problematic ways of interacting and relating to the world. Personality Disorders refer to a pervasive and enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. The pattern is generally inflexible, has an onset of adolescence or early adulthood, and is actually stable over time (APA, 2000), and leads to distress or impairment for the individual experiencing one of the Personality Disorders.

Personality Disorders are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are manifested in various different groupings. Only when these personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute an actual Personality Disorder.

The general diagnostic criteria for all of the Personality Disorders include at least two of the following four elements.

1. Cognition – for example, ways of perceiving, interpreting and thinking about self, other people, and events 2. Affectivity – for example, the range, intensity, lability, and appropriateness of emotional response to the environment and other people 3. Interpersonal Functioning – for example, how one functions with society and other people in the world 4. Impulse control – for example, people with Personality Disorders may lack the ability to control impulses (drinking, speeding, erotic, etc.) One ethical issue involved is that the DSM system, by design and necessity, uses a categorical approach. In other words, this perspective posits that the Personality Disorders are qualitatively distinct clinical syndromes and fall neatly into simple categories.

An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent a varied range and span of personality characteristics that merge imperceptibly into normality and into one another (APA, 2000). Thus, despite the requirement to choose a specific Personality Disorder to use as a diagnosis as in the categorical approach, the dimensional approach notes that people are not so predictable and are more complex than the simple categorical perspective allows. Therefore, the Personality Disorders are grouped into three “Clusters” in which there are Personality Disorders with similar characteristics that overlap.

Additionally, Axis II is used for coding both (a) Prominent Maladaptive Personality Features and (b) Habitual Use of Defense Mechanisms. Personality Disorders and Mental Retardation are listed on this separate axis so that they will not be overlooked in favor of the more florid Axis I disorders that receive more attention in most cases. Indeed, the Axis II disorders, which are considered more long lasting and resistant to change, are treated differently than those coded on Axis I (APA, 2000). As mentioned previously, insurance companies seldom reimburse for Personality Disorder diagnoses. This will be discussed in more detail later in the course.

In sum, the ten Personality Disorders and Mental Retardation are coded on Axis II while all other primary mental disorders and V-Codes are coded on Axis I. This is so the longer-lasting Axis II disorders that are more resistant to change will not be overlooked or lost among the more obvious Axis I disorders.

Appendix B – Criteria Sets and Axes Provided for Further Study (p. 759)

This appendix contains a number of proposals for new diagnoses and axes. In the 1990s, the DSM-IV task force and work groups subjected the information to a careful empirical review, inviting broad commentary from professionals in the field. The task force determined there was insufficient evidence for inclusion of these various criteria sets to be placed into the primary text at this time (APA, 2000). Please see Appendix B for numerous diagnostic possibilities the may capture the client’s symptom manifestation more accurately.

The following proposals are included in Appendix B: Criteria Sets and Axes Provided for Further Study:

APPENDIX B: CRITERIA SETS AND AXES PROVIDED FOR FURTHER STUDY Postconcussional disorder Mild neurocognitive disorder Caffeine withdrawal Alternative dimensional descriptors for Schizophrenia Postpsychotic depressive disorder of Schizophrenia Simple deteriorative disorder (simple Schizophrenia) Premenstrual dysphoric disorder Alternative Criterion B for Dysthymic Disorder Minor depressive disorder Recurrent brief depressive disorder Mixed anxiety-depressive disorder Factitious disorder by proxy Dissociative trance disorder Binge-eating disorder Depressive personality disorder Passive-aggressive personality disorder (negativistic personality disorder) Medication-Induced Movement Disorder Neuroleptic-Induced Parkinsonism Neuroleptic Malignant Syndrome Neuroleptic-Indsduced Acute Dystonia Neuroleptic-Induced Acute Akathisia Neuroleptic-Induced Tardive Dyskinesia Medication-Induced Postural Tremor Medication-Induced Movement Disorder Not Otherwise Specified

These categories are included in the “Other Conditions That May Be a Focus of Clinical Attention” Section.

Defensive Functioning Scale Global Assessment of Relational Functioning (GARF) Scale Social and Occupational Functioning Assessment Scale (SOFAS)

Section One – Proposed Diagnoses for Further Study

Passive-Aggressive Personality Disorder was once the eleventh Personality Disorder in the DSM-III-R in 1987. In studies and feedback sessions, the task force groups removed Passive-Aggressive Personality Disorder and placed this diagnosis in Appendix B for further study due to a lack of these particular cluster of symptoms existing among the general population at the tine the DSM-IV was published. However, it had enough support to remain poised for further study in Appendix B rather than to be removed from the DSM-IV altogether. When a clinician wishes to use a diagnosis housed in Appendix B, he or she should first review suggested methods given by the DSM for that particular diagnosis at the conclusion of each section.

Otherwise, one can assign a diagnosis of “Not Otherwise Specified” (see Section C, Method Four below) and then the chosen Appendix B diagnosis that corresponds most accurately.

Example:

Axis II 301.9 Personality Disorder Not Otherwise Specified Passive-Aggressive Personality Disorder (p. 791)

Please note that the NOS categories are given a numbered code; in most cases, insurance companies consider this a full diagnosis and will reimburse for the NOS diagnoses.

Section Two – Proposed Axes for Further Study

There are two proposed axes for further study, if added in the DSM-V, these might increase the multiaxial system to seven axes.

Defensive Functioning Scale

Defense mechanisms or coping styles are automatic psychological processes used to protect people from feeling overwhelming anxiety. Defense mechanisms are often unconscious and are important processes that mediate emotional conflicts and internal and external stressors. According to this model (see pages 807 to 810) individual defense mechanisms are divided conceptually and empirically into related groups that are referred to as Defense Levels.

Example:

Axis I 296.32 Major Depressive Disorder, Recurrent, Moderate

Axis II 301.83 Borderline Personality Disorder Antisocial Personality Features

Axis III None

Axis IV Recent loss of job Past abuse as a child

Axis V GAF = 62 (Current)

A. Current Defenses or Coping Styles: 1. Splitting 2. Acting out 3. Denial

B. Predominant Current Defense Level: Mental Inhibitions Level

AXIS II

1. PERSONALITY DISORDERS

Cluster A – Odd and Eccentric Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder

Cluster B – Dramatic and Emotional Antisocial Personality Disorder Borderline Personality Disorder Narcissistic Personality Disorder Histrionic Personality Disorder

Cluster C – Anxious and Fearful Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder

2. MENTAL RETARDATION (pp. 41-49)

3. PROMINENT MALADAPTIVE PERSONALITY FEATURES (p. 29)

4. HABITUAL USE OF MALADAPTIVE DEFENSE MECHANISMS (pp. 807- 813)

QUESTION 1

There are ____ Personality Disorders plus one NOS.

a. 8 b. 9 c. 10

QUESTION 2 There are ____ Personality Disorder Clusters.

a. 3 b. 4 c. 6

QUESTION 3

Personality Disorders are:

a. Enduring b. Inflexible c. Long term d. All of the above

Answers: The answer to question one is (c) as there are 10 Personality Disorders plus one NOS; The answer to question two is (a) as there are three Personality Disorder Clusters; The answer to question three is (d) all of the above as all a-c apply.

QUESTION 1

Personality Disorders generally begin:

a. In early childhood b. In adolescence or early adulthood c. In adulthood

QUESTION 2

Personality Disorders and Mental Retardation are coded on a separate axis from the main clinical disorder because:

a. They are enduring and resistant to change b. They are problems in living c. They need to be assessed more carefully than the clinical disorders

Answers: The answer to question one is (b) in adolescence or early adulthood; The answer to question two is (a)personality disorders generally manifest in adolescence or early adulthood;

AXIS III – GENERAL MEDICAL CONDITIONS Axis III is for reporting current general medical conditions “that are potentially relevant to the understanding or management of the individual’s mental disorder” (APA, 2000, p. 29). In general, this is the purview of medical doctors, and not mental health professionals such as psychologists, social workers, or marriage and family therapists who would be practicing outside their area of expertise in diagnosing a medical condition. For a brief summary of General Medical Conditions that are coded on Axis III, see page 30 of the DSM-IV-TR. For a complete list of all ICD-9-CM codes (international classification of diseases-9- clinical modification), see Appendix G beginning on page 867. For a complete list of all ICD-10-CM Codes see Appendix H beginning on page 883.

The multiaxial distinction among Axis I, Axis II, and Axis III disorders does not imply that there are fundamental differences in their conceptualization, that mental disorders are unrelated to physical or biological factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes. The purpose of distinguishing general medical conditions is to encourage thoroughness in evaluation and to enhance communication among health care providers. (APA, 2000, p. 29)

It is unethical and illegal for a psychologist, marriage and family therapist, or social worker to “diagnose” a medical condition in a client. However it is completely ethical and legal to refer a client to a medical doctor to rule out a general medical condition or the use of substances as the source of symptoms. Another possibility is to indicate “None” or “Deferred” is that is the case. Thus, a mental health professional has an obligation to refer a client complaining of physical symptoms to a medical doctor to rule out or rule in a general medical condition as the origin of the symptoms.

Additionally, since psychotherapists are not medical doctors, they may not simply put the general medical condition on Axis III when they learn of it from the patient, patient’s family, or the patient’s medical doctor. As shown in the example below, a non-medical psychotherapist must phrase the Axis III diagnosis in the appropriate method such as “as reported by patient…” or similarly.

If a client refuses to attend his or her physician to rule out a general medical condition or substance use as the etiology of the symptoms, this refusal should be recorded in the patient chart. Continued discussion and consultation should be considered throughout treatment with the client.

To reiterate, the only information that should be placed on Axis III is what is related to Axis I. When there is more than one general medical condition that is clinically relevant, all should be reported.

Example 1: Axis I 309.24 Adjustment Disorder with Anxiety

Axis II V71.09 No Diagnosis

Axis III Migraines, as reported by patient

Example 2:

Axis I 309.24 Adjustment Disorder with Anxiety

Axis II 301.83 Borderline Personality Disorder

Axis III None

Example 3:

Axis I 300.4 Dysthymic Disorder

Axis II 301.9 Personality Disorder Not Otherwise Specified

Axis III Deferred

Please note the only issue with the “deferred” category is that an insurance company may expect further information or a further revision to the Axis III diagnosis. Deferred means there is “insufficient information to make any diagnostic judgment about” a diagnosis or condition (APA, 2000, p, 743).

General Medical Conditions are listed on page 30 and include the following:

GENERAL MEDICAL CONDITIONS (p. 30) Infectious and parasitic Diseases Neoplasms Endocrine Nutritional, and Metabolic diseases and Immunity Disorders Diseases of the Blood and Blood-forming Organs Diseases of the Nervous System and Sense Organs Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Complications of Pregnancy, Childbirth, and the Puerperium Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomallies Certain Conditions Originating in the Perinatal Period Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning

QUESTION 1

General Medical Conditions should be coded:

a. Whenever the patient has any general medical condition b. Whenever he or she is being treated by a physician c. Whenever the general medical condition is related to the treatment or management of the Axis I disorder

QUESTION 2

Mental Health Providers can ethically and legally diagnose a medical condition if the patient reports that it is related to the Axis I disorder.

a. TRUE b. FALSE

QUESTION 3

One of the problems with the use of “Diagnosis Deferred” is:

a. Insurance companies will not accept this as a formal diagnosis b. The insurance company may request a revision or further consideration in the future c. There is no problem with using this format

Answers to questions 1-3: The answer to question one is (c) general medical conditions should be coded when they are related to the management or treatment of Axis I. The answer to question two is (b) false, as this would be practicing outside of one’s scope of practice. The answer to question three is (b) as diagnosis deferred means there is insufficient evidence of a diagnosis at this time, but there may be a revision in the future.

AXIS IV - PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS

Axis IV accounts for psychosocial and environmental problems that effect the diagnosis, treatment, and prognosis of mental disorders coded on Axis I and Axis II. These problems may be negative or positive life events, familial or other interpersonal stress, lack of social support or personal resources, or any other context where a person has difficulty adjusting to a new life situation. These problems should be considered in the development of the treatment plan.

The clinician should note as many of these issues as he or she judges is relevant to the Axis I or Axis II disorder. Generally, only the problems that have been present for the year prior to the current evaluation should be listed. However, the clinician may use clinical judgment in order to list problems occurring prior to the previous year if they clearly contribute to the mental disorder or are a focus of the current treatment. Examples include abuse as a child, combat experiences, 9/11 trauma, being mugged, rape, home fire, and other large scale traumatic events.

AXIS IV - SUMMARY

Problems with the Primary Support Group – includes death of a family member or health problems within the family; disruption of family by separation or divorce, removal from the home; sexual or physical abuse or alienation of a child; overprotection or neglect of a child; inadequate discipline, discord with siblings; new child in the home.

Problems related to the social environment – death or loss of loved one or friend; inadequate social support; living alone; acculturation difficulties; discrimination; adjustment to new issue in life cycle transition.

Educational problems – illiteracy; academic problems; discord with teachers or school or classmates; inadequate school support or environment.

Occupational problems – unemployment; threat of job loss; stressful work schedule; difficult work environment or conditions; job dissatisfaction; job change; discord at work.

Housing problems – homelessness; inadequate housing; unsafe neighborhood; discord with neighbors or landlord.

Economic problems – extreme poverty; inadequate finances; insufficient welfare support.

Problems with access to health care services – inadequate health care services; transportation to facilities unavailable; inadequate health insurance.

Problems related to interaction with the legal system/crime – arrest; incarceration; litigation; victim of crime.

Other psychosocial and environmental problems – exposure to disasters, war, other hostilities; discord with nonfamily caregivers such as counselor, social worker, or physician; unavailability of social services agencies.

QUESTION 1

How many psychosocial problems may be listed on Axis IV? a. Three b. Five c. As many as are relevant

QUESTION 2

On Axis IV, only list negative psychosocial or environmental problems.

a. TRUE b. FALSE

QUESTION 3

A clinician may only list problems that have existed for the previous year prior to psychotherapeutic treatment.

a. TRUE b. FALSE

Answers to questions 1-3: The answer to question one is (c) list as many psychosocial or environmental problems as you deem relevant. The answer to question two is (b) false, as the therapist should list both positive and negative psychosocial or environmental events that are relevant to the treatment of the patient . The answer to question three is (b) as the therapist is required to list problems that have occurred in the previous year to treatment, he or she may also wish to list past problems such as divorce, child abuse, or unemployment even if it occurred prior to the previous year..

AXIS V – GLOBAL ASSESSMENT OF FUNCTIONING

Axis V is for reporting the clinician’s assessment of the person’s overall level of functioning in a global fashion. It is an important part of treatment planning for measuring and predicting treatment outcome. The Global Assessment of Functioning (GAF) Scale uses a single measure to track clinical progress. The GAF rates psychological, social, and occupational functioning by assigning the person a single number on a scale from zero to 100. The scale is divided into 10 ranges of functioning where the clinician chooses a single value best reflecting the individual’s overall level of functioning. The clinician must report the current Global Assessment of Functioning in all cases.

In many situations it can be helpful to assess the “highest level of functioning during the past year” Global Assessment of Functioning in order to compare and contrast past adjustment Global Assessment of Functioning to current status Global Assessment of Functioning. For details on the four step process of using the Global Assessment of Functioning Scale, review page 33. For the Global Assessment of Functioning Scale itself, see page 34.

The GAF scale is divided into ten ranges of functioning. Thus, the clinician must pick a single value that best reflects the person’s functioning overall. The scale lists descriptions of the ten point ranges which have two components:

1. The first part covers symptom severity (a number value within the ten point range must be chosen) 2. The second part covers functioning (descriptive portion with suggested symptoms and behaviors)

In other words, the clinician must evaluate the where in the particular number range the person’s functioning falls, and if the level of functioning falls within the range. For example, the first part of the range 41-50 describes “serious symptoms (e.g., “suicidal ideation, severe obsessional rituals, frequent shoplifting” and the second part includes “any serious impairment in social, occupational, or school functioning (e.g., “no friends, unable to keep a job”). It should e noted that in situations where the person’s actual symptom severity and level of functioning are not similar, the final GAF rating should reflect the worse of the two (APA, 2000, pp. 32-33).

In order to be certain that all elements of the GAF scale are considered when a rating is made, the following method is used for determining a GAF rating:

STEP 1: Starting at the top level, evaluate each range by asking “is either the individual’s symptom severity OR level of functioning worse than what is indicted in the range description?

STEP 2: Keep moving down the scale until the range that best matches the individual’s symptom severity OR the level of functioning is reached, whichever is worse.

STEP 3: Look at the next lower range as a double-check against having stopped prematurely. This range should be too severe on both symptom severity and level of functioning. If it is, the appropriate range has been reached (continue with step 4. If not, go back to step 2 and continue moving down the scale.

STEP 4: To determine the specific GAF rating within the selected ten point range, consider whether the individual is functioning at the higher or lower end of the ten-point range. For example, consider an individual who hears voices that do not influence his behavior (e.g., someone with long-standing Schizophrenia who accepts his hallucinations as part of his illness). If the voices occur relatively infrequently (once a week or less), a rating of 39 or 40 might be most appropriate. In contrast, if the individual hears voices almost continuously, a rating of 31 or 32 would be more appropriate. (APA, 2000, p. 33)

Inpatient

In an inpatient facility, the Global Assessment of Functioning is used slightly differently. When listing the “current” Global Assessment of Functioning for an inpatient, one generally lists this as on admission. Another helpful coding feature is to indicate where the patient score is upon discharge.

EXAMPLE OF COMPLETE DSM-IV MULTIAXIAL EVALUATIONS (p. 35)

Example 1

Axis I 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features 305.0 Alcohol Abuse

Axis II 301.6 Dependent Personality Disorder

Axis III None

Axis IV Threat of job loss

Axis V GAF = 35 (current)

Example 2

Axis I V61.10 Partner Relational Problem

Axis II V71.09 No diagnosis

Axis III None

Axis IV Unemployment

Axis V GAF = 62 (current) GAF = 75 (highest level past year)

Example 3 Axis I 296.23 Major Depressive Disorder, Single Episode, Severe Without Psychotic Features 306.0 Alcohol Abuse

Axis II 301.6 Dependent Personality Disorder

Axis III None

Axis IV Threat of job loss

Axis V GAF = 35 (upon admission) GAF = 50 (upon discharge)

NON-AXIAL FORMAT

The DSM-IV-TR offers a non-axial format for those clinicians who do not wish to use the traditional multiaxial format. Choosing this option may mean that insurance companies will not recognize the diagnosis for billing purposes, which will be discussed in detail in later sections of this course. In essence, clinicians using this non-axial option should follow the general rule of recording coexisting mental disorders along with any general medical conditions, psychosocial or environmental problems and any other factors that are relevant to the care and treatment of the person. For more examples and a more detailed discussion of this option, see page 37 of the DSM-IV-TR.

Example 1

300.4 Dysthymic Disorder

305.00 Alcohol Abuse

301.6 Dependent Personality Disorder, Frequent use of denial

Example 2

V61.10 Partner Relational Problem

Question 1

According to the DSM-IV-TR, unless otherwise indicated, the diagnosis on Axis I is the primary diagnosis being treated.

a. TRUE b. FALSE

See Section B – “AXIS I – CLINICAL DISORDERS & OTHER CONDITIONS AS FOCUS OF TREATMENT” for review of answer to Question 9

Question 2

There are _____ total Personality Disorders (not counting Personality Disorder Not Otherwise Specified) on Axis _____?

a. 10; I b. 12, II c. 10; II

See Section B – “AXIS II – PERSONALITY DISORDERS” for review of answer to Question 10

ANSWERS - As mentioned earlier in Section B, the answer to question 1 is (a), TRUE. The answer to question 2 is (c), there are 10 Personality Disorders on Axis II. LEARNING OBJECTIVES FOR SECTION C

• To review the six methods of diagnosing according to the DSM • To gain knowledge of the benefit, value, influence and importance of the DSM • To understand the potential harm, limitations, criticisms, and legal and ethical dilemmas when using the DSM

RELEVANCE OF DIAGNOSIS TO LAW AND ETHICS

The reason proper diagnosis is important to the subject of law and ethics is that improper diagnosis, improper billing, and fraudulent insurance practices are a major area of potential harm and violation for psychologists, marriage and family therapists and social workers, not to mention harmful to the patient population. Many mental health professionals struggle with the role of diagnosis in their work with regard to helping patients gain and maintain psychotherapy services. It can become a battle with health maintenance organizations (HMOs) and insurance companies for money, sessions, parity versus non-parity diagnoses and patient dignity. The bottom line is to provide care and accurate diagnoses simultaneously.

SIX METHODS OF DIAGNOSING As mentioned earlier, the traditional method of diagnosing is to place the primary diagnosis on Axis I in order of importance, or in order of what diagnosis is currently the focus of treatment. In other words, the main clinical diagnosis gets placed first on Axis I with other Axis I diagnoses following in the order of treatment importance at the moment. Normally, the secondary diagnosis or diagnoses go on Axis II in the order in which they are being treated unless otherwise stated (see previous Section B, Axis I). With that basic tenant in mind, there are six fundamental methods for diagnosing an individual that will be discussed in this section.

METHOD ONE – “Principle Diagnosis”

METHOD TWO – “Reason for Visit”

When more than one diagnosis for a person is given, and when at least one diagnosis is given on Axis I and the diagnosis responsible for the inpatient stay is diagnosed on Axis II, the term “principle diagnosis” is placed after the diagnosis on Axis II. Thus, this notation on Axis II establishes the Axis II diagnosis as the occasion for the admission to the inpatient facility. Additionally, if more than one diagnosis is given for a person in an outpatient setting, and the diagnosis accounting for the outpatient treatment is on Axis II, the “reason for visit” notation is used after the Axis II diagnosis as below (APA, 2000, p. 3):

Inpatient – Principle Diagnosis

Axis I 300.4 Dysthymic Disorder Axis II 301.83 Borderline Personality Disorder (Principle Diagnosis)

Outpatient – Reason for Visit

Axis I 300.4 Dysthymic Disorder Axis II Borderline Personality Disorder (Reason for Visit)

METHOD THREE – “Provisional Diagnosis”

This specifier is used when the clinician is certain, or at least has a strong presumption, that the full criteria for the diagnosis will ultimately be met. However, at this time, not enough information is available to make the firm diagnosis. To indicate diagnostic uncertainty, the clinician merely places the words “Provisional” after the diagnosis on Axis I or Axis II. Here the clinician can indicate some uncertainty about the exact diagnosis.

Examples include situations where either the duration for the full diagnostic threshold is lacking, or the severity with regard to symptomotology and criteria is lacking. For example, the person seems to have a Major Depressive Disorder, but is unable to give an adequate history to show whether or not the full criteria has been met. Criteria may sometimes be lacking because the patient’s history is unknown (see pages 3-4).

Example 1

Axis I 300.4 Dysthymic Disorder (Provisional)

Here, the individual who is receiving the diagnosis may have had symptoms for 15 months and has not yet reached the threshold for the duration component.

Example 2

Axis II 301.81 Narcissistic Personality Disorder (Provisional)

METHOD FOUR – “Not Otherwise Specified”

Because individuals have varied clinical presentations, it is not possible for the diagnostic nomenclature to cover all possible situations. Clinical presentation are certainly diverse as are individuals who express these symptoms. Thus, every diagnostic classification has at least one “Not Otherwise Specified” (NOS) category. There are four situations where an NOS diagnosis is appropriate (APA, 2000, p. 4):

TYPE 1 - “Close but no Cigar” - Here the diagnostic picture does not meet the criteria for any specific disorder, but comes fairly close. The person’s diagnostic picture comes just below the diagnostic threshold. He or she may present a mixed or atypical picture.

TYPE 2 – The diagnosis is not presently in the main text section of the DSM. It still causes significant distress or impairment to the client as do the other diagnoses in the primary sections of the DSM. Some of these items may be in Appendix B for further study.

TYPE 3 – The clinician is uncertain of the etiology of the disorder. It could be accounted for by general medical condition or substance use.

TYPE 4 – There may not enough time for data collection but a diagnosis is important at this time. A specific category is established with certainty now but not a specific diagnosis.

METHOD FIVE (a) – No Diagnosis or Condition on Axis I

METHOD FIVE (b) – No Diagnosis on Axis II Here, Axis I provides for No Diagnosis or CONDITION on Axis I and omits the word CONDITION when referring to Axis II because Axis II does not include “conditions” such as V-Codes. V-Codes refer to conditions that can be the subject of treatment but are not due to a mental disorder (see page 743).

Examples of V-Codes are as follows:

Axis I V61.20 Parent-Child Relational Problem

Axis I V61.10 Partner Relational Problem,

Axis I V61.8 Sibling Relational Problem

METHOD SIX (a) – Diagnosis or Condition Deferred on Axis I

METHOD SIX (b) – Diagnosis Deferred on Axis II

Here, Axis I provides for Diagnosis or CONDITION Deferred on Axis I and omits the word CONDITION when referring to Axis II because Axis II does not include “conditions” such as V-Codes. V-Codes refer to conditions that can be the subject of treatment but are not due to a mental disorder (see page 743)

INDICATIONS OF DIAGNOSTIC UNCERTAINTY

There are three primary methods to indicate diagnostic uncertainty. They are listed below:

Not Otherwise Specified – A formal diagnosis with a code number Axis I 298.9 Psychotic Disorder Not Otherwise Specified

Provisional – Full criteria will eventually be met Axis I 300.4 Dysthymic Disorder (Provisional)

Deferred – More time required to make a diagnosis Axis I Deferred

Question 1

How many methods are there for coding a diagnosis on Axis I or II? a. Two b. Four c. Six

Question 2 The term “provisional” refers to when:

a. The patient has not yet met the threshold for the duration or severity of the diagnosis but most likely will in the future b. The insurance company is unsure if they are going to reimburse the clinician or patient c. The diagnosis is still in Appendix B and not in the primary text yet

Question 3

“Principle Diagnosis” means:

a. The Axis I disorder is the primary disorder being treated at this time b. The Axis II disorder is the primary disorder being treated at this time for an outpatient c. The Axis II disorder is the primary disorder being treated at this time for an inpatient

Question 4

“Reason for Visit” means:

a. The Axis I disorder is the primary disorder being treated at this time b. The Axis II disorder is the primary disorder being treated at this time for an outpatient c. The Axis II disorder is the primary disorder being treated at this time for an inpatient

Answers to questions 1-4 - As mentioned earlier in Section B, the answer to question 1 is (c), as there are six methods of diagnosing. The answer to question 2 is (a), meaning the patient has not yet met the threshold for the duration or severity of the diagnosis but most likely will in the future. The answer to question 3 is (c) as principle diagnosis refers to inpatient treatment. The answer to question 4 is (b) as reason for visit refers to outpatient treatment.

BENEFITS AND CRITICISMS OF THE DSM

“The DSM has become the most widely used system for the diagnosis of mental disorders” (Eriksen & Kress 2000, p. 2).

Vignette: Jack opens a bar of soap, tosses out the packaging, washes his hands in steaming hot water, opens another bar of soap, tosses out the packaging, washes his hands in steaming hot water, and repeats the process five more times before turning off the water and drying his hands on an immaculate white towel.

Practice Question

What are your diagnostic impressions of Jack in the above vignette?

a. Generalized Anxiety Disorder (GAD) b. Obsessive-Compulsive Disorder (OCD) c. Post Traumatic Stress Disorder (PTSD)

Answer: The fact that most psychologists, marriage and family therapists, and social workers know that the person in the scenario shows typical signs of Obsessive Compulsive Disorder (answer b) is one of the valuable benefits of the DSM system.

THE ETHICS AND BENEFITS OF THE DSM SYSTEM

The DSM provides professionals with a common language to compartmentalize the vignette above. It provides a “shorthand” for information and aids in making complex material more understandable. It helps in treatment planning by evaluating therapy effectiveness and causal mechanisms (Eriksen & Kress, 2005). The DSM gives useful general information about prevalence, course of diagnosis, and gender and familial issues. Additionally, the DSM aids in the referral process in assessing a client is beyond one’s competence. It may provide an “external label” thereby reducing guilt and shame by objectifying the problem (White, 2001). Advocates for the DSM system claim it “increases comprehension of the pathological processes involved in disorders, improves control over the outcomes of psychiatric disorders, and promotes prevention of the disorders (e.g., as a result of conducting research on etiology” (Erikson & Kress, 2005, p. 2). Many experts agree professionals may lose credibility and status in their professions if they fail to gain adequate knowledge of proper diagnostic techniques (Eriksen & Kress, 2005; Chambliss, 2000; Sperry, 2002).

Benefits of the DSM System

1. Common language – the DSM system categories reduce complex information into a form that is gathered in one place. All clinicians are familiar with the terminology and are able to easily communicate symptom distress, signs of remission, insurance information and this alone can aid in the treatment of patients.

2. Shorthand for information – this shorthand for information facilitates communication within and among professional groups. Clinicians can categorize psychological problems, researchers and those who develop theories of pathology can compare various approaches to treatment for specific DSM diagnoses.

3. Aids in treatment planning - Here the DSM system may help treatment planning by evaluating what works and what does not work for specific diagnoses. It helps to evaluate the underlying causal mechanisms and processes of particular diagnoses (Erikson & Kress, 2005).

4. Useful general information in text – Throughout the DSM there are relevant citations to the course, prevalence, and cultural, gender, and familial issues related to each diagnosis.

5. Aids in the referral process – Since the DSM is set up to divide diagnoses into categories, it can aid in helping the clinician to know when to refer a client. Receiving a referral that is outside one’s expertise or competence requires some careful consideration prior to accepting the client for treatment. Ethically, clinicians are required to know their limitations. Clinicians are required to either refer a client who is outside of one’s competence or to seek consultation on a regular basis while treating the patient.

6. Use of external labels – The DSM may benefit clients when they receive a concrete explanation for their behavior and experiences. Clients have reported feeling some freedom when they have their experiences labeled (Wetterling, 2000).

Erikson and Kress (2005) relate the following example:

One client known to the first author struggled with depression for many years. A psychologist who tested her said that she would be in psychiatric hospitals for the rest of her life. During counseling sessions, she kept “thrashing” herself with messages like “I should be better,” “I shouldn’t keep struggling with this,” “I am such a loser compared with everyone else.” When the therapist shared the diagnostic labels of major depression and borderline personality disorder with her and urged her to think of these disorders as physical, like having diabetes or like being a paraplegic, the client was ble to refocus her efforts toward managing the problems, coping with then, developing realistic expectations of herself, and garnering appropriate kinds and levels of support for herself. Having a label to hang onto actually freed her from the paralysis of self-blame and helped her to invest her energy more productively in activities that, in the end, were successful in keeping her out of the hospital. (p. 2)

The idea of focusing family members and patients on an external label helps to identify the “enemy” as outside of themselves. External labels can reduce blaming of specific individuals and can put less pressure on the one so labeled about idiosyncratic behavior. It can decrease mental blame and guilt as well.

Erikson and Kress give another example of how the external label was helpful to an adoptive family of a child who had been abused at the hands of the biological mother:

When the counselor diagnosed some developmental problems resulting from physical agues and neglect in the biological family, the adoptive family breathed a collective sigh of relief and buckled down to rectify and manage the problems that they had inherited. (p. 3)

7. Credibility and respect in the profession – Full and conversant knowledge of the DSM system increases the clinician’s credibility within the profession, may fulfill specific employment requirements, and may help clinicians to use critical thinking and creativity.

POTENTIAL ETHICAL HARM AND MISUSE OF THE DSM SYSTEM

Where there are benefits, there are also negative examples of potential harm that can occur to clients as a result of the DSM’s diagnostic labeling system that needs to be acknowledged (Eriksen & Kress, 2005). First, family therapists have considered it problematic to diagnose one family member when the problem exists or originates within the family. For example, in Napier and Whitaker’s The Family Crucible (1988), the teenager gets diagnosed with schizophrenia as were other out of control teens of that era. Thus, this story emphasizes the unethical use of diagnoses to control and manipulate.

Second, each era has its own “garbage can” diagnosis or favorite diagnosis often given to those who do not easily fall into any other diagnostic category. Schizophrenia was once the 1950s such diagnosis, Borderline Personality Disorder belonged to the 1980s, Dissociative Identity Disorder, or Multiple Personality Disorder was favored in the 1990s, and ADHD is popular in the 2000s (Eriksen & Kress, 2005; Blum, 1978). Thus, clinicians must be wary of falling into the trap of stretching the symptoms to fit a favored or popular diagnosis.

Third, some experts (Kutchins & Kirk, 1997) claim the DSM system contributes to the “over-medicalizing” of our society in that it “determines how we think about social and other problems” (Eriksen & Kress, 2005, p. xii). In other words, the DSM attributes psychopathology to common behaviors allowing mental health professionals to find psychopathology where there is none or where there is merely stress or adjustment to new or complex situations. Thus, the DSM system can allow clinicians to reorient their thinking in ways that affect social institutions by labeling behaviors as illnesses or disorders when the problems may only be life issues (Kutchins & Kirk, 1997).

For example, note that in 1973 homosexuality as a diagnosis was eliminated from the DSM-II classification of mental disorders available for use. It was replaced by the category Sexual Orientation Disturbance, according to Spitzer, (1981). A compromise was reached between the view that preferential homosexuality is invariably a mental disorder and the view that it is merely a variation of normal sexual behavior.

According to Spitzer (1981), the controversy involved what became the DSM-III category of Ego-dystonic Homosexuality. Spitzer’s article argues that what is at issue is a value judgment about heterosexuality rather than a factual dispute about homosexuality (p. 210).

After acrimonious and lengthy debate in both 1973 and 1974, the American Psychiatric Association voted in 1974 to remove homosexuality from the DSM-II. The vote was 5,854 votes to remove it as a mental disorder and 3,810 not to remove it from the manual. Although this was a milestone in gay and lesbian rights, it was an embarrassment for psychiatry (Butcher, Mineka. & Hooley, 2010).

Fourth, Humanistic therapists question the usefulness of diagnoses in that they tend not to focus on “wellness.” They argue that a person’s character is unique and cannot be labeled, judged, totally understood or identified (Frankl, 1969; May, 1981; Rogers, 1951, 1961). The Client-Centered approach focuses on the person’s ability to “diagnose” him- or herself, rather than the therapist doing the diagnosing. Rogers was famous for his compelling model in which the therapist considers the client from the client’s frame of reference (Rogers, 1961). In 1951, Rogers developed a Client-Centered Rationale for Diagnosis which directs attention to the client’s internal experiences:

• The client is the only one who can fully know his or her dynamics or perceptions or behaviors • A change in perception must occur in order for a change in behavior to occur • Forces for change exist primarily within the client and cannot come from without • Therapy is a diagnosis that is a process that occurs in the experience of the client rather than the intellect of the clinician. (pp. 221-223)

Fifth, many clinicians feel forced to “play the insurance game” by providing a diagnosis that is acceptable and reimbursable to the insurance company or Health Maintenance Organization (HMO). These diagnoses are often required to be “medically necessary” and are primarily Axis I clinical disorders, not Axis II or V-Codes (Ackley, 1997). Giving a false or misleading “insurance” diagnosis is insurance fraud and misrepresentation, an ethical violation, and one of the most frequent acts of financial misconduct brought before licensing boards (Welfel, 2002). This will be discussed in detail in Section E.

Sixth, the stigma or disgrace associated with having a psychiatric diagnosis is difficult for some people, especially in various cultural groups. Most people are far more comfortable disclosing they have a medical condition rather than a psychiatric diagnosis. Fear that disclosure can cause unwanted social or occupational consequences is enough to keep some people away from seeking therapy.

In Rosenhan’s famous pseudopatient experiment in 1973, Being Sane in Insane Places, Rosenhan looked into the validity of psychiatric diagnosis. This study is considered important and influential criticism of the entire system of diagnosing patients.

Rosenhan himself and seven mentally healthy associates (pseudopatients) gained admission to psychiatric hospitals in several different states by feigning auditory hallucinations. The hospital staff members were unaware of the experiment. The pseudopatients were a mixture of psychology graduate students, psychologists, a pediatrician, a psychiatrist, a painter and a housewife who used pseudonyms and had no history of mental illness.

They claimed to be hearing voices of the same sex as the patient which were often unclear but which pronounced certain words. No other symptoms were feigned. Once admitted, the pseudopatients were instructed to act normally, report they felt fine, and no longer heard voices. They were friendly and cooperative.

All were admitted to twelve different psychiatric facilities around the United States. These facilities ranged from run-down underfunded facilities to private expensive hospitals. Stays ranged from seven to fifty-two days, with the average being nineteen days. All were given a diagnosis of Schizophrenia in remission. Rosenhan took this to mean “once a patient, always a patient.” In other words, once given a chronic and serious diagnosis, the patient carries it throughout his or her lifetime.

None of the pseudopatients were identified as such, despite taking extensive notes and claiming to have no further symptoms; however, it seems that other psychiatric patients were able to correctly identify them as imposters (Rosenhan, 1973).

Question 1

What does the term “over-medicalizing” refer to?

a. Only medical doctors can use the DSM system accurately b. The potential for the DSM attributes psychopathology to common behaviors c. Clinicians who are not medical doctors try to diagnoses on Axis III

QUESTION 2

How can use of a DSM “external label” aid a patient?

a. It helps them get reimbursed by the insurance company b. It makes them feel understood by the clinician c. It reduces guilt and blame

QUESTION 3

What was one of the primary finding in the famous Rosenhan experiment of 1973?

a. It is easy to trick hospital staff b. Once a patient always a patient c. Hospital staff do not fully respect psychiatric patients

Answers to questions 1-3 - The answer to question 1 is (b), there is a potential to attribute psychopathology to common, everyday behaviors. The answer to question 2 is (c), giving a label tends to reduce guilt and blame or the patient and the patient’s family members. The answer to question 3 is (b) once a patient always a patient. In other words, once the healthy individuals received a diagnosis of schizophrenia, they were considered schizophrenic thereafter and in fact were given the discharge diagnosis of “schizophrenia, in remission.”

LIMITATIONS TO USING THE DSM ETHICALLY

Fails to Predict

The DSM system fails to predict treatment outcomes or to promote understanding of underlying pathology (Spitzer, 1975; Tsuang & Faraone, 2002). Robert Spitzer, who is a primary author of many of the DSM editions, claims that diagnosis is somewhat effective in enabling professional communication and somewhat helpful in predicting usefulness of certain treatments for specific diagnoses. Indeed, Spitzer suggests the DSM has been woefully inadequate in helping practitioners to comprehend the pathological processes involved and to prevent the disorders from developing. In fact, Spitzer recommends against the use of diagnostic categories for outpatients who are not seriously ill (Eriksen & Kress, 2005).

Self-fulfilling Prophecy

The DSM can lead people to accept a self-fulfilling prophecy that they are doomed to act out certain behaviors. For example, the Rosenhan experiment discussed previously where (Seligman, Walker & Rosenhan, 2001) healthy individuals had themselves admitted to an inpatient psychiatric facility after claiming to have only a single symptom (they claimed to have heard an empty, meaningless voice and a thud-type noise). Once seen as psychotic, these healthy individuals were never again treated as “normals” by the staff. Staff made less-than-normal eye-contact with them, never fully communicated with them, and never spoke to them as if they could understand what was being told to them. The experiment demonstrates the potentially negative impact of placing a diagnostic label on people for both the potential clients and the caregivers. It demonstrates the classic idea of “once crazy, always crazy.”

Jensen and Hoagwood (1997) note the inaccuracies and contextual nature of the process of assessment for diagnosis. Both client and practitioner shape the nature of the intake and diagnostic process in the give-and-take nature of the initial assessment in the question and answer format and observation method. Clients decide what they wish to reveal based upon the reaction of the clinician, what he or she decides to write down, the clinician’s facial expressions, his or her body language, questions asked and so forth. White and Epston (1990) note “we prune… those events that do not fit with the dominant evolving stories that we and others have about us” (pp. 11-12).

Stigma

The stigma of many diagnoses alone should challenge clinicians assigning diagnoses to question the ethics of using the DSM coding system (Rosenhan (1973). The subjects who were admitted as inpatients in the Rosenhan experiment of 1974 were immediately labeled psychotic due to their own reporting of hearing voices and the thud-type noise. An important finding of the Rosenhan experiment was the unfortunate and seemingly unavoidable stigma associated to individuals given psychotic diagnoses and the subsequent treatment given to them by staff members. As noted previously, these healthy inpatients were treated with decreased eye-contact, disdain, treated as if they were invisible, and there was a reduced amount of total interactions in general along with other dehumanizing behavior (Rosenhan, 1974)..

Television, films, and other media sometimes portray the mentally ill as socially disgusting, incompetent, bizarre and violent (Eriksen & Kress, 2005). Such stigma can lead to job discrimination, lack of insurance, housing, and loss of self- esteem (e.g., shame, exclusion from the mainstream, self-blame).

Science versus Consensus

Challengers of the DSM claim it is “more a political consensus document than a scientifically valid one” (Eriksen & Kress, 2005, p. 8). Others expand this criticism when they claim the DSM is a mechanism of social control.

Medical journals began introducing conflict of interest disclosure requirements for authors of the DSM at least twenty years ago at the start of the original research. There was an uncomfortable growing awareness of the conflict of interest inherent where authors of the document received compensation from the pharmaceutical companies.

Conflict of interest can bias the outcome of those making recommendations to the advisory panels. “The importance of protecting the integrity and public trust in svcientifi and medical advisory committees has been wifely discussed. Yet there remain areas that lack the transparency of financial conflict of interest (statements) that have become standard procedures in many medical publications” (Cosgrove, Krimsky, & Vijayaraghavan, 2006, pp. 154-155).

Cosgrove, Krimsky, Vijayaraghavan, & Schneider (2006) conducted a study evaluating the prevalence of DSM panel members who had some relationship with, or other financial tie to the pharmaceutical companies. Below are the results of their research.

PERCENTAGE OF DSM-IV PANEL MEMBERS WITH FINANCIAL TIES

1. Task Force on the DSM-IV 56.7 2. Anxiety Disorders 81.3 3. Delirium, Dementia, Amnestic and Other Cognitive Disorders 25.0 4. Disorders Usually First Diagnosed during Infancy, Childhood and Adolescence 61.9 5. Eating Disorders 83.3 6. Medication-Induced Movement Disorder (DSM-IV-TR) 87.5 7. Mood Disorders 100.0 8. Multiaxial Issues 28.6 9. Personality Disorders 55.6 10. Premenstrual Dysphoric Disorder 83.3 11. Psychiatric Systems Interface Disorder 50.0 12. Schizophrenia and Other Psychotic Disorders 100.0 13. Sexual Disorders 40.0 14. Sexual and Gender Identity Disorders (DSM-IV-TR) 50.0 15. Sleep Disorders 50.0 16. Substance-Related Disorders 16.7 17. Committee on Psychiatric Diagnosis and Assessment 41.4 18. Joint Committee of the Board of Trustees and Assembly of District Branches on Issues to DSM-IV 0.0

Despite the above findings, the study needs to be interpreted in light of several limitations. First, it is reasonable for some type of financial relationships were not detected by the methods used in this study. Second, the screening procedures used “fell short of allowing us to quantify or to set a temporal sequence for the association. In most instances information about the amount of money received from pharmaceutical companies are not disclosed. Also, disclosures were reported strictly in terms of whether a person was a current or past recipient of industry support” (Cosgrove, Krimsky, & Vijayaraghavan, 2006, pp. 157-159).

These authors note that no conclusion can be drawn about the extent or possible impact these financial relationships may have had upon the panel members thinking or decision making process. “However, there are ethical concerns in these relationships regardless of the amount of money given or the timing of the financial association” (p. 159). Public trust in the independence of medical science can be eroded when former or current panel members may exert their influence upon prescription practices through “consulting, public speaking, and participation in industry-sponsored educational workshops” (p. 159).

Third, these authors relied on self-report from the parties involved using disclosure data that was available in the open literature. Thus, there is no way to know the exact representation of panel members having active or former relationships with the pharmaceutical companies.

These authors note that receiving financial support from the pharmaceutical companies should not automatically disqualify a person from serving on a panel, nor does it automatically mean the person has been influenced in one way or another by the relationship. The issue here is transparency: the public and mental health professionals have a right to know about the financial ties with pharmaceutical companies as the companies have a vested interest in what diagnoses are included in the DSM.

Many authors have challenged the reliability and validity of the scientific basis for the DSM (Blashfield & Breen, 1989; Brown, 1992; Frances & Widiger, 1986; Jensen & Hoagwood, 1997; Spitzer, Williams, Kass, & Davies, 1989; Szasz, 1974; Widiger & Sankis, 2000). Authors posit that DSM classifications are more the reflection of the observer and the nature of the questions being asked than the true nature of the problem. They note that clinicians possess the human need to simplify complex phenomena and that mental illness is certainly complex. Giving complex symptoms an understandable label simplifies the problem and reduces the anxiety of the therapist (Szasz, 1974; Jensen & Hoagwood,1997).

Judith Graham of the Chicago Tribune writes (4/20/06) (www/biopsychiatry.com/bigpharma/dsm-doctors.html)

The manual is of enormous importance to pharmaceutical firms, as the Food and Drug Administration will not approve a drug to treat a mental illness unless the condition is in the DSM. (Sheldon Krimsky, a Tufts University professor’s) study found that 56 percent of 170 panel members responsible for overseeing the DSM-IV had some type of financial tie to the drug industry – including getting research grants from drug companies (42%), serving as consultants (22%), and participating in speaker’s bureaus (16%).

“Classifying” individuals into neat and tidy labels may require clinicians to make decisions to censor out specific symptoms in order to make a good fit. Such censoring means that patients are made to conform to the DSM criteria for the sake of the researcher’s needs (Ussher, 2000).

Although the DSM is ostensibly based on scientific evidence, Kutchins and Kirk (1997) claim:

Barely concealed beneath the surface is an intricate process that involves old fashioned political horse-trading, complex economic considerations, elaborate systems for consensus building, and other mechanisms for mobilizing power and negotiating social conflicts. (p. 16)

The development of the DSM involved negotiations among contending interest groups of theoreticians, researchers, practitioners, hospitals, clinics, and drug companies – and, at times, potential patients. Changing the psychiatric nosology involved struggles among constituencies and required a balancing of conflicting interests” (p. 37)

Revisions can seldom be explained by advances in science… but are better explained by the shifting fortunes of various powerful factions within the American Psychiatric Association. (p. 37)

All or Nothing Classification

Another criticism of the classification system is that it can assume a symptom either exists or it does not, rather than the symptom can appear anywhere along a continuum. Additionally, a symptom can exist on one occasion and disappear at another point in time (Livesley, Jang, & Vernon, 1998).

The DSM classifies people by symptoms. For example, most clinicians use the simple terminology “an alcoholic” or “a schizophrenic” when referring to a patient rather than the more cumbersome language “a person with the criteria for alcohol dependence” or “a person with the criteria for schizophrenia.”

Lack of Transparency

The DSM system has been publicly criticized by many experts such as Robert Spitzer, head of the DSM-III task force, for lack of transparency in the development of the DSM-V. Contributors are required to sign a “non-disclosure” agreement, effectively allow the entire process to be conducted in private. Spitzer has complained bitterly about this lack of transparency saying it decreases credibility of the DSM system and prevents people from challenging the contents (Carey, (2008).

The American Psychiatric Association has responded by instituting a disclosure statement policy in an effort to promote transparency. However, many feel it is not enough effort to allow for complete transparency and to protect industry influence (Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006).

Medical Model

The medical model is reflected in the DSM and may be its guiding paradigm (Tomm, 1989; Eriksen & Kress, 2005). Research from the medical model focuses upon concerns related to the underlying genetic, chromosomal or biochemical causes for the symptoms. This model conflicts with many schools of psychotherapy, counseling and psychological thought. Tomm (1989) refers to the notion where clients are “diagnosed” with a “mental disorder” then get “treatment” to “cure” their “illness.” He believes the patient gets identified with his or her illness as “depressed” or “anxious” or “borderline” which fits with the idea of self-fulfilling prophesy discussed previously.

The medical model, in its more rigid form, is reductionistic and “and particularly antithetical to the values of some groups of mental health practitioners and of some clients, despite the continuing use of the DSM by members of these groups” (Eriksen & Kress, 2005, p. 9). Phemister (2001) discusses the “disconnect” between the DSM’s use of the medical model and family therapists, humanistically and developmentally oriented therapists, social workers, and the underlying values of most psychotherapists in general.

Question 1 One of the primary complaints about the “medical model” aspect of the DSM is:

a. Only medical doctors can become proficient in its use b. It is too confusing to be used easily c. It focuses upon diagnosing and curing the mental disorder

See Section C – Review “Medical Model” for answer to Question 11

ANSWER – Of course, as discussed in Section C above, the answer to question 1 is (c). One of the primary complaints about the DSM is its sometimes rigid focus upon the disease, the cure of the disease, and the diagnosis of the disease or disorder.

Question 2

Jenna and her partner seek couples counseling with you while asking you to bill their insurance company for individual therapy for one of them so that they can be reimbursed by the insurance carrier. This is sometimes known as:

a. Playing the insurance game b. Ethical billing practice c. Avoiding the stigma of couples counseling

See Section C - Review “POTENTIAL ETHICAL HARM AND MISUSE OF THE DSM SYSTEM” (5th Item) for answer to Question 2

ANSWER – Many clinicians wind up (a) playing the insurance game which is an unethical practice and fraudulent billing even if it is in the service of attempting to aid the client(s) financially. It would be better to either refer the clients to a reduced fee clinic or reduce one’s own fee instead.

REFERENCES

Ackley, D. (1997). Breaking free of managed care. NY: Guilford Press.

Blashfield, R., & Breen, M. (1989). Face validity of the DSM-III-R personality disorders. American Journal of Psychiatry, 146, 1575-1579.

Blum, J. (1978). On changes in psychiatric diagnosis over tine,. American Psychologist, 33(11), 1017-1031.

Brown, L. (1992). A feminist critique of the personality disorders. In .S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 206-228). NY: Guilford Press. Campbell, W.C. (April, 2004). Current Psychiatry Online. http://www.currentpsychiatry.com/

Cato Institute. (1776/2002). The Declaration of Independence and the Constitution of the United States. Washington, DC: Author.

Chambliss, C. (2000). Psychotherapy and managed care. Boston, MA: Allyn & Bacon.

Cosgrove, L., Krimsky, S., Vijayaraghavan, M., & Schneider, L. (2006). Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychotherapy Psychosomatics, 75, 154-160.

Council for Accreditation of Counseling and Related Educational Programs (CACREP). (2001). Accreditation manual and application. Alexandria, VA: Author.

Dziegielewski, S. (2002). DSM-IV-TR in action. NY: Wiley & Sons.

Eriksen, K., & Kress, V. (2005). Beyond the DSM Story: Ethical Quandaries, Challenges, and Best Practices. Thousand Oaks, CA: Sage Pub.

Frances, A. & Widiger, T. (1986). Methodological issues in personality disorder diagnosis. In T. Millon & G. L. Klerman (Eds.), Contemporary directions in psychopathology: Toward the DSM-IV (pp. 381-402). NY: Guilford Press.

Frankl, V. (1969). The will to meaning: Foundations and application to logotherapy. NY: American Library.

Gardner, B. (Ed) (1996). Black’s Law Dictionary. St. Paul, Minn: West Publishing Co.

Hoagwood, K., & Jensen, P. (1997). Developmental psychopathology and the notion of culture: Introduction to the special section on “The fusion of cultural horizons: Cultural influences on the assessment of psychopathology in children and adolescents.” Applied Developmental Science, 1(3), 108-112.

Jensen, P., & Hoagwood, K. (1997). The book of names: DSM-IV in context. Development and Psychopathology, 9, 231-249.

Kutchins, H., & Kirk, S. (1997). Making us crazy: DSM: The psychiatric bible and the creating of mental disorders. NY: Free Press. Livesley, W., Jang, K., & Vernon, P. (1998). Phenotypic and genotypic structure of traits delineating personality disorders. Archives of General Psychiatry, 55, 371-410.

May, R. (1981). Freedom and destiny. NY: W.W. Norton.

Phemister, A. (2001). Revisiting the principles of free will and determinism: Exploring conceptions of disability and counseling theory. Journal of Rehabilitation, 67(3), 5-13.

Rogers, C. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton Mifflin.

Rogers, C. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston: Houghton Mifflin.

Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250-258.

Seligman, M., Walker, E., & Rosenhan, D. (2001). Abnormal psychology. NY: W.W. Norton.

Stromberg, C. (et al.) (1988). The Psychologist’s Legal Handbook. Washington, DC: The Council for the National Register of Health Care Providers in Psychology.

Speery, L. (2002). DSM-IV: Making it more clinician-friendly. Journal of Individual Psychology, 58(4), 434-441.

Spitzer, R. (1975). On pseudoscience in science, logic in remission and psychiatric diagnosis: A critique of “”On Being Same in Insane Places.””: Journal of Abnormal Psychology, 84, 442-452.

Spitzer, R., Williams, J., Kass, F., & Davies, M. (1989) National field trial of the DSM-III-R diagnostic criteria for self-defeating personality disorder. American Journal of Psychiatry, 146, 1561-1567.

Szasz, T. (1974). The myth of mental illness. NY: Harper & Row.

Tomm, K. (1989) Externalizing the problem and increasing personal agency. Journal of Strategic and Systemic Therapies, 8, 54-59.

Tsuang , M., & Faraone, S. (2002). Diagnostic concepts and the prevention of schizophrenia. Canadian Journal of Psychiatry, 47(6), 515-518. Ussher, J. (2000). Women’s madness: A material-discursive-intrapsychic approach. In D. Fee (Ed.), Pathology and the postmodern: Mental illness as discourse and experience (pp.205-230). London: Sage.

Welfel, E. (2002). Ethics in counselling and psychotherapy: Standards, research, and emerging issues (2nd ed.). Pacific Grove, CA: Brooks/Cole.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. NY: Norton.

White, V. (2001). Renaming and rethinking the “diagnosis and treatment” course. In G. A. McxAuliffe & K. Eriksen (Eds.), Teaching counselors and therapists: Constructivist and developmental course designs (pp. 203-218). Westport, CT: Bergin & Garvey.

Widiger, T., & Sankis, L. (2000). Adult psychopathology: Issues and controversies. Annual Review of Psychology, 51, 377-404. LEARNING OBJECTIVES FOR SECTION D

• To gain knowledge about informed consent with diagnosis • To review the Ethics Codes applicable to proper diagnosing • To gain knowledge of record keeping and ethics in diagnosis

ETHICS MEETS DIAGNOSIS

Ethics implies that psychologists act with integrity, morality and with patient welfare as their primary concern. In this section, some of the challenges to traditional diagnosis will be reviewed and discussed. For instance, informed consent, confidentiality, and multiple relationships.

INFORMED CONSENT aka CONSENT FOR TREATMENT

General Discussion

As early as 1914, Justice Cardoza commented “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages” (Schloendorff v. Society of New York Hospital, 211 NY.125, 1914).

What actually is informed consent? The patient consents to be in treatment with the psychologist after being informed of office policies, treatment methods, risks and benefits, and limits of confidentiality. Fridhandler (2004), in the California Psychological Association Division I Expertise Series, points out The client or patient should have enough information to make a knowledgeable, informed choice about whether to proceed with the services offered by the psychologist. The psychologist may make a judgment about what information a specific client/patient is likely to find relevant in making this decision. Accordingly, it is appropriate to tailor the information to the client/patient’s particular needs and ability to understand. The psychologist should answer all client/patient questions relevant to the services being offered and their potential effect on him or her. (p. 1)

Fridhandler notes psychologists must abide by the APA Ethics Codes, document that the client/patient was fully informed about services offered and rendered, and that informed consent rests upon the assumption that the client/patient has the ability to make such a decision whether or not to accept services. “Court decisions have established a legal consensus about additional aspects of informed consent” (Fridhandler, 2004, p. 2). Case law, says Fridhandler, has established that clients/patients must be told the risks, benefits, and alternatives of treatment, along with the fact that treatment is strictly voluntary.

There are two basic forms of civil liability regarding informed consent according to Corey, Corey & Callanan, (2007):

• Breach of contract – This type of civil liability includes promises made by the therapist and not kept. For example, “I can make you lose weight and never gain it back.” This is clearly not possible.

According to Black’s Law Dictionary (1996) breach of contract refers to a “violation of a contractual obligation, either by failing to perform one’s own promise or by interfering with the other party’s performance.” (p. 73)

• Information not given – Here, the therapist may try to enforce office policies not previously discussed with the client. For example, trying to charge the client for a late cancellation without informing the client in advance of this policy.

Berner (1998) and Simon (1992) agree with the APA (former 1992 Code 4.02 but not retained in 2002) when they discuss the elements required for informed consent to be viable.

Voluntariness – It is generally required that the client give consent voluntarily. Even if one is treating a couple, and one partner is a reluctant participant in therapy, this still constitutes voluntary consent because the reluctant party is choosing, of his or her own volition, to attend therapy. This is true for hostile teens as well as those who choose treatment versus jail time (court referred cases). This may not be true when the court requires treatment as a part of the sentence (“court ordered”) (see APA code 3.10(c) for further discussion). In order for consent to be considered voluntary it must be given freely by the client and without coercion, duress or fraud. There can be no impingement upon the client’s ability to make a free decision. Courts, if necessary, will evaluate the psychologist’s manner, environmental conditions, and the client’s mental state (Simon, 1992).

Capacity to give consent – Legally, only competent individuals can give consent to be treated. Capacity is generally assumed unless there are court documents to prove otherwise; for example if the therapy client has a guardian or conservator. Incapacity does not prevent treatment; it does mean that the psychologist must obtain consent from the appropriate person. This is derived largely from the laws governing such transactions.

If a person is too upset to give proper consent for treatment, the standard of care allows a psychologist to delay getting consent in a crisis situation in order to provide emergency treatment. The general rule suggests getting informed consent formally at the onset (early in the treatment) unless otherwise indicated. If unsure, always seek legal or ethics consultation (Simon, 1997).

Information – This element refers to giving the information in a language and at a level the patient can easily understand. If the person’s first language is other than English, there must be a translator (family member or appropriate other) or it must be given in the language of origin. In other words, it is up to the psychologist to make certain the consent in truly “informed”.

There is no law stating what exactly has to be disclosed to the client; however, most experts agree upon the following (Bennett, Bryant, VandenBos, & Greenwood, 1992; Simon, 1997):

• Treatment approach (theoretical orientation • Treatment plan and goals • Risks and benefits • Possible alternatives (including no treatment) • Prognosis: projected outcome with and without treatment • Diagnosis (if applicable) • Limits of confidentiality and privilege • Cancellation policy • Emergency and off-hours contact policy • Payment and fee policy

Finally, as Guithiel said in 1980, “If it isn’t written down, it didn’t happen”. Document in the patient’s chart that informed consent was given, the patient agrees to treatment voluntarily, and has the capacity to consent voluntarily. Most individuals have forms that cover these issues, especially with HIPPA provisions being added recently (more later). ETHICS CODES THAT APPLY TO INFORMED CONSENT

American Psychological Association

APA 3.10 Informed Consent

• This code discusses obtaining informed consent in a language that is reasonably understandable to the person. • When persons cannot give consent (minors, incapacitated) psychologists seek “assent” or permission for legally authorized others. Welfare of patient is always the primary consideration, • With court ordered services, psychologists must inform as fully as possible including the limits of confidentiality. • Documentation of the above

APA 4.02 Discussing the Limits of Confidentiality

The limits of confidentiality are:

• Discuss at the “outset” of treatment; however “outset” is not defined • HIPAA considerations were considered here • Inform clients of risks to privacy to their records

APA 4.05 Disclosures

This principle, in section (b) states the actual limits of confidentiality as:

• Professional consultations • Danger to self or other • Other requirements by law (i.e., child, elder, dependent abuse)

APA 10.01 Informed Consent to Therapy

• This code pertains to confidentiality when the primary therapist is an unlicensed supervisee, when unrecognized and newly developing therapeutic models are being used, and informing “as soon as if feasible” the limits of confidentiality.

INFORMED CONSENT, CONFIDENTIALITY AND DIAGNOSIS

In order to set an environment for a trusting relationship, confidentiality is a must. The client must be able to depend upon the therapist to keep his or her word about intimate experiences discussed in therapy. Thus, clients must be informed about the limits to privilege and confidentiality. Clients must be informed about the risks and benefits of being given a diagnosis. Clinicians must obtain informed consent in order to release diagnostic information to insurance carriers or any other entities.

Informed Consent and Diagnosis

Denton (1989) notes concerns that diagnosing an individual may provide an excuse for personal irresponsibility. For example, a person with Alcohol Dependence allows him- or herself to use alcohol because he or she “has a disease” and has no control over this disease.

Additionally, Denton (1989) voices concern that clients get reduced to symptoms rather than recognized as unique people. Furthermore, being given a diagnosis by the clinician allows the clinician to keep a safe distance between the patient and him- or herself. For example, the clinician is able to place the patient in the category of “diseased person” while the clinician is in a separate category of “healer.” The goal here is for the clinician, in his or her fantasy, to remain protected from becoming the “diseased person.”

Other authors focus upon the negative aspects of the “identified patient” theory with the many assorted labels involved such as “scapegoat,” “enabler,” and “adult child” to name a few. Yahav and Sharlin (2002) suggest a diagnosis may reinforce the family’s perceptions of the family effort to blame one person or “scapegoat” a family member.

One question related to informed consent remains: should clinicians inform clients of all the possibilities involved in having a diagnosis in their history? For example, in a university setting, students receive extra credit for participating in counseling from the intern therapists in training at the counseling center. Generally, this is therapy without insurance reimbursement. The counselors in training get experience and the student “patients” get counseling services. The student patients are not fully informed they will receive a DSM diagnosis nor are they provided information about the future ramifications of receiving a diagnosis NOW; in fact, they do not know what diagnosis they are given (Eriksen & Kress, 2005).

Eriksen and Kress (2005) discuss the possibilities with regard to the future of these students as they become adults. What about possible court proceedings for custody, real or false accusations of domestic violence, or any other situation that could be influenced by having been given a former diagnosis of which they were unaware? (Woody, 2000).

Confidentiality and Diagnosis

Authors express concern that clients who have signed a release of information on a job application allowing a potential employer to seek the employee’s counseling information could be harmed when assigned a DSM diagnosis. For example, such a client could lose the opportunity for a desired job or promotion should the employer choose not to hire or promote individuals with certain diagnoses (Corrigan; Couture & Penn, 2003).

For example, in one placement service (see Erikson & Kress, 2005, p. 15), a number of large companies regularly ask questions about psychiatric histories and assessments of potential hires as part of the interview process. Large companies justified this practice by claiming to identify drug addicts or antisocial individuals who were “likely to steal or lie” (Eriksen & Kress, 2005).

Revealing Diagnoses to Insurance Companies

Since this is such a vast topic it will be covered thoroughly in a separate section. However, it must be mentioned here that it is important to inform clients about the risks of revealing diagnostic codes to insurance companies and HMOs. Eriksen and Kress (2005) note:

Once insurance reimbursement requests are submitted with the required diagnosis, the client’s diagnosis is entered into a central information bank. If the client changes employers or wants to change insurance companies, and submits another insurance claim form, the new company may consult this central information bank to discover if the client has a preexisting condition If the new request has the same diagnosis as the request previously submitted, the employer or company may not pay for the preexisting condition at all… (p. 18)

The problem here is that some insurance companies do not want to pay for the treatment of disorders that pre-dated the start of coverage by their insurance policy for that client. Although this position is understandable, it is extremely difficult and economically limiting for the insured and his or her family (Kjorstad, 2003; Sherer, 2003).

Informing Clients of Risks of Failing to Diagnose

Some clients and their families are relieved to receive a diagnosis so that they can finally gain an understanding of their problem. They report feeling they can stop “beating themselves up” for not handling their lives better or their problems more successfully. It may lead to ways of managing their lives with less blame and more willingness to participate in a treatment plan (Denton, 1989).

Loss of benefits is a very real issue for clients who are not assigned a DSM diagnosis. For example, without a diagnosis, insurance companies will not reimburse treatment and psychotherapy and medication become an out-of- pocket expense (Anderson, 2000; Kjorstad, 2003; Sherer, 2003). Often, families cannot afford medication or therapy without insurance reimbursement. Furthermore, it becomes difficult to communicate with other professionals without the benefit of a DSM diagnosis and a mutual language. For instance, without a diagnosis, those in need of psychiatric medication or hospitalization, especially those who require involuntary commitment to a hospital, might not be eligible and could become homeless and/or dangerous (Fisher, 2002).

Without a formal DSM diagnosis, those who have committed a crime as a result of a mental disorder could not be found incompetent to stand trial due to that mental disorder. Indeed, children could not qualify for special services in school settings (Anderson, 2001). Various clients might not qualify for social security mental health benefits, disability benefits, day treatment resources, and other basic living skill training necessary to live a better quality of life (Rogers, MacDonald-Wilson, & Massaro, 2003; Steyn, Schneider, & McArdle, 2002).

Thus, failing to use a DSM diagnosis can be a severe problem for a client and prevent an individual from needed services.

Responsible Informed Consent

Psychologists must present to clients a balanced discussion of the risks and benefits of giving a diagnosis when asking a client to make informed choices about psychotherapy. Clients must be made aware of the diagnostic process, how clinical decisions are made, what the terminology means, the long term ramifications, and the ultimate risks and benefits involved.

Eriksen & Kress (2005) recommend the clinician be guided by his or her theoretical orientation, work setting, client needs, DSM diagnosis, personal ramifications to the client of receiving a diagnosis. “The decisions about how much to discuss about diagnosis during the informed consent process is ultimately based on the practitioners’ clinical judgment” (p. 22).

Question

Since there are so many serious risks involved in giving a client a DSM diagnosis, most experts in the literature suggest it would probably be best not to use the DSM at all.

a. TRUE b. FALSE

See Section D – review general tone of section for answer to this Question

ANSWER – Naturally, the answer here is (b) FALSE. Even though the literature evaluates more negative aspects of diagnosing than positive aspects, the bottom line is that the DSM is a valuable document that aids clinicians in helping clients to get services. PATIENT RECORD KEEPING GUIDELINES

Stromberg et al (1988), a group of eight attorneys who were consulted by the APA in the 1980s, said it well: “Detailed records usually help rather than hurt a health care professional in defending against claims… sloppy, sparse records … appear unprofessional, uncaring, haughty or deceptive” (p. 487). The primary purpose in keeping records is continuity of patient care in the event the psychologist must transfer care to another professional. Other purposes include review of the delivery of services, self-monitoring, documentation of what is working, and progress of the patient. In essence, properly kept records enhance the treatment and protect the psychologist from litigation and spurious ethics and licensing allegations.

Psychotherapists are required to know the laws for record keeping in his or her state. For example, the California Association of Marriage and Family Therapists attorneys Benitez and Pelchat (2006) note California has no statutes delineating exactly what must be kept in patient records for California social workers or marriage and family therapists. However, “requirements for record keeping can be inferred from another section of California law – what must be included in a summary of the patient’s treatment” (p. 89). California Health & Safety Code 123130, provides the basics of Summary of Patient Records:

• Chief complaint or complaints including pertinent history • Findings from consultations and referrals to other health care providers • Diagnosis, where determined • Treatment plan and regimen including medications prescribed • Progress of the treatment • Prognosis including significant continuing problems or conditions • Pertinent reports of diagnostic procedures and tests and all discharge summaries • Objective findings from the most recent physical examination, such as blood pressure, weight, and actual values from routine laboratory tests

How Long Should Patient Records be Retained?

Once again, each mental health professional is required to know laws regarding retention of patient records in his or her state. According to California law, under Business & Professions Code 4982(v), 4992.3(s) “It is unprofessional conduct to fail to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered” (effective 1/1/00). California Health & Safety Code 123145 requires that certain entities retain patient records at least seven years after cessation of services or at least one year past majority. What this actually requires is that clinics and hospitals and other entities mentioned in this law must keep the records of minors at least one year after majority (18 years old) and a minimum of seven years. Most states have similar record keeping laws. NEW CALIFORNIA LAW FOR PSYCHOLOGISTS

Many states are in the process of updating laws regarding private practice record retention. California has been one of the states that has never had a statute for private practice record retention. The California legislature recently passed an Assembly Bill 2257 recently signed into law record retention law for PSYCHOLOGISTS only beginning January 1, 2007 stating:

A licensed psychologist must retain a patient’s health service records for a minimum of 7 years from the patient’s discharge date, and would also require a minor patient’s records to be retained for a minimum of 7 years from the date the patient reaches 18 years of age. Violation of the bill would be a crime…”

Unusually, prior to this new bill, there was no California law that dictated how long private practice psychologists and other clinicians were to retain patient records. Experts maintain psychologists should follow the Specialty Guidelines for the Delivery of Services (1981) when there is no state statute that gives absolute guidelines to follow (Caudill & Pope, 1995; Stromberg et al., 1988; Bennett, 1990).

Specialty Guidelines for Delivery of Services Prior to AB2257:

a. Full records be kept for 3 full years b. Full or summary records be kept for additional 12 years c. Records kept for a total of 15 years

In other words, in states where there are no state laws for private practice record retention, psychologists are to follow the Specialty Guidelines of 1981, despite their old age!

Question

How long should California psychologists keep private practice records according to Assembly Bill 2257 effective January 1, 2007?

a. Seven years after cessation of treatment b. Ten years after cessation of treatment c. Fifteen years after cessation of treatment

See Section D – Review “New California Law” for answer to this Question

ANSWER - The best answer is (a) seven years after cessation of treatment. This is new California law.

Chart Notes There are many good treatment planners aiding clinicians in preparing chart notes (see The Adult Psychotherapy Progress Notes Planner by Arthur E. Jongsma, Jr.; Therapist’s Guide to Clinical Intervention by Sharon L. Johnson) for detailed descriptions. All psychotherapy notes are under subpoena and court order. There is no such thing as what are sometimes called “shadow notes” which refer to personal notes the psychologist takes and uses for consultation, counter-transference consultation, and peer supervision groups. Any notes that have to do with a specific patient may be subject to subpoena (Caudill & Pope, 1995; Thompson, 1990; Bennett et al., 1990). In fact, Thompson (1990) notes, “Many therapists keep shadow notes containing personal speculations… the legal status of such records is largely undetermined” (p. 111). Psychologists must know case law and get consultation from experts on a case-by-case basis.

Stromberg et al (1988) take a very strong stance in this area. They note many psychologists are under the false belief that “process” notes are private and the property of the psychologist. This couldn’t be more untrue according to these attorneys (Stromberg et al (1988). However, in the terminology, “progress” and “process” notes are considered different. HIPPA now refers to “process” notes as “psychotherapy” notes.

PROCESS/PSYCHOTHERAPY PROGRESS NOTES NOTES Less for defending oneself Solid treatment plan documentation

More for documenting therapy Especially in crisis situations relationship Safety planning in crises Follows one’s theoretical orientation based upon the research Public record of goals set…goals met

Thoughts, hunches, speculations Decision-making

Question

Psychologists can keep their own personal thoughts about a patient in personal files at home. These are separate from “progress” notes.

a. TRUE b. FALSE See Section D – Review “Chart Notes” for answer to this Question

ANSWER - All record information is the property of the patient (b) false and there is no such thing as “shadow” records or keeping private records at home.

HIPAA AND PATIENT RECORDS

Once again, there are numerous courses both online and in person where psychologists can learn how to become HIPAA compliant. Here, the basics will be discussed in order to integrate record keeping into the discussion with HIPAA compliance.

The Health Information Portability and Accountability Act (HIPAA) dictates therapists to follow new and complicated federal guidelines with regard to confidentiality of patient records for storage, informed consent, employee training, security of records, and certain electronic transactions of patient information. Normally federal law supersedes state law; with regard to HIPAA, psychologists are instructed to follow whichever law most adequately and completely protects patient’s privacy more completely. Psychologists are required to study both federal and state laws that are applicable and decide which ones supersede the others! Fortunately, many available courses do this work for clinicians.

Electronic transmission refers to computer transmission of information and computer faxes, not telephone lines nor free standing fax machines. If you receive or send patient information via your computer, either by a computer fax or email, you are required, under federal law, to be HIPAA compliant. If you use telephone lines verbally, free standing faxes, or snail mail for transmission of patient information, you are not required to be HIPAA compliant. However, if you use any billing service that does any such transactions via computer lines or computer faxes, then you are required to make your office HIPAA compliant even if you personally do not transmit information via the electronic methods included in HIPAA. Additionally, you are required to have a contract with the billing agent guaranteeing he or she is, indeed, following HIPAA guidelines on your behalf.

HIPAA’s purpose is to “cut back” on paperwork by using primarily computer storage and transactions. Some experts say all psychologists will eventually have to be HIPAA compliant whether or not they make electronic transactions (as in New York state). Stay tuned!

HIPAA HIPAA PROCESS/PSYCHOTHERAPY PROGRESS NOTES NOTES Private notes of the psychologist Readily available to insurance not readily available to insurance company and patient company and patient Records must be separated into Records must be separated into two different and distinct file folders two different and distinct file folders Subpoenable Subpoenable Available by Court Order Available by Court Order

Question

HIPAA refers to a group of federal laws that supersede state laws except when:

a. State laws are less protective of patient’s confidentiality b. State laws never supersede federal laws c. State laws are more protective of patient’s confidentiality

See Section D – Review “HIPAA and Patient Records” for answer to this Question

ANSWER: As mentioned earlier, HIPAA are federal laws that often, but do not always, supersede state laws. The exception is when state law gives more protection to the patient’s confidentiality rights. Thus, answer (c) is the best answer here.

APA ETHICS CODES THAT APPLY TO RECORD KEEPING

American Psychological Association Code of Ethics

APA 6 Record Keeping and Fees

(Please see codes within APA 6 that apply as we go along)

APA 6.01 Documentation of Professional & Scientific Work & Maintenance of Records

The idea here is to:

• Facilitate provision of services later if needed to the client by other professionals • To allow for replication of research • To aid in accuracy of billing • To ensure compliance with law

APA 6.02 Maintenance, Dissemination, & Disposal of Confidential Records of Professional & Scientific Work

• This is related to storage of records in databases using coding systems. APA 6.03 Withholding Records for Nonpayment

• It is unethical to withhold payment when the records are required for emergency or crisis work.

APA 6.06 Accuracy in Reports to Payors & Funding Sources

• Records, insurance information, and billing are done accurately and appropriately. The idea here is to avoid billing for a false diagnosis (Axis I 300.4 Dysthymic Disorder) that is commonly and universally paid for by the insurance company rather than what is actually being treated (V61.1 Partner Relational Problem) which may not be covered by insurance because a V-code is “a condition, not a mental disorder.” This is insurance fraud and a severe license and ethics violation.

REFERENCES

Anderson, C. (2000). Dealing constructively with managed care: Suggestions from an insider. Journal of Mental Health Counseling, 22(4), 343-354.

Anderson, C. (2001). The role of managed mental health care in counseling gifted children and families. Roeper Review, 24(1), 26-32.

APA. (1981). Specialty Guidelines for the Delivery of Services. Washington, DC: Author.

Bennett, B., Bryant, B., VandenBos, G., & Greenwood, A. (1990). Professional Liability and Risk Management. Washington, DC: APA.

Benitez, B. & Pelchat, Z. (2006). Recordkeeping. Compendium: A Collection of Articles Concerning the Legal & Ethical Obligations of CAMFT Licensees, Interns, & Trainees. San Diego: CAMFT.

Berner, M. (1998). Informed consent. In L. Lifson & R. Simon (Eds.), The Mental Health Practitioner and the Law (pp. 23-43). Cambridge, Mass: Harvard University Press.

Campbell, C., & Gordon, M. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research & Practice, 34, 430-434.

Corey, G., Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions. Belmont, CA: Brooks/Cole. Corrigan, P. (2003). Perceptions of discrimination among persons with serious mental illness., Psychiatric Services, 54(8), 1105-1110.

Couture, S., & Penn, D. (2003). Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health, 12,(3), 291-306.

Denton, W. (1989). DSM-III-R and the family therapist: Ethical considerations. Journal of Marital and Family Therapy, 15(4), 367-377.

Fisher, C. (2002). A goodness-of-fit ethic of informed consent. Urban Law Journal, 30, 159-171.

Fridhandler, B. (2004). Informed consent. Expertise Series: Division of Clinical and Professional Practice, CPA. Sacramento: CPA

Guralnik, D.B. (Ed.) (1983). NY: Warner

Guthiel, T. (1980). Paranoia and progress notes: A guide to forensically informed progress notes. Hospital and community Psychiatry, 31,479-482.

Johnson, S. (1997). Therapist’s Guide to Clinical Intervention. London: Academic Press.

Jongsma, A. (2001). The Adult Psychotherapy Progress Notes Planner. NY: Wiley

Kjorstad, M. (2003). The current and future state of mental health insurance parity legislation. Psychiatric Rehabilitation Journal, 27(1), 34-43.

Rogers, E., MacDonald-Wilson, K,., & Massaro, J. (2003). Identifying relationships between functional limitations, job accommodations, and demographic characteristics of persons with psychiatric disabilities. Journal of Vocational Rehabilitation, 18(1), 15-25.

Sherer, R, (2003). The mental health care parity debate continue. Psychiatric Times, 20(5), 1-3/

Simon, R. (1992). Psychiatry and law for clinicians. Washington, DC: American Psychiatric Press, Inc.

Steyn, B, Schneider, J. & McArdle, P. (2002). The role of disability living allowance in the management of attention deficit/hyperactivity disorder. Child: Care, Health, and Development, 28, 523-528. Stromberg, C. (et al.) (1988). The Psychologist’s Legal Handbook. Washington, DC: The Council for the National Register of Health Care Providers in Psychology.

Woody, R. (2001). Psychological information: Protecting the right to privacy: A guidebook for mental health practitioners and their clients, Madison, CT: Psychosocial Press.. www.apa.org (HIPAA compliance instruction) .

Yahiv, R., & Sharlin, S. (2002). Blame and family conflict: Symptomatic children as scapegoats. Child and Family Social Work, 7(2), 91-99. LEARNING OBJECTIVES FOR SECTION E

• To understand and apply proper financial arrangements • To understand and apply federal parity laws • To gain understanding and awareness of ethical issues surrounding managed care, diagnosis and billing

FEES AND FINANCIAL ARRANGEMENTS

Finances are difficult for most psychologists who would much rather be doing the work of psychology than discussing how much they are going to charge per session hour or debating with clients over fees and diagnoses. Often the collection of fees takes a back seat to clinical considerations. Most clinicians rely upon practice income to pay current living expenses; thus regular collection of fees is mandatory.

Stromberg et al (1988) suggest several basic principles to maximize effective billing and collection whether or not the client is utilizing an HMO or PPO for insurance coverage:

• Inform at the outset what the fees are and when they will be paid • Wherever possible, require payment at time of session • Maintain careful accounting records so money does not “slip through the cracks” • Render statements to patients in a timely manner • Issue appropriate reminders regarding unpaid bills • Openly discuss with patients possible resolution of payment problems prior to accounts becoming overdue

During a first evaluation, financial considerations should be discussed and a permanent fee should be set. Many psychologists customarily raise their fee annually along with either the cost of living, or the cost of the increase in their rent. Whichever the case, this must be discussed in advance so the patient can consider this in entering long-term treatment. Most clinicians include these issues on the informed consent form or at the intake at the outset of treatment.

ETHICS CODES THAT APPLY TO FINANCIAL ARRANGEMENTS

Principle B–Fidelity & Responsibility

• The suggestion here is to contribute a portion of time for work that returns little or no remuneration or financial compensation.

APA 6.03 Withholding Records for Nonpayment

• This code states records may not be withheld due to nonpayment if they are needed for emergency treatment.

APA 6.04 Fees & Financial Arrangements

• Discuss fee structure as early as is feasible • Discuss fees honestly • Discuss limits in services at the start (i.e., HMO refusals) • If collection services are used, patient is informed first and given opportunity to make arrangements

APA 6.06 Accuracy in Reports to Payors & Funding Sources

• Accurately report information to any and all funding sources

APA 6.07 Referrals & Fees

• Psychologists may pay referral services for referrals, but cannot pay a service or person for each patient referral. For example, one can pay an annual fee to be part of a referral service. One cannot pay the referral service for each patient they refer.

INSURANCE FRAUD

It is extremely important to avoid any hint of impropriety in billing practices. This includes putting all information into the chart so no misrepresentation of the facts can occur. If something is left out of the chart for some legitimate reason, simply chart it with the correct date it is being placed into the file with the notation that it actually occurred on a previous date. Never “fudge” the date or try to force something into the file that does not belong. It makes the entire record suspect and subject to question.

Intentional Misdiagnosis of Mental Disorders Managed care has significantly impacted the income and billing practices of psychotherapists. Managed health care guidelines can determine whether or not the patient or therapist gets reimbursed or receives or is denied psychological care (Braun & Cox, 2005). Since clients may not be able to afford out-of-pocket fees, it becomes important to resist the temptation to “agree to submit inaccurate mental health diagnoses that are reimbursable so that clients can receive counseling” (Braun & Cos, 2005). Wylie (1995, p. 22) called this practice “diagnosing for dollars.”

Many mental health practitioners consistently try to meet the requirements of the managed care organizations for which they work, but they do not necessarily think that the managed care system is effective (Braun & Cos, 2005). When surveyed (Smith, 1999) about their satisfaction in working with managed care:

• 42% of licensed professionals were either very satisfied (6.6%) or were at least somewhat satisfied (35.7%) • 47% were not satisfied

Danzinger & Wolfe (2001) note that the majority of mental health workers perceived managed care requirements as a negative impact on the therapy practices.

Ethical and Legal Issues with Managed Care

There are both negative and positive outcomes of the managed care situation. Managed care allows those individuals who might not otherwise seek treatment for mental disorders to afford such services. However, it also limits the amount of treatment due to the requirement for “medical necessity” in order to warrant more than a handful of sessions. Case management and review boards determine whether services are granted and decide whether services are effective (Kiesler, 2000). Mental health professionals involved with managed care struggle to maintain a balance between the demands of the managed care system and their obligations to clients.

Below are various actions that are considered insurance fraud:

• Giving an “insurance diagnosis” rather than the real diagnosis This means giving a diagnosis that is meant to meet the specifications of the insurance company for reimbursement rather than the correct and actual diagnosis that may not receive reimbursement from the insurance company. For instance, some insurance companies and managed care companies will not pay for Axis II Personality Disorders due to their long- term nature. Some will not pay for V-Codes either (e.g., parent-child issue) because, by definition, they are “condition not due to a mental disorder” even though they can be helped by treatment from a mental health professional. Many psychotherapists believe this is a rather short- sighted view taken by some insurance companies.

• Changing the start date of treatment to avoid pre-existing conditions Sometimes a patient, with the best of intentions will request a psychologist change or alter the start date of treatment to coincide with the start of his or her insurance coverage at a new job. For example, if treatment begins with the therapist on September 1 but the patient’s insurance does not begin until October 15, the client may ask the psychologist to “pretend” as if therapy began after the insurance became effective. The effect of this endeavor is to try to eliminate any pre-existing conditions. o A pre-existing condition refers to any medical or mental health diagnosis that was being treated prior to the insured person’s new carrier’s coverage taking effect o Insurance carriers can only refuse to cover pre-existing conditions when the insured person is paying for “individual” coverage – no pre-existing clauses are legal in California with group insurance coverage

• Missed sessions Insurance companies will not pay for unattended sessions. It must be indicated on the billing form which, if any, sessions have been unattended in order to be billing ethically and legally. Indeed, if the psychologist is billing parents for a teen’s therapy sessions, clear this up in advance with regard to the confidentiality of the minor so the minor does not view billing statements to parents as a breach of confidentiality. Otherwise, billing statements to parents or guardians could actually be a breach of confidentiality in that they disclose to others individuals the status of attendance of the minor patient. Please note, this is true when any third party is paying for a patient’s sessions (husband, wife, domestic partner).

• Billing at an accurate fee Psychologists may not bill at any other rate than that being charged to the patient. It is unethical and illegal to try to collect the entire fee through charging a higher rate to the insurance company. The insurance company will pay their co-payment dependent upon your bill or their contract with the patient or his/her employer; thus your bill must be accurate. Some well-meaning psychologists will try to bill at a higher rate to collect the entire co-payment from the insurance company so the patient does not have to pay any fee. This is considered insurance fraud. PARITY DIAGNOSES

History of Parity

According to Otten (1998), insurance parity coverage for mental illness demands the same benefits and the same limits for mental illness as for other types of illnesses and diseases. Federal legislation was implemented on January 1, 1998 mandating a limited parity in employee health benefit plans covering mental illness.

Many states had already established parity prior to federal enaction in 1996. The National Alliance for the Mentally Ill (NAMI) convened a meeting of experts who had firsthand knowledge of the effects of parity in June of 1996. “Participants included officials of states that required parity laws for treating mental illness in employee health plans, executives of self-insured corporations that offer some sort of parity to their own employees and of firms that manage behavioral health care coverage, federal officials and researchers who were assessing evidence from states and employers for its relevance in implementing the new federal parity legislation, researchers and advocates” (Otten,1998, p. 3).

Each state has made its own statutes regarding the Mental Health Parity Act and their version of compliance and conformity with this act. Most psychologists can easily become familiar with the diagnoses that are included within the parity diagnoses that are exempt from limitations by managed care and/or insurance company dictates with regard to number of sessions or amount of treatment.

In 2000, California enacted Assembly Bill 88 where nine specific diagnoses were included in the exempt category referred to as “severe mental illnesses” (SMI) and “serious emotional disturbance” (SED) that are to be treated with the same status as severe physical illnesses in that state as far as unlimited treatment is concerned. These diagnoses stem from the DSM-IV-TR:

• Schizophrenia • Schizoaffective Disorder • Bipolar Disorder • Major Depressive Disorder • Obsessive Compulsive Disorder • Panic Disorder • Eating Disorders • Serious Emotional Disorders in Children and Adolescents • Pervasive Developmental Disorder

However, various insurance companies include other diagnoses on their own list of parity diagnoses. Riemersma (2001) breaks it down further with regard to children: Serious emotional disturbances of a child are defined as:

A child who has one or more mental disorders identified in DSM-IV, other than a substance use or developmental disorder, which results in behavior inappropriate to the child’s age according to expected developmental norms. Members of this target population shall meet one or more of the following criteria:

1. As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community; and either of the following occur:

• The child is at risk of removal from home or has already been removed from home. • The mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment.

2. The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder. 3. The child meets special education eligibility requirements under chapter 26.5 (Riemersma, 2001, p.18).

Mental Health Professionals Can Appeal Denials

It is possible to appeal the denial of an insurance company who is unwilling to reimburse for parity services citing these sections:

• Health Care Services Plans (Managed Care Organizations) California Health & Safety Code 1374.72 • Disability Insurers (Indemnity Insurance Plans) California Insurance Code 10144.5

To have the greatest impact, one must write a professional, well-written letter of appeal that creates a clear paper-trail.

Accuracy in Diagnosing

Mental Health Professionals are expected to accurately diagnose their clients in all cases and no matter what reason the psychologist might have. There is a temptation to “stretch” symptoms to fit parity diagnostic categories in order to achieve easier billing and to assure receipt of sessions. Some authors claim practitioners only marginally invest in the process of using the DSM diagnostic process and see it as a game to be played, allowing them to misrepresent their work to third parties such as insurance companies (Danzinger & Wolfe, 2001; Kanapaux, 2003). Clients who can pay without insurance assistance allow their therapists to feel less bound to give a DSM diagnosis as it becomes irrelevant.

Socioeconomic Status and Diagnosis

How do ethics enter into the process of diagnosis when socioeconomic level is concerned? When middle or lower socioeconomic status clients enter therapy it is unlikely they will be able to afford the full psychotherapy rates charged without insurance reimbursement. Additionally, most practitioners will be unable to continue to stay in practice without maintaining a level of paying clients who can afford to pay the normal fees charged. This entire process requires giving a client a DSM diagnosis (Cohen, 2003; Danzinger & Wolfe, 2001).

Does the ability for a psychotherapy client to pay out of pocket lessen the “game playing?” If so, does socioeconomic status stimulate misrepresentation? In other words, is it likely that clinicians feel the need to give more parity or more serious diagnoses to certain clients who cannot afford out of pocket treatment fees so that they can receive services? Some ask the question is it possible diagnosticians are discriminating among their lower socioeconomic clients in order to get them services. One ramification is that this practice initially seems like a humanistic idea, but actually may not serve clients in the long run if a serious diagnostic label lurks in their history (Eriksen & Kress, 2005).

Statistics

In survey research, a number of practitioners admit to committing insurance billing fraud. In anonymous surveys, Danziger and Welfel (2001) found that 44% of respondents admitted they had changed or would change their client’s diagnosis in order for the client for to qualify for additional HMO reimbursement of services.

Couple and family therapists admitted to providing Axis I diagnoses for reimbursement such as Dysthymic Disorder when there was no such diagnosis when they were actually performing couples or family services with no Axis I disorder evident for any family member. Why questioned, the clinician admitted giving a false diagnosis on Axis I was done primarily to receive reimbursement for services rendered to the couple or family (Mead, Hohenshil, & Singh,1997).

Under-diagnosing

Mental health professionals, in an attempt to protect clients from the stigma of specific diagnoses such as Axis II Borderline Personality Disorder, will avoid diagnosing certain diagnoses. They will assign less severe diagnoses despite the fact that the full criteria for another more severe or stigmatizing diagnosis is met (Cooper & Gottlieb, 2000). Indeed, often an Axis I diagnosis is used for reimbursement despite the fact that the clinician is actually treating an Axis II Personality Disorder which is not be reimbursable. Many clinicians will submit the Axis I diagnosis for reimbursement because it is less stigmatizing and will not “follow” the client throughout his or her life.

WHY DO CLINICIANS MISREPRESENT DIAGNOSES?

Advocacy for Clients

Some clinicians assign a diagnosis that they believe is helpful to a client in order to fulfill the clinicians own moral stance. They may believe that insurance companies or HMOs should pay for psychotherapy from a moral and ethical point of view. These therapists are engaged in a sort of rebellion or civil disobedience against a flawed process (Laungani, 2002).

Pressure from Clients

Pressure from clients who are desperate for psychotherapy and cannot afford out-of-pocket fees is another reason given by practitioners for misrepresenting DSM diagnoses to insurance companies and managed care organizations. Therapists believe their misrepresentations are a form of caring for their clients’ welfare who feel a desperate need for services but are unable to afford psychotherapy services if required to pay without any insurance reimbursement (Mead et al., 1997). Indeed, some therapists reported if they did not give a reimbursable diagnosis, some other psychotherapist would (Denton, 1989).

Financial Incentive/Multiple Relationship

Part of the difficulty of private practice work is earning a living and getting referred clients who can pay for therapy. Practitioners are invested in receiving money from clients, keeping clients for financial reasons, and maintaining a steady stream of referred clients. Sometimes this need for an income from patients may conflict with insurance billing and diagnosing patients (Catalano, Libby, Snowden, & Cuellar, 2000). It could be considered a multiple relationship when one is trying to maintain a relationship with the insurance company simultaneously, use proper and ethical diagnostic techniques, and balance one’s own financial interests.

Question

The federal government developed “parity” diagnoses in order:

a. To make billing insurance companies easier b. To allow V-Codes to be fully reimbursed c. To make some DSM diagnoses on par or equal with medical diagnose

See Section E – Review “History of Parity” for answer to the Question

Question

The following are all insurance fraud EXCEPT:

a. Billing for a parity diagnosis b. Billing for a missed session without indicating it was unattended c. Treating a couple and billing it on Axis I as Dysthymic Disorder

See Section E – Review “Missed Sessions” & “Insurance Diagnosis” for answer to this Question

ANSWERS - the answer to Question 17 is (c) on par with medical diagnoses; the answer to Question 18 is (a) billing for a parity diagnosis. Billing for missed session without indicating it was unattended (b), and treating a couple which is a V-Code and billing it as if it is an Axis I single individual (c) are both illegal and unethical practices considered insurance fraud.

PSYCHOTHERAPY IN A MANAGED CARE ENVIRONMENT

Fee-For-Service versus Managed Care

In the distant past, many unethical psychologists practiced under the assumption “the longer a patient is in therapy, the better” strictly for financial reasons. The managed care environment saw an opportunity to lure big business away from allowing patients to make psychotherapy choices for themselves. They seized the moment by suggesting to big business they stop allowing their employees to choose their own psychotherapists in a fee-for-service approach (Eriksen & Kress, 2005).

FEE-FOR-SERVICE MANAGED CARE

Collaboration between Collaboration between therapist, client therapist and client and managed care company Fee set by therapist and client Fee set by managed care company No outside review Continued sessions depend upon outside reviewer at managed care Collaboration between Collaboration between therapist, client therapist and client and managed care company Length and duration of Time-limited interventions interventions are unlimited based upon managed care decisions

Managed Care and Ethics

As mentioned earlier in this course, managed care is in charge of what DSM diagnoses they choose to reimburse and which diagnoses they refuse to reimburse. This sets psychologists up to view managed care with contempt and/or disdain when a patient does not “fit” the system of reimbursement set up by the managed care company.

MacCluskie and Ingersoll (2001) succinctly come to the point:

This is not to imply that managed care is unethical care; only that in the context of managed care, the motives for decision making are primarily economic. Economic parsimony does not necessarily constitute unethical behavior unless it sacrifices the sufficiency or quality of care in the process. (pp. 102-103)

Managed care is driven by economics as most other businesses. Most managed care practices are characterized by a primary interest in reducing costs over quality of care. Cost containment and profitability are primary concerns with consumer needs secondary issues (Davis & Meier, 2001; Shore, 1996).

In her discussion of the ethical issues in managed care, Austad (1996) reviews the financial incentive in the unethical practice of withholding treatment from patients to increase dividends. When psychotherapists are offered a share in the profits at the end of the year that are not spent on patient care, it become very tempting to cut therapy short in order to reap a financial dividend. This is CLEARLY a conflict of interest that is unethical and opposed to patient welfare. Austad (1996) notes therapists and managed care companies under-serve patients in the following ways:

• Deny and limit access to long-term therapy • Narrow clients’ choice of therapists • Disrupt continuity of care • Rely on less-qualified providers to provide services • Use less-qualified providers to review care • Breach client confidentiality by giving reviewers too much personal information about clients • Base practices on a business ethic instead of a professional ethic

Four Ethical Issues Associated With Managed Care

Issue One – Informed Consent. Glosoff, Garcia, Herlihy, and Remley (1999) note clients who are being seen under the managed care system are especially vulnerable to problems with informed consent. It is up to the clinician to make certain clients understand any policies or arrangements with managed care systems that are pertinent prior to beginning the therapeutic relationship. For this reason, the informed consent procedure must be as clear as possible (Cooper & Gottlieb, 2000).

It is important to let the managed care client know what alternative forms of treatment – perhaps other forms of treatment that might be more successful or helpful to the client outside of their managed care system – are being denied to them solely for cost-containment reasons. The client has a right to be fully informed. Ethical practices demand that providers inform clients of all treatments available whether they are being offered by their managed care company or not (Corey, Corey, & Callanan, 2007).

Issue Two – Confidentiality. Confidentiality is not considered to be absolute in the managed care environment within the therapeutic relationship. Davis and Meier (2001) note “while maintaining confidentiality has always been a cornerstone of counseling and psychotherapy, for some managed care companies, it is unfamiliar terrain” (p. 42). These authors note that clients in therapy managed by HMOs may withhold crucial information, or not seek treatment, for fear therapists may disclose sensitive personal information to institutional review boards (Acuff et al., 1999).

The demand for client information inherent in managed care far exceeds fee-for- service limitations to confidentiality. Clients should be made aware that managed care contracts may require therapists in their network to reveal sensitive client information in order to authorize initial or additional sessions (Corey, Corey, & Callanan, 2007).

Clinicians have very little control over client information after it leaves the office of the clinician. Since practitioners are required to submit various levels of treatment records before payment is issued, therapists often work with the managed care company as a third party in the consulting room. Some professionals claim that managed care has the effect of eroding the traditional sense of confidentiality between client and therapist (Hering, 2000).

Issue Three – Abandonment. The APA instructs psychologists not to abandon patients (see below). Termination is a collaborative effort in the best of circumstances. Termination should not occur because the managed care utilization review board makes a financial decision to deny the psychologist’s request for needed additional sessions. The bottom line is that that additional session may or may not be granted by a non-therapist reviewer at the patient’s managed care company based upon economics, not necessarily based on standard of care or patient need.

In numerous HMOs members are granted 20 sessions annually, with lifetime caps for mental health care. Despite the possibility of 20 sessions, the client may only be granted 6 sessions no matter what diagnosis is given (unless a parity diagnosis is given – see parity discussion). It is essential to apply for additional sessions well in advance of the last authorized session to avoid unethical and/or illegal patient abandonment (Cooper & Gottlieb, 2000).

The policy of forcing the psychologist to seek sessions in a timely manner prior to treatment running out shifts the responsibility and the risk onto the psychologist such that psychologists are ethically and legally obligated to offer standard of care services to clients in order not to abandon them. In other words, if the HMO denies sessions, the psychologist is still the first line of defense with regard to patient abandonment (Haas & Cummings, 1991).

One colleague told this author she complained to a well-known managed care company because they refused her suicidal bipolar patient continued sessions. The HMO responded quickly to her complaints in this way: “Well, we can’t give anymore sessions. You decide what to do, it’s your license, Doc!”

Issue Four – Utilization Review. Utilization Review is the use of pre-defined criteria at the managed care company to evaluate the need for treatment and/or continued treatment for the client. The people who do this job look for treatment necessity, appropriateness of therapeutic intervention, and therapy effectiveness. This takes place anywhere along the way (Cooper & Gottlief, 2000).

People on the Utilization Review Staff make decisions about the duration of treatment, types of treatment, setting of treatment, if the psychologist is doing an effective job, if the client is improving, and continuation of treatment. The “reviewer” weighs the needs of the patient with the cost-effectiveness of the treatment. This is generally done by way of written documentation that is routinely sent to the HMO by the psychologist before the last few sessions are completed.

One primary disadvantage of this model is that routine telephone reviews generally take place that force the clinician to be available, wait by the phone, and make office time for the call. This procedure is repeated for numerous patients, for various managed care companies, each time more treatment sessions are requested (Davis & Meier, 2001). Additionally, there is no guarantee the person making the decisions about the outcome of the patient is competent to do so. Often the reviewer is (a) not a clinician, (b) not a psychologist, or (c) may not even have a bachelor’s degree in psychology. What makes the reviewer competent to make a clinical decision about a patient? It is a good idea to get this information (Corey, Corey, & Callanan, 2007).

REFERENCES

Acuff, C., Bennett, B., Bricklin, P., Canter, M., Knapp., S., Moldawsky, S., & Phelps, R. (1999). Considerations for ethical practice of managed care. Professional Psychology: Research and Practice. 30(6), 563-575.

American Psychological Association. Committee on Accreditation. (2002). Self- study directions for doctoral programs. Washington, DC: Author.

American Psychiatric Association. (2008). Current activities: Report of the DSM-V task force (September, 2008). (downloaded 1/17/10 www.psych.org/MainMenu/Research/DSMV/DSMRevisionActivities/TaskForceR eports.aspx)

Applebaum, P., & Guthiel, T. (1991). Clinical Handbook of Psychiatry & Law. Baltimore: Williams & Wilkins.

Austad, C. (1996). Is long-term psychotherapy unethical? Toward a social ethic in an era of managed care. San Francisco, CA: Jossey-Bass.

Braun, S., & Cox, J. (2005). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling & Development, 83, 425-433.

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Wylie, M. (1995, May-June). The power of DSM-IV: Diagnosing for dollars. Family Therapy Networker, 22-32. LEARNING OBJECTIVES FOR SECTION F

• To gain awareness of multicultural challenges when using the DSM • To gain awareness of California law with regard to discrimination • To gain awareness of APA ethics codes with regard to discrimination and pro bono and sliding-fee services

The goal of experts in the area of multicultural counseling is to blend diagnostic skill, knowledge, multicultural awareness, and gender sensitivity with scholarship and political concerns (Eriksen & Kress, 2005). This clearly includes sensitivity to the following:

• Race • Ethnicity • Age • Differences in physical abilities • Gender • Religious differences • Sexual orientation • Social and economic differences

APA ETHICS CODES THAT APPLY

There is a very strong suggestion for psychologists to carry out their responsibility to participate in activities that contribute to a better community, society and environment by devoting part of their professional activities to services for which there is little or no financial return. Principle B, as mentioned previously and again below, directs psychologists to provide pro bono services where possible. This may include a variety of professional activities:

• Volunteering • Consulting for clinic clients • Donating supervision hours to interns or trainees • Lecturing on one’s expertise or specialty at no fee • Working on professional committees (no financial return)

Principle B–Fidelity & Responsibility

• The suggestion here is to contribute a portion of time for work that returns little or no remuneration or financial compensation.

Pro Bono and Sliding Fee Services

In order to give back to the community by those who have opportunities others may not have, psychotherapists are expected to provide pro bono or sliding fee services. The idea is to be available to many populations who might otherwise not be able to attain psychotherapeutic services. It is the responsibility of the professional to participate in activities that will contribute to a better community and society and to devote a portion of their time for little or no remuneration.

PRO BONO SLIDING FEE

Little or no remuneration Reduce fee significantly Must have good back up reason Slide down to what client can afford Document rationale Document rationale

Ethically, if one is unable to give up an office hour due to one’s own financial issues for pro bono or sliding fee services, performing volunteer services is a way to give back to the community in general. The following are methods in which one can contribute to society:

• Public lectures on an area of expertise • Committee work • Volunteer consultation or supervision • Clinic work • Donating an office hour

MULTICULTURAL TERMINOLOGY

Lee and Richardson (1991) define multicultural counseling as “a relationship between a counselor and a client that takes both personal and cultural experiences into consideration in the helping process” (p. x). It is the ethical responsibility of each psychologist to become a “culturally skilled” counselor. This requires gaining knowledge, awareness and intervention techniques that are successful for clients “from culturally diverse backgrounds” (Sue, Bernier, Durran, Feinberg, Pedersen, Smith, & Vasquez-Nuttall, 1982). Culture is a word that has a number of meanings, according to which book or article is being read. Pedersen (2000) gives a description of culture which includes demographic variables such as age, gender, place of residence, and other status variables such as social, educational, and economic background. Pedersen includes formal and informal affiliations, ethnicity, language, and religion.

The following are some accepted, universally agreed upon terminology used in reference to multicultural counseling.

Ethnicity – Refers to a sense of common identity stemming from shared ancestry, history, nationality, religion, and race providing cohesion and strength. Ethnicity refers to a powerful unifying force offering a sense of belonging (Lum, 2000).

Ethnic Minority Group – A group of people singled out for differential and unequal treatment regarding themselves as discriminated against and powerless. These words apply to the condition of oppression rather than the numerical criteria. It also applies to women, elderly, gay men and lesbians, bisexuals, and people with disabilities (Atkinson, 2004).

Multiculturalism – This is a generic term indicating any relationship between and within two or more diverse groups. Cross-cultural, transcultural, and intercultural are terms with similar meanings and are often used interchangeably. The multicultural perspective takes into consideration specific values, beliefs, and actions conditioned by a client’s ethnicity, gender, religion, socioeconomic status political views, sexual orientation, geographic region, and historical experiences with the dominant culture (Wright, Coley, & Corey, 1989).

Cultural Diversity – This refers to a spectrum of differences that exist within various groups of individuals with unique cultural backgrounds (Diller, 2004).

Cultural Empathy – This term refers to the therapists’ awareness of the clients’ varied worldview with respect to the therapists’ own potential biases or stereotypes (Roysircar, 2004).

CALIFORNIA LAWS RELATED TO DISCRIMINATION

Business and Professions Code 125.6 (B&PC)

It is illegal, not only unethical, for a psychologist in the state of California to practice discrimination by refusing to treat a potential or current client for reasons that could be interpreted as discrimination. B&PC 125.6 describes in detail possible violations of the law as follows:

• Race • Color • Sex (included sexual orientation) • Religion • Ancestry • Physical handicap • Marital status • National origin

The Unruh Civil Rights Act - Civil Code 51 (CC 51)

The Unruh Civil Rights Act, Civil Code 51, directs all business establishments, including those that provide mental health services, to practice without discrimination of any sort. Once again, this civil code dictates the violations as follows:

• Age • Color • National origin • Religion • Sexual orientation • Ancestry • Disability • Race • Sex

QUESTION 19

Jeremy, a screen writer, fails to sell his 23rd script and is now living in his car. You do not wish to abandon him, so you decide to lower his $100 fee to $65 until he finds work. This is known as:

a. Pro bono b. Sliding fee

QUESTION 20

You are performing your ethical duty of donating time for free at the clinic downtown seeing AIDS patients. This is known as:

a. Pro bono b. Sliding fee See Section F – Review “Pro Bono & Sliding Fee Scale” for answers to Questions 19 and 20

ANSWERS: Psychologists are required to give back to the community, as mentioned earlier in this section. There are a number of ways to fulfill this requirement two of which appear in questions 19 and 20. The answer to question 19 is (b), sliding fee. The answer to 20 is (a), pro bono.

APA CODE THAT APPLIES TO DISCRIMINATION

See Principle D: Justice

This principle suggests that psychologist keep in mind that fairness and justice are entitled to all persons and equal quality of care is a requirement for everyone with which the psychologist works. The psychologist is asked to maintain awareness of potential biases and lack of competencies.

See APA Code 3.01 Unfair Discrimination

This code cautions psychologists to follow all state and federal laws with regard to discriminatory practices.

Consultation

When you are uncertain whether to report child abuse, the child abuse hotlines provide a consultation service. When you call the hotline telephone number, merely push the number the voicemail system tells you will allow for a consultation rather than a report. Be certain to get the vital information from the consultation:

1. Name of consultant 2. Date of consultation 3. Exact quote from consultant

DIAGNOSING WITH THE DSM: NORMAL VERSUS ABNORMAL?

One of the primary questions asked about the DSM is “Who gets to decide what is abnormal? And on what basis do they get to decide?” (Eriksen & Kress, 2005, p. 56). As mentioned in Section C (see Science versus Consensus), these decisions do not seem to be grounded in a strict scientific foundation.

People in power seem to make the decisions about what is normal and what is abnormal (Richardson, 1999). Some authors insist that at some points in time the people in power making these decisions were medical doctors (Sarbin, 1997). Kutchins and Kirk (1997) note that these decisions are generally made depending upon the zeitgeist, or climate, of the times and are subject to constant change.

So, who are these people in power who make the decisions? Szasz angered the medical world in 1974 when he suggested psychiatrists were interested in expanding their treatment domain thereby gaining greater power. He posited that psychiatrists were self-serving in their quest for more and more mental illness labels when “mental illnesses” were really only “problems in living.”

Whether or not one agrees or disagrees with Szasz and the demonizing of the entire medical profession, as discussed earlier, adding diagnoses to the DSM allows for more insurance reimbursements and more funding sources are able to contribute. The question becomes: Is adding more diagnoses to the DSM really a problem if more people can seek and afford treatment? Or, is it actually a positive development?

The negative side of the coin is that an ever increasing DSM leads to a greater pathologizing of everyday life and normal life’s everyday concerns (Chrisler & Caplan, 2002). Quite clearly, the more diagnoses in the DSM, the more to choose from for the insurance industry. This gives the clinician a great chance to place a “label” on behavior that indicates pathology that may not actually exist within the patient.

Experiences such as feeling “blue”, sleeplessness, bearing a grudge, lack of sexual interest, loneliness and the like are easily translated into pathological symptoms. The more diagnoses in the DSM, the more diagnoses they are part of and the more diagnoses the clinician has from which to choose.

Once again, Section C reviews the ethics of the battle between prescription drug manufacturers and developers of the DSM-IV-TR with regard to which diagnoses gained inclusion into the pages of the DSM. Kirmayer and Minas stated in 2000 “ ‘the sponsorship of so much activity in psychiatry (research, professional meetings, and continuing medical education activities) by pharmaceutical companies raises disturbing questions about the forces shaping psychiatric knowledge’ (p. 445) Professional autonomy takes a back seat to marketing’ (p. 446).” (as cited in Eriksen & Kress, 2005, p. 58).

MULTICULTURAL UTILITY IN THE DSM

Written into the various ethics code is the requirement to consider cultural issues in all areas of professional work. The DSM defines “mental disorder” in the context of cultural issues as follows:

A clinically significant behavioral or psychological syndrome or pattern that occurs in a individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom…this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, or example, the death of a loved one. (APA, 2000, p. xxxi)

There is a concerted effort in the preparation of the DSM-IV to incorporate awareness in all areas of culturally diverse populations in the United States and internationally as well. Since diagnostic assessment can be particularly challenging when the mental health professional and the client are from diverse cultural groups, clinicians must become familiar with the individuals frame of reference (APA, 2000).

There is considerable variation in how different cultures describe distress caused by psychological issues. For example, in the languages of certain Native Americans, Alaska Natives, and Southeast Asian cultures, there is no word for “depressed” (Butcher et al., 2010). It does not necessarily follow that no members of these societies have depression.

The DSM system makes an attempt to assist the clinician to systematically evaluate and report the impact of the individual’s cultural context and its influence upon the choice of diagnosis. Both the in-text discussion and Appendix I make an attempt to add to the clinicians’ knowledge about diversity issues. Appendix I, beginning on page 897, is divided into two sections which will be explained in this section.

Methods to Address Cultural Issues

In-Text Discussion - Specific Culture, Age, and Gender Features.

Each diagnosis has an in-text discussion about the possible impact and influence of the client’s culture on his or her symptoms or behavior. This section has the heading Specific Culture, Age, and Gender Features. It provides guidance for the therapist with regard to variations in presentation attributable to cultural setting, developmental stage of life, or gender. It suggests other information that may help in treatment planning.

For example,

“Regarding the course of Schizophrenia, women have a better prognosis than men as defined by number of rehospitalizations and lengths of hospital stay…” (APA, 2000, p. 308)

Appendix I – Two Parts

Part One – Outline for Cultural Formulation The Outline for Cultural Formulation is meant to supplement the multiaxial system and to also address difficulties that may be encountered when attempting to apply the system in a multicultural world. Part One provides a systematic evaluation of the individual’s cultural background, role of the cultural context, evaluation of symptoms and dysfunction and effect cultural differences may have upon the dyad of therapist and client (APA, 2000).

The therapist provides a narrative discussion and summary of the client for each of the following five categories (see DSM pp. 897-898 for a full discussion):

1. Cultural identity of individual – Note ethnic or cultural reference groups. Note degree of involvement with culture of origin and host culture. Note language abilities, use, preferences.

2. Cultural explanations of individual’s illness – Note predominant idioms of distress through which symptoms are communicated (e.g., nerves, possessing spirits, somatic complaints), the meaning of symptoms in reference group.

3. Cultural factors related to psychosocial environment and levels of functioning – Note culturally relevant interpretations of social stressors, available social supports, levels of functioning and disability. Includes stresses in local social environment and role of religion, kin.

4. Cultural elements of relationship between individual and clinician – Indicate differences in culture and social status between individual and clinician and problems that differences cause in diagnosis and treatment; difficulty in communication, language, intimacy.

5. Overall cultural assessment for diagnosis and care – Discussion of how cultural considerations specifically influence comprehensive diagnosis and care.

The DSM-IV-TR authors have made an attempt to steer users of the DSM in the appropriate direction: It is always correct to conceptualize the client as a unique individual influenced by numerous issues, culture being a primary and significant feature. However, this section falls far short (nor did it intend to accomplish such a vast task due to limitations in time) of “curing” the masculine-biased assumptions about health and illness feminists complain were codified in early versions of the DSM. (Ritchie, 1994; Kaplan, 1983; Ussher, 2000).

In terms of other cultural areas that the DSM-IV-TR could not address completely, Ussher states:

Feminist critics have argued that misogynist assumptions about gender roles and normal femininity are used in diagnosing ‘deviant’ women… Assumptions about the proper position of women within the institution of heterosexuality, furthermore, are used to prescribe notions of normality. (2000, p. 217).

Erikson and Kress (2005) remark on another a common concern from experts:

Can practitioners…” draw any definite conclusions about people of color, gay or lesbian people, or women based on a diagnostic system whose development was grounded in the knowledge of European American men and that claims to be based on “scientific” evidence from research studies that did not include diverse participants… (p. 56)

Appendix I – Two Parts

Part Two – Glossary of Culture-Bound Syndromes

Culture specific Disorders

Certain forms of pathology seem to be highly specific to certain cultures. These are found only in certain areas of the globe and are linked to culturally bound concerns. For example, taijin kyofusho is a syndrome prevalent in Japan that relates to an anxiety disorder It involves a marked fear of offending another person with one’s own body, body parts, or body functions that could embarrass or make others feel uncomfortable (Butcher et al., 2010; Levine & Gow, 1995).

The term Culture-Bound Syndrome refers to a recurrent and locality-specific pattern of aberrant behavior that may or may not be linked to a particular diagnosis (see Appendix I, p. 898). Some of these patterns have local names and are considered to be indigenous to specific areas and can be found throughout the world. They can be identified by particular symptoms, a particular course, and social response that can be influenced by local cultural factors. According to the DSM, there is seldom a one-to-one equivalence of any culture- bound syndrome with any specific DSM diagnosis. In other words, a clinician would never replace the diagnosis of Schizophrenia with one of the Culture- Bound Syndromes given a patient from a specific culture.

The glossary presents in alphabetical order many of the best-studied Culture- Bound Syndromes and idioms of distress that may be encountered in clinical work in North America. It also includes DSM-IV diagnoses where data has suggested that the clinician should consider both.

For example, on page 903 of the DSM-IV-TR:

Zar A general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies to the experience of spirits possessing an individual. Persons possessed by a spirit may experience dissociative episodes that may include shouting, laughing, hitting the head against a wall, singing, or weeping. Individuals may show apathy and withdrawal, refusing to eat or carry out daily tasks, or may develop a long-term relationship with the possessing spirit. Such behavior is not considered pathological locally.

It does not seem clear how this term should be used, or how the entire section should be used. A clinician will not place “Zar” on Axis I, even if the client is from one of the countries mentioned in the description above. However, it does seem the clinician is instructed to consider the possibility that the client may not actually have Schizophrenia or one of the Dissociative disorders if he or she is from Ethiopia, Somalia, Egypt, Sudan, Iran or another North African or Middle Eastern Society where “Zar” may apply.

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