Assessment and Diagnosis “Under the Gun”

Section 9: Assessment

9.01 Bases for Assessments  (a) Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. (See also Standard  2.04, Bases for Scientific and Professional Judgments .)

(b) Except as noted in  9.01c , psychologists provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. When, despite reasonable efforts, such an examination is not practical, psychologists document the efforts they made and the result of those efforts, clarify the probable impact of their limited information on the reliability and validity of their opinions, and appropriately limit the nature and extent of their conclusions or recommendations. (See also Standards  2.01, Boundaries of Competence , and  9.06, Interpreting Assessment Results .)

(c) When psychologists conduct a record review or provide consultation or supervision and an individual examination is not warranted or necessary for the opinion, psychologists explain this and the sources of information on which they based their conclusions and recommendations. Assessment and Diagnosis “Under the Gun”

9.02 Use of Assessments  (a) Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques. Assessment and Diagnosis “Under the Gun”

(b) Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation.

(c) Psychologists use assessment methods that are appropriate to an individual’s language preference and competence, unless the use of an alternative language is relevant to the assessment issues.

9.03 Informed Consent in Assessments  (a) Psychologists obtain informed consent for assessments, evaluations, or diagnostic services, as described in Standard 3.10, Informed Consent, except when (1) testing is mandated by law or governmental regulations; (2) informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity (e.g., when participants voluntarily agree to assessment when applying for a job); or (3) one purpose of the testing is to evaluate decisional capacity. Informed consent includes an explanation of the nature and purpose of the assessment, fees, involvement of third parties, and limits of confidentiality and sufficient opportunity for the client/patient to ask questions and receive answers. Assessment and Diagnosis “Under the Gun”

(b) Psychologists inform persons with questionable capacity to consent or for whom testing is mandated by law or governmental regulations about the nature and purpose of the proposed assessment services, using language that is reasonably understandable to the person being assessed.

(c) Psychologists using the services of an interpreter obtain informed consent from the client/patient to use that interpreter, ensure that confidentiality of test results and test security are maintained, and include in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, discussion of any limitations on the data obtained. (See also Standards  2.05, Delegation of Work to Others ;  4.01, Maintaining Confidentiality ;  9.01, Bases for Assessments ;  9.06, Interpreting Assessment Results ; and  9.07, Assessment by Unqualified Persons .)

9.04 Release of Test Data  (a) The term test data refers to raw and scaled scores, client/patient responses to test questions or stimuli, and psychologists’ notes and recordings concerning client/patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data. Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release. Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law. (See also Standard  9.11, Maintaining Test Security .)

(b) In the absence of a client/patient release, psychologists provide test data only as required by law or court order.

9.05 Test Construction  Psychologists who develop tests and other assessment techniques use appropriate psychometric procedures and current scientific or professional knowledge for test design, standardization, validation, reduction or elimination of bias, and recommendations for use.

9.06 Interpreting Assessment Results  When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences, that might affect psychologists’ judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations. (See also Standards  2.01b and c, Boundaries of Competence , and  3.01, Unfair Discrimination .)

9.07 Assessment by Unqualified Persons  Psychologists do not promote the use of psychological assessment techniques by unqualified persons, except when such use is conducted for training purposes with appropriate supervision. (See also Standard  2.05, Delegation of Work to Others .)

9.08 Obsolete Tests and Outdated Test Results  (a) Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose.

(b) Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose. Assessment and Diagnosis “Under the Gun”

9.09 Test Scoring and Interpretation Services  (a) Psychologists who offer assessment or scoring services to other professionals accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use.

(b) Psychologists select scoring and interpretation services (including automated services) on the basis of evidence of the validity of the program and procedures as well as on other appropriate considerations. (See also Standard  2.01b and c, Boundaries of Competence .)

(c) Psychologists retain responsibility for the appropriate application, interpretation, and use of assessment instruments, whether they score and interpret such tests themselves or use automated or other services.

9.10 Explaining Assessment Results  Regardless of whether the scoring and interpretation are done by psychologists, by employees or assistants, or by automated or other outside services, psychologists take reasonable steps to ensure that explanations of results are given to the individual or designated representative unless the nature of the relationship precludes provision of an explanation of results (such as in some organizational consulting, preemployment or security screenings, and forensic evaluations), and this fact has been clearly explained to the person being assessed in advance.

9.11 Maintaining Test Security  The term test materials refers to manuals, instruments, protocols, and test questions or stimuli and does not include test data as defined in Standard  9.04, Release of Test Data . Psychologists make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law and contractual obligations, and in a manner that permits adherence to this Ethics Code. Assessment and Diagnosis “Under the Gun”

The Influence of Payment Method

on Psychologists’ Diagnostic Decisions

Regarding Minimally Impaired Clients

Andrew M. Pomerantz and Dan J. Segrist

Department of Psychology

Southern Illinois University Edwardsville

Are psychotherapy clients who pay via health insurance more likely to receive Diagnostic

and Statistical Manual of Mental Disorders (4th ed. [DSM–IV], American

Psychiatric Association, 1994) diagnoses than identical clients who pay out of

pocket? Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) indicates

that when psychologists consider a mildly depressed or anxious client, payment

method significantly influences diagnostic decisions. This study extends the scope of

the previous study to include clients whose symptoms are even less severe. Independent

practitioners responded to vignettes of clients whose profiles deliberately included

subclinical impairment and a high level of functioning. Half of the participants

were told that the clients would pay via managed care; the other half were told

that the clients would pay out of pocket. As in the earlier study, payment method had

a highly significant impact on diagnosis such that relative to out-of-pocket clients,

managed care clients were much more likely to be assigned DSM–IV diagnoses. In

addition, a noteworthy percentage of participants assigned diagnoses regardless of

payment method. Ethical implications are discussed.

Keywords: diagnosis, managed care, independent psychotherapy practice, ethics,

payment

A recent study (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) found that the

method by which a private practice client pays for psychotherapy very significantly

influences both the likelihood that the psychologist will assign a diagnosis

and the specific diagnosis that the psychologist chooses. Specifically, when comETHICS

& BEHAVIOR, 16(3), 253–263

Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Andrew M. Pomerantz, Southern Illinois University

Edwardsville, Department of Psychology, Edwardsville IL 62026. E-mail: apomera@siue.edu

pared to identical clients paying out of pocket, clients paying via managed care

were much more likely to receive diagnoses and were more likely to receive adjustment

disorder diagnoses in particular. In the Kielbasa et al. (2004) study, the fictional

vignettes to which participants responded included mildly depressed and

anxious clients whose symptoms placed them very near the threshold for Axis 1

disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.

[DSM–IV], American Psychiatric Association [APA], 1994). The purpose of this

study was to replicate the Kielbasa et al. (2004) study using vignettes of clients

whose level of pathology was even less severe. In other words, when considering a

generally high functioning client whose symptoms may fall below the threshold

for any DSM–IV disorder, will psychologists be influenced by payment method

when making diagnostic decisions? Assessment and Diagnosis “Under the Gun”

This study, as well as its predecessor (Kielbasa et al., 2004), stems from a growing

body of literature examining the effects of managed care and other forms of

third-party payment on the independent practice of psychology. This literature includes

numerous empirical surveys of practitioners regarding the impact of managed

care on their practices (e.g., Bell, 1999; Murphy, DeBernardo, & Shoemaker,

1998; Phelps, Eisman, & Kohout, 1998; Rothbaum, Bernstein, Haller, Phelps, &

Kohout, 1998), most of which have concluded that the impact has been quite negative.

In addition, the literature includes nonempirical commentaries on the impact

of managed care on psychotherapy (e.g., Karon, 1995; Miller, 1996), most of

which describe managed care as having a detrimental effect. However, diagnosis

has not been the primary focus of these surveys and commentaries. Instead, they

have focused primarily on the therapy process, and to a much more limited extent,

assessment techniques. Very few studies in this field have yielded conclusions regarding

diagnostic issues; these studies have found that independent practitioners

strongly believe that managed care influences psychologists to alter diagnoses to

ensure reimbursement and to protect confidentiality (Murphy et al., 1998) and that

accurate diagnosis in a managed care system is problematic for many mental

health counselors (Danziger & Welfel, 2001). Thus, with the exception of these

isolated studies and the Kielbasa et al. (2004) article, the impact of payment

method on specific diagnostic decisions made by clinicians has not been the focus

of empirical research, particularly for clients who present with mild or subthreshold

symptoms.

Kielbasa et al. (2004) considered numerous interpretations for the finding that

managed care clients are far more likely to receive diagnoses than out-of-pocket

clients, including the common requirement of a diagnosis by managed care companies

to justify reimbursement as described by Ackley (1997), Chambliss (2000),

and Kutchins and Kirk (1997), among others. Peck and Scheffler (2002) similarly

discuss “intentional upcoding,” by which clinicians exaggerate symptoms to increase

the chances or amount of reimbursement from third-party payers (p. 1094).

To the extent that the client falls below the criteria for a mental disorder, the clini-

254 POMERANTZ AND SEGRIST

cian engaging in such practices may be acting in a manner that violates the ethical

code of the APA (2002) or laws concerning insurance fraud. In light of this, this

study specifically sought to examine the impact of payment method on diagnostic

decisions regarding clients whose symptoms may fall below the threshold of a

DSM–IV disorder. Assessment and Diagnosis “Under the Gun”

METHOD

Participants

Members of Division 42 (Psychologists in Independent Practice) of the APA were

randomly selected and surveyed via mail. Of the 1,000 members who were initially

surveyed, 91 surveys were returned as undeliverable. Of the remaining 909 surveys

that were presumably delivered, 275 respondents provided usable data, representing

a 30.25% return rate. Mean age of participants was 59.4 years (SD = 9.63) and

mean number of years in private practice was 23.8 (SD = 10.11). Respondents

were primarily male (63%) and White (78%). Most had earned PhD degrees (86%)

as opposed to EdD (6%) or PsyD (7%) degrees, and most specialized in clinical

psychology (74%) as opposed to counseling psychology (20%) or other areas

(4%). Eclectic orientation was most frequently endorsed (57%), followed by cognitive

(18%) and psychodynamic (16%). Most (62%) worked primarily in solo independent

practices, whereas some (22%) worked primarily in group independent

practices. Assessment and Diagnosis “Under the Gun”

Materials, Design, and Procedure

Each participant received a survey that included two vignettes, one describing a client

with minimal depressive symptoms and another describing a client with minimal

anxious symptoms. The order of the two vignettes was counterbalanced such that

eachappearedfirstonapproximatelyhalfofthesurveys.Forparticipantsinthemanaged

care condition, both fictional clients were described as paying via managed

care. For participants in the out-of-pocket condition, both fictional clients were described

as paying out of pocket. The Appendix provides an illustration of these vignettes.

Participants also received a cover letter and a brief demographic survey.

Each vignette was intended to portray a client whose presenting problems fell

below the threshold for a DSM-IV diagnosis. They were similar to the vignettes

used in the Kielbasa et al. (2004) study in terms of the type of symptoms described,

but the severity and duration of the symptoms were deliberately subclinical, and

the level of functioning was deliberately high. Specifically, the minimally anxious

client is described as demonstrating some symptoms of generalized anxiety disorder,

but they are insufficient in number and duration (only a “couple of months”

PAYMENT METHOD AND DIAGNOSIS 255

rather than 6 months) to qualify for this diagnosis. Similarly, the minimally depressive

client is described as demonstrating some symptoms of a major depressive episode,

but they are insufficient in number and duration (only a week rather than 2

weeks) to qualify for this diagnosis. In both vignettes, the client was described as

“generally functioning well in all areas of [his/her] life,” and experiencing symptoms

that have “typically passed quickly and have caused only slight impairment.”

These two phrases closely mimic the language found in the “71–80” and “81–90”

range of the Global Assessment of Functioning scale of the DSM-IV. They were intentionally

incorporated into the vignettes to corroborate that, as the minimal

symptoms imply, these clients are subclinically impaired and are functioning at a

relatively high level. In addition, the vignettes included the statements that the clients

can identify “no specific triggers” for their symptoms; this statement was included

as an attempt to ensure that the clients could not qualify for adjustment disorder

diagnoses.

After reading each vignette, which included presenting problem, symptoms,

and some background and demographic information, participants responded to

four questions: (a) “Would you assign this client a DSM–IV diagnosis?” (“yes” and

“no” choices provided), (b) “If you answered yes to the previous question, what

specific diagnosis would you provide?” (blank space, rather than specific choices,

provided), (c) “Assuming that the client does not prematurely terminate, predict

the length of therapy, in number of sessions,” and (d) “What prognosis would you

give this client?” For the final question, participants were provided with a 5-point

Likert-type scale ranging from 1 (extremely poor) to 5 (extremely good). Assessment and Diagnosis “Under the Gun”

RESULTS

Tables1and2displaythefrequenciesof“yes”and“no”responses,forbothpayment

conditions, to the item, “Would you assign this client a DSM–IV diagnosis?” As the

tables illustrate, assignment of a diagnosis was more common for managed care clients

than for out-of-pocket clients across both vignettes. The percentage of “yes”

and “no” responses to the managed care condition were used as comparisons for the

out-of-pocket condition in two chi-square tests for goodness of fit (one for each vignette).

For the first vignette (minimally anxious symptoms), χ2(1,N= 270) = 22.29

p < .001, and for the second vignette (minimally depressive symptoms, χ2 (1, N =

272) = 21.02, p < .001, there was a significant association between the method of

payment and whether or not the client would be diagnosed. These highly significant

chi-squarestatisticsindicatethatthelikelihoodofaparticipantassigningadiagnosis

to a minimally impaired client paying via managed care is significantly higher than

the likelihood of a participant assigning a diagnosis to the same client paying out of

pocket. Specifically, based on the odds ratio calculated from data in all four cells of

the chi-square, the client with minimally depressive symptoms paying via managed

256 POMERANTZ AND SEGRIST

care was 3.17 times more likely than an identical client paying out of pocket to be diagnosed

with a DSM disorder. Similarly, based on the odds ratio, the minimally anxious

client paying with managed care was 3.33 times more likely to be diagnosed

with a DSM disorder than an identical client paying out of pocket.

Anecdotally, it is noteworthy that 9.68% of participants in the managed care

condition who responded “yes” to the initial question (“Would you assign this client

a DSM–IV diagnosis?”) included unsolicited written comments about thirdparty

reimbursement. Specifically, these participants inserted comments to the effect

that assigning a diagnosis was a necessity for payment or reimbursement. Examples

of these comments include, “She has not had symptoms long enough to really

warrant the diagnosis but I would need to give her a diagnosis to bill her

HMO,” and “Need a code for insurance.” The appearance of these comments is especially

interesting because there was no request or designated space for comments

on the questionnaire.

The item “If you answered yes to the previous question, what specific diagnosis

would you provide?” generated a wide variety of responses from participants. TaPAYMENT

METHOD AND DIAGNOSIS 257

TABLE 1

Frequencies of “Yes” and “No” Responses to the Item “Would You Assign

This Client a DSM-IV Diagnosis?” by Payment Method Regarding Vignette

No. 1 (Minimally Anxious Client)

Yes No

Frequency % Frequency % Total

Managed care 90 72.0 35 28.0 125

Out of pocket 63 43.4 82 56.6 145

Total 153 117 270

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric

Association, 1994).

TABLE 2

Frequencies of “Yes” and “No” Responses to the Item “Would You Assign

This Client a DSM-IV Diagnosis?” by Payment Method Regarding Vignette

No. 2 (Minimally Depressive Client)

Yes No

Frequency % Frequency % Total

Managed care 79 63.7 45 36.3 124

Out of pocket 53 35.8 95 64.2 148

Total 132 140 272

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric

Association, 1994). Assessment and Diagnosis “Under the Gun”

bles 3 and 4 display the frequencies and percentages of the specific diagnoses provided

for each vignette.

Regarding estimated number of sessions needed to treat each client, participants

predicted a mean of 9.97 sessions (SD = 9.92) for the minimally anxious

client, with a mean prognosis of 4.40 (SD = .65). For the client with minimally

depressive symptoms participants predicated a mean of 10.08 sessions (SD =

10.79) and a prognosis of 4.43 (SD = .62). Independent samples t tests indicated

that portrayed method of payment had no significant effect on estimates

of the duration of therapy or the prognosis of the hypothetical clients. Specifically,

there was no significant difference in the estimated duration of therapy

for the minimally anxious client paying for therapy through managed care,

M = 9.43, SD = 8.04, and the same client paying for therapy out of pocket,

M = 10.38, SD = 11.16; t(229) = –.72, p = .47. In addition, there was no significant

difference in the perceived prognosis of the minimally anxious client paying

through managed care, M = 4.35, SD = .71, and paying out of pocket, M = 4.45, SD

= .60; t(221.36) = –1.22 , p = .23. Similarly there was no significant difference in

the estimated duration of therapy for the client with minimally depressive symptoms

paying for therapy through managed care, M = 10, SD = 9.76, and the same

client paying for therapy out of pocket, M = 10.15, SD = 11.52; t(228) = –.13, p =

.90. There was also no significant difference in the perceived prognosis of the client

with minimally depressive symptoms paying through managed care, M = 4.41,

SD = .65, and paying out of pocket, M = 4.45, SD = .60; t(256) = –.58, p = .57.

258 POMERANTZ AND SEGRIST

TABLE 3

Frequencies and Percentages of DSM-IV-TR Diagnoses Assigned

to Vignette No. 1 (Minimally Anxious)

DSM-IV Diagnosis Frequency %

Adjustment disorder with anxiety 46 31.1

Anxiety NOS 41 27.7

Generalized anxiety disorder 22 14.9

Adjustment disorder with mixed anxiety and depression 20 13.5

Adjustment disorder NOS 5 3.4

Diagnosis deferred 5 3.4

Depression NOS 4 2.7

Dysthymic disorder 2 1.4

Major depression, recurrent, moderate 1 .7

Panic disorder with agoraphobia 1 .7

V code 1 .7

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric

Association, 1994); DSM-IV-TR = DSM-IV (Text Rev., 2000); NOS = not otherwise specified.

Sample (n = 148) composed of those participants who responded “Yes” to the question, “Would you assign

this client a DSM-IV diagnosis?”

It is also notable that, regardless of payment method, a sizable number of participants

chose to assign diagnoses to clients whose symptoms and level of functioning

suggested that no diagnosis was applicable. Altogether, 56% and 48% of the

participants assigned a diagnosis to the minimally anxious client and minimally

depressive client, respectively. Assessment and Diagnosis “Under the Gun”

DISCUSSION

Results of this study suggest that, even when the client seeking services does not

meet criteria for a mental disorder, the method by which the client pays for psychological

services has a very strong influence on the diagnostic decisions of the psychologist

providing the services. Specifically, these results indicate that, relative to

identical clients who pay out of pocket, clients who pay via managed care are far

more likely to be diagnosed with a DSM–IV disorder. This finding was previously

established with fictional clients whose symptoms were more serious (Kielbasa et

al., 2004), but results of this study confirm that the finding holds true even when

the clients’ issues fall below diagnosable levels. The finding that clients paying via

managed care are more likely to receive diagnoses than those paying out of pocket

is illustrated not only by the significant chi-square statistics reported earlier, but

also by the odds ratio, which indicates that clients paying via managed care are

PAYMENT METHOD AND DIAGNOSIS 259

TABLE 4

Frequencies (Percentages) of DSM-IV-TR Diagnoses Assigned to Vignette

No. 2 (Minimally Depressive)

DSM-IV-TR Diagnosis Frequency %

Adjustment disorder with depression 38 29.7

Depression NOS 37 28.9

Dysthymic disorder 20 15.6

Adjustment disorder with mixed anxiety and depression 10 7.8

Diagnosis deferred 10 7.8

Adjustment disorder NOS 5 3.9

Major depression, single episode, mild 3 2.3

Adjustment disorder mixed disturbance of emotion and conduct 1 .8

Anxiety NOS 1 .8

Generalized anxiety disorder 1 .8

Major depression, recurrent, moderate 1 .8

V code 1 .8

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric

Association, 1994); DSM-IV-TR = DSM-IV (Text Rev., 2000); NOS = not otherwise specified.

Sample (n = 128) composed of those participants who responded “Yes” to the question, “Would you assign

this client a DSM-IV diagnosis”?

slightly over three times more likely to be assigned a DSM–IV diagnosis than identical

clients paying out of pocket.

Kielbasa et al. (2004) offered the interpretation that the policy of many managed

care companies to require a diagnosis for payment (Ackley, 1997; Chambliss,

2000; Kutchins & Kirk, 1997) was a likely reason for the finding that payment

method influences diagnostic decision making. The same interpretation continues

to apply to these results. In fact, these results (both empirical and anecdotal) suggest

that psychologists may upcode clients whose symptoms are subclinical to secure

payment when those clients pay via managed care but not when they pay out

of pocket. Kielbasa et al. also suggested that diagnosing a client without merit can

have various negative consequences: an unwarranted view of the self as mentally

ill (Ackley, 1997; Caplan, 1995); the presence of a mental disorder on the client’s

medical record, the confidentiality of which is not entirely in the hands of the clinician

(Kutchins & Kirk, 1997); or an altered course of treatment (Beutler & Harwood,

2000; Nathan & Gorman, 2002). All of these negative consequences are especially

applicable to a situation in which a client receives an unwarranted

diagnosis. In addition, Kielbasa et al. described the importance of this finding for

the clinicians themselves, whose behavior may be unethical (APA, 2002) or illegal

(per insurance fraud regulations), and for society at large, which will pay higher insurance

rates to cover unwarranted claims. Both of these outcomes are particularly

salient in the context of the findings of this study, which extend the findings of the

Kielbasa et al. study to subclinical clients. Assessment and Diagnosis “Under the Gun”

Although the primary intent of this study was to compare responses to managed

care and out-of-pocket clients, it is striking that, regardless of payment method, approximately

half of the participants chose to assign diagnoses to these subclinical

clients. This result suggests that clinicians may tend to overestimate clients’symptoms

or apply DSM–IV criteria quite liberally in all payment circumstances, and

that the presence of a managed care party in the therapy situation simply exacerbates

this tendency. The tendency is troubling, and its causes are not entirely clear.

Perhaps psychologists themselves generally view diagnosis as a prerequisite for

treatment; perhaps the increasing presence and influence of managed care in the

professional lives of psychologists (e.g., Murphy et al., 1998) has contributed to

this view. In any case, this issue is worthy of further study.

As in the Kielbasa et al. (2004) study, the importance of informed consent is

a primary ethical implication of the results of this study. The APA ethics code

(2002) clearly emphasizes the necessity of informed consent for clinical services

(e.g., standards 3.10 [a], 10.01 [a]). Numerous authors have debated the specific

content to be included in an adequate informed consent procedure (e.g., Appelbaum,

1993; Newman & Bricklin, 1991; Pope & Vasquez, 1998), but it seems

reasonable to consider the effect of payment method on diagnostic decisions

among the essential points to include, especially if the client’s symptoms are as

minimal as those included in this study. These and previous (e.g., Kielbasa et al.,

260 POMERANTZ AND SEGRIST

2004) findings suggest that, to obtain truly informed consent, psychologists

should advise clients that their method of payment might influence the diagnostic

decisions made about them. Assessment and Diagnosis “Under the Gun”

This study focuses only on what psychologists decide in terms of diagnosis.

One potential avenue for future studies is an exploration of how psychologists

communicate their diagnostic decisions to clients. The impact of the diagnosis on

clients may vary greatly as a result of the manner and extent to which psychologists

share, explain, or discuss it with them.

Several limitations apply to the results and conclusions of this study. It incorporated

brief vignettes with limited information rather than more detailed vignettes

or actual clients. The fictional clients were described as presenting with minimal

symptoms and as relatively high functioning; it is unclear how common such

subclinical presentations are in the practices of most independent practice psychologists.

Respondents included a subset of the membership of Division 42, and

the extent to which respondents are representative of the division or the profession

as a whole is unclear. In spite of these limitations, the results of this study confirm

and extend the results of previous research (Kielbasa et al., 2004) demonstrating

the importance of payment method in the diagnostic decisions of psychologists in

independent practice. Assessment and Diagnosis “Under the Gun”

ACKNOWLEDGMENTS

This research was conducted with the support of a Dean’s Grant for Research

Enhancement from the School of Education at Southern Illinois University

Edwardsville.

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37–42.

APPENDIX

Sample Vignettes

Vignette #1

A 35-year-old married man in good physical health is a father of two children. He

generally functions well in all areas of his life; however, for the past couple of

months he has been experiencing increased anxiety and worry. He cannot identify

any stressful events that may have triggered this worry. Specifically, he has experienced

mild anxiety about work; temporary difficulty concentrating; and occasional

difficulty sleeping. These symptoms have typically passed quickly and have

caused only slight impairment.

This person has come to you today seeking therapy. He intends to pay for therapy

[through his managed care plan/out of pocket].

Vignette #2

A 55-year-old married woman in good physical health is a mother of two children.

She generally functions well in all areas of her life; however, for the past week she

262 POMERANTZ AND SEGRIST

has been experiencing increased sadness. She cannot identify any stressful events

that may have triggered this sadness. Specifically, she has experienced a depressed

mood; decreased interest in her activities and hobbies; and some difficulty sleeping.

These symptoms typically last for a short period of time, and have caused only

slight impairment. Assessment and Diagnosis “Under the Gun”

This person has come to you today seeking therapy. She intends to pay for therapy

[through her managed care plan/out of pocket].