Article Measurement and Evaluation in

Counseling and Development

Volume 42 Number 1
April 2009 3-14

Diagnostic Variance Among

© 2009 The Author(s)
10.1177/0748175609333559
http://mec.sagepub.com

Counselors and Counselor Trainees

Danica G. Hays
Old Dominion University, Norfolk, Virginia
Amy L. McLeod
Argosy University, Atlanta, Georgia
Elizabeth Prosek
Old Dominion University, Norfolk, Virginia

This study, based on grounded theory, explored aspects of diagnostic variance in the clinical
decision-making process among 41 counselors and counselor trainees. As such, this article
discusses the various forms of diagnostic variance and the cognitive information-processing
tools used by practitioners, to highlight an evolving theory of how helping professionals vary
in their clinical decision making. Implications for practice, training and future research are
provided.

Keywords:   counseling; diagnosis; diagnostic variance; clinical decision-making

C linical diagnosis is an important part of

the evaluative role of counselors. With
the increased reliance on managed-care dol-
lars for clients’ access to treatment, counsel-
ors have to justify their clinical decisions
and provide diagnoses that may subsequently
affect clients’ psychological, social, occupa-
tional, and/or academic functioning (Eriksen
& Kress, 2005). In essence, counselors make
two types of interdependent clinical judg-
ments: classification (i.e., diagnosis) and
continuum (i.e., symptom severity; Lopez,
1989). Furthermore, the task of making nec-
essary treatment accessible for most clients
involves identifying diagnoses that appropri-
ately speak to clients’ symptomology within
a culturally sensitive framework.
Although benefits of diagnosing have
been documented (Eriksen & Kress, 2005),
diagnostic error or misdiagnosis is a serious
concern when considering that labels often
determine type and duration of treatment,
clients’ perceptions of self in relation to
labels, and others’ perspectives about cli-
ents’ level of pathology and its effect on
daily functioning. Misdiagnosis refers to a
clinician’s giving a client a diagnosis when
no mental disorder is present, giving the
wrong diagnosis, or not detecting a disorder
when one is present. In addition, misdiagno-
sis may be associated with differential treat-
ment protocols and poorer clinical outcomes
(Lawson, Hepler, Holladay, & Cuffel, 1994).
Diagnostic variance influences misdiagno-
sis and assumes the form of several chal-
lenges. Diagnostic variance refers to
Authors’ Note: This study was funded by grants from
Old Dominion University and the Association for
Counselor Education and Supervision. We would like to
give special thanks to the following research assistants:
Rebekah Byrd, Jessie Guyton, Donna Henry, Holly
Moore, Desaree Murden, Tracy Roberts, Breyan
Williams, and Rebecca Witcher. Correspondence con-
cerning this article should be addressed to Danica G.
Hays, Old Dominion University, 110 Education
Building, Norfolk, VA 23529; e-mail: dhays@odu.edu.

3
4    Measurement and Evaluation in Counseling and Development
the extent to which one’s grasp of the
realities of life is pervasively influenced
by what one has been conditioned to see,
what one wants to see, what one has been
instructed to see, and what one is afraid to
see. Both clients and clinicians suffer from
these limitations. (Dumont & LeComte,
1987, p. 433)
Diagnostic variance occurs in the diag-
nostic process largely because counselors
use a variety of cognitive and information-
processing tools in clinical decision mak-
ing (Gigerenzer, 2002). Thus, the clinical
decision-making process involves diffe­
rential expression and interpretation of
available client data produced within the
therapeutic relationship.
Types of Diagnostic Variance
Four types of diagnostic variance affect
the type, quality, and amount of clinical data
collected. Natural variance refers to how a
mental disorder manifests itself; this involves
the duration and intensity of client symp­
tomology and different cultural expressions
of symptoms. To this end, natural variance in
clinical judgments may occur because clients
do not fit criteria fully, because they fulfill
multiple criteria within the same diagnostic
category, and/or because they fulfill criteria
for multiple diagnoses. The remaining three
sources of diagnostic variance may be largely
based on clients’ trust level with counselors
and their level of expertise and theoretical
orientation. Information variance relates to
the amount and type of data collected. There
are limits to how much clients report to
counselors, as well as what data counselors
seek. Observation/interpretation variance
refers to the variability in how the same data
are interpreted among counselors. Criterion
variance involves the use of different criteria
to diagnose (Gigerenzer, 2002).
Cognitive Tools in Clinical
Decision Making
Cognitive tools are information-processing
methods that are used in clinical decision
making when counselors have little infor­
mation about a client or when a client does
not fit a diagnostic category well—common
occurrences in clinical practice given the
limitations of the clinical decision-making
process. Although cognitive tools are generally
helpful in reducing the complexity of clinical
judgment, there is risk for mis­diagnosis.
Furthermore, even though diagnoses are
intended to be based on beha­vioral criteria
(to maximize the objectivity of the clinical
decision-making process), research indicates
that counselors and other mental health
professionals rely more on subjective, global
notions of client sympto­mology and cultural
variables, rather than attend to specific criteria
in making diagnoses (Lopez, 1989; Paniagua,
2005; Rosenthal, 2004; Tversky & Kahneman,
1973).
Cognitive tools include representative­
ness, availability, vividness criterion, ancho­
ring, locus of attribution, and confirmation
bias. Representativeness refers to the likeli­
hood that a criterion belongs to a specific
diag­nosis, and it is based on the idea that
there are expected frequencies for certain
disorders within a population; as such, these
probabilities may create generalizations
when counselors expect to find a diagnosis
under certain conditions. Availability invol­
ves the degree to which familiarity, retrieva­
bility, and salience of events or criteria
become the basis for clinical diagnosis.
Furthermore, some cues are more available
to counselors and so play an important role
in final clinical judgments. Vividness crite­
rion speaks to the idea that certain diagnostic
criteria may present more intensely and thus
heavily influence a diagnosis. Anchoring
refers to how clinical data that are presented

early in the therapeutic relationship may be
over­represented in final clinical impres­
sions; as such, faulty interpretations in early
clinical judgment may bias later diagnoses.
Locus of attribution relates to the degree to
which counselors couch client symptomology
with­in a dispositional framework (i.e.,
problem lies within the client) and/or situa­
tional frame­work (i.e., problem is a result of
contextual or environmental factors); theo­
retical orien­tation and attention to cultural
factors largely influence locus of attribution.
Finally, con­firmation bias refers to the idea
that “we look for what we want to or expect
to see”; counselors may have difficulty
challenging or disconfirming their clinical
judgments because of their a natural pro­
pensity to seek out data that support their
judgments (Dumont & LeComte, 1987;
Ellis, Robbins, Schult, Ladany, & Banker,
1990; Tversky & Kahneman, 1973).
Treatment decisions are largely based on
diagnosis; as such, an emphasis is warranted
on accurate diagnoses, through a deeper
understanding of the process by which
counselors come to make clinical decisions—
which involves their degree of diagnostic
variance and use of cognitive tools. Further­
more, findings from this study, as related to
counselors’ level of knowledge and decision-
making processes, have important impli­
cations for counselor preparation. That is, to
the degree that counselor educators and
clinical supervisors understand the relation­
ships between the stated constructs, they
may effectively instruct trainees to diagnose
in a thorough, objective, and culturally
competent manner. The result of such training
suggest better treatment opportunities and
outcomes for clients.
Previous research in misdiagnosis has
used quantitative methods, using archival
client files and hypothetical case studies,
and it has investigated this issue primarily
outside the counseling profession. In addition,
Hays et al. / Diagnostic Variance in Counseling    5
clients (actual or fictional) have mostly
been of lower socioeconomic status (SES)
and African American, with participants
(i.e., clinicians) mostly being White. Thus,
the purpose of this study is to examine how
diagnostic variance and perceived client func­
tioning factor into clinical decision making
through an expansion of research method­
ology (qualitative) that includes greater
diversity in clients and participants. The over­
arching research question to be addressed
is as follows: How do counselors and coun­
selor trainees arrive at clinical (diagnostic)
decisions? Specifically, how does diagnostic
variance relate to the clinical decision-making
process between counselors and counselor
trainees?
Method
Participants and Procedure
To further ensure anonymity, research
team members independently selected par­
ticipants. The 41 participants in this study
represented a diverse group, with respect
to cultural identity and additional variables,
including amount and type of clinical experi­
ence and credentialing. The participants
consisted of 33 women and 8 men with a
median age of 32 (range = 34).
Participants identified with the following
racial/ethnic categories: White/European
American (n = 28), African American (n =
10), Hispanic/Latino American (n = 1),
biracial/multiracial (n = 1), and Other/Not
Specified (n = 1). A majority identified as
heterosexual (n = 39), with one identifying
as gay and one as bisexual. With respect to
household income, participants classified
themselves as such: less than $20,000 (n =
5), $20,001–40,000 (n = 11), $40,001–
60,000 (n = 10), $60,001–80,000 (n = 9),
$80,001–100,000 (n = 2), and greater that
$100,000 (n = 4). Participants identified
6    Measurement and Evaluation in Counseling and Development
with the following religious/spiritual orien­
tations: Christian (n = 28), Jewish (n = 7),
Buddhist (n = 1), Hindu (n = 1), Muslim
(n = 1), and Other/Not Specified (n = 10). A
majority (n = 16) stated they were active in
their spiritual practice; 10 identified as non­
practicing and 7 as somewhat practicing.
In terms of highest educational degree,
30 participants were presently enrolled in a
graduate program (17 master’s, 2 educational
specialist, and 11 doctoral). At the time of
the study, 37 participants had completed a
course in diagnosis and treatment planning,
and 29 had attended at least one multicultural
workshop. In addition, a majority (n = 35)
had completed a master’s-level internship
experience, with a median of 4 years’ clinical
experience, currently counseling 10 clients
per week. With respect to current work
setting (1 not reporting), 14 were working in
community mental health settings, 8 in
hospitals, 8 in university counseling centers,
5 in schools, 3 in residential facilities, 3 in
private practice, and 1 in other / not specified.
Three participants reported that they were
not currently working.
After ensuring that they met criteria for
the study, participants reviewed an informed
consent form, completed a demographic
sheet, and received one of six packets of
client materials (narrative summary, intake
report). Participants assigned a multiaxial
diagnosis to the participants after reviewing
the materials. The mean length of time
reported to diagnose was 50.54 min (SD =
30.64, range = 108; four participants did
not report length of time to diagnose). They
were then interviewed by members of the
research team using a semistructured inter­
view protocol.
Research Team
Researchers may be considered instru­
ments in qualitative inquiry, given that their
experiences and assumptions related to a
research topic influence data collection and
analysis (Patton, 2002). The research team
for this study consisted of 11 individuals
selected to ensure diverse experiences and
views related to clinical diagnosis. The team
consisted of one counselor educator and
two doctoral-level and eight master’s-level
counseling students. The first and second
authors have extensive training and research
experiences in qualitative inquiry, assess­
ment, and multicultural issues. A majority
of the research team members had didactic
and clinical experiences regarding clinical
diagnosis and multicultural issues. The
primary researcher provided training in
qualitative interviewing to those research
team members who had not conducted such
research before this study. Although the
team agreed that diagnosing is necessary,
most members reported negative experi­
ences in clinical settings—with misdiagnosis
based on counselors’ previous experiences
with clinical decision making and their
perceptions of clients’ cultural makeup.
Common assumptions for the research
team included the following: First, diagnostic
variance may be common among partici­
pants, with underdiagnosis characteristic of
those who may be reluctant to diagnose and
with overdiagnosis common for those who
hold negative attitudes toward marginalized
or oppressed groups. Second, depending on
their amount of training and perceived nega­
tive clinical experiences, participants may
rely on cognitive tools that indicate less
complex clinical decision making. Last,
parti­cipants may minimally integrate culture
and oppression experiences related to more
negative perceptions regarding severity of
functioning, prognosis, and overdiagnosis.
Data Sources
Demographic sheet. The survey packet
included a demographic sheet that solici­
ted information about participants’ cultural
 Hays et al. / Diagnostic Variance in Counseling    7

Table 1
Narrative Summary
Client is a 32-year-old [race/ethnicity] [gender] presenting to a treatment facility for an emergency intake inter-
view after [his/her] partner suggested [he/she] get evaluated. [He/She] has been partnered for five years and
has two small children. [He/she] has been a customer service manager for approximately four years, working
in a large metropolitan area. [He/She] is accompanied to the interview by [his/her] partner. Client presents
somewhat disheveled and appears anxious throughout the intake. As you go through the intake, you notice
[his/her] affect changes, from depressed to flat to angry. [He/She] appears teary during several parts of the
intake session, and [he/she] appears to have a difficult time concentrating. In addition, [he/she] is guarded
with you—particularly as you ask for examples and more detailed questions surrounding presenting symp-
toms and environmental stressors.
Client presents with a variety of mental health symptoms, including anhedonia, helplessness, depressed mood,
crying spells, self-injury, sleep and appetite disturbance, anxiety, obsessive worry, and impulsivity. [He/She]
denies psychotic symptoms, but does report some hearing voices particularly in the evening. Client denies
substance abuse problems and reports increased drinking to manage stress. Many of these symptoms have
occurred for the duration of several months.
Client states that [he/she] recently did not receive a bonus from [his/her] boss while many of [his/her] cowork-
ers did. [He/She] reports that this has caused [him/her] significant stress, and [he/she] no longer talks to
people at work. [He/She] fears that people are watching and talking about [him/her] at work, constantly
judging [his/her] performance. Client reports poor concentration at home and work. In addition, [he/she] is
involved in a court case that is associated with a customer. Client explains that the customer was angry about
some products and is now blaming [him/her]. The client reports some concern that [he/she] might lose his
job. [He/She] states that [he/she] has severe financial stressors and recently went bankrupt. [He/She]
reports that [he/she] is not able to provide for [his/her] family at this time.
Client reports that [his/her] spouse is supportive. Recently, [he/she] has been more involved with [his/her]
spirituality and prays several times per day. In addition, [he/she] states that spending money, gambling, and
drinking help [him/her] manage [his/her] stress.
Client denies mental health treatment history, past medical problems, or current medications. [He/She] reports
involvement in a substance abuse program five years ago that “helped [him/her] a lot.”

Note: Italicized text was included for clients labeled lower socioeconomic status.

makeup (e.g., race, ethnicity, gender, SES)
and academic and clinical experiences,
including assessment of training in diagno-
sis and treatment planning.
Case. Participants were presented with
the narrative summary (Table 1), which was
manipulated by race/ethnicity, gender, and
SES to develop six clients: White male,
lower SES (Client A); White female (Client
B); African American male (Client C); Latina
female (Client D); Latino male, lower SES
(Client E); and African American female,
lower SES (Client F). Participants received
more detailed information on the symptom-
ology presented in the narrative summary.
The intake report included information on
the client’s demographics (i.e., age, race/
ethnicity, gender, occupation, relationship
status, number of children, and residential
status), mental status, presenting symptoms,
family history, environmental stressors, and
medical information and treatment history.
All information was the same across partici-
pants, with the exception of the above-stated
manipulation of cultural variables.
Interview protocol. Research team mem-
bers used a semistructured interview proto-
col that contained 11 questions that assessed
assigned diagnosis or diagnoses, any con-
tributing salient presenting symptoms, any
cultural factors that contributed to present-
ing concerns or the diagnosis or diagnoses,
8    Measurement and Evaluation in Counseling and Development

Table 2
Interview Protocol
  1. What diagnosis or diagnoses would you give this client?
  2. How would you summarize the symptoms used to arrive at your diagnosis/diagnoses?
  3. Are there other diagnoses that could explain the client’s symptoms?
  4. What aspects of the case did you use to arrive at your diagnosis/diagnoses?
  5. What cultural characteristics, if any, are important to this client’s presenting problem? How so?
  6. What cultural characteristics, if any, are important in your diagnostic decision? How so?
  7. How would you describe this client’s level of functioning? How, if at all, do you see this changing with
treatment?
  8. What additional information or area of inquiry would have been helpful to you in arriving at a diagnosis?
What might make it difficult to get this additional information?
  9. As you weigh all the factors influencing your diagnostic decision, what was the most single important
factor in your decision about the client?
10. What were your initial impressions of the client? To what degree did this weigh into your diagnostic decision?
11. Were there salient/intense aspects of the client’s story? To what degree did this weigh into your diagnostic
decision?

perceived level of client functioning and
prognosis, and any limitations to the
assigned diagnosis or diagnoses (Table 2).
Several of these questions were adapted or
modeled from Trierweiler, Muroff, Jackson,
Neighbors, and Munday’s (2005) interview
protocol. For the purpose of this study,
select questions were analyzed (Questions
1–4, 8–11).
Data Analysis
Qualitative data were analyzed using
grounded theory procedures (Strauss &
Corbin, 1998) to develop a theory of how
counselors vary in their clinical decision-
making process. The authors independently
developed open codes for 10 randomly
selected interview transcripts and met to
reach consensus. During the open-coding
process, the authors went through several
iterations of a codebook to thickly describe
initial segments of information related to the
phenomenon of diagnostic variance. Data
appeared saturated after the 10 interviews
were coded, and the authors divided the
remaining 31 interviews for independent
coding. Data from each interview were
man­aged using within-case displays (Miles
& Huberman, 1994), which were used in
further coding procedures. Upon comple­
tion of open coding of the remaining
interviews, researchers met to develop
axial codes in which causal conditions and
interactions among open codes were outlined.
Descriptive data were analyzed using SPSS
14.0.
Results
Forms of Diagnostic Variance
Diagnostic variance was evident for
these participants. Specifically, participants
reported that the process of developing a
diagnosis presented challenges and limitations
owing to client and counselor characteristics
that influ­enced the clinical decision-making
process. Several Axis I and II diagnoses were
noted in this study, thereby creating 18 cate­
gories with 72 diagnoses (see Table 3). In
assigning Axis I diagnoses, 19 participants
(46%) identified a level of severity (mild,
moderate, severe) and 23 (56%) included
 Hays et al. / Diagnostic Variance in Counseling    9

Table 3
Assigned Diagnoses With Severity Rank
Rank Diagnosis n %

1 V-codes (occupational problem, bereavement problem) 2 2.7

2 Adjustment disorder 2 2.7
2 Impulse control disorder, NOS 2 2.7
2 Anxiety disorder, NOS 1 (2) 4.1
2 Mood disorder, NOS 1 1.4
3 Dysthymic disorder (2) 2.7
3 Major depressive disorder 12 (2) 19.2
4 Cyclothymic disorder 1 1.4
4 Bipolar I disorder 20 (1) 28.8
4 Bipolar II disorder 1 1.4
5 Psychotic disorder, NOS 1 1.4
5 Schizoaffective disorder 2 (1) 4.1
6 Schizophreniform/schizophrenia (1)/1 2.7
6 Personality disorder (borderline, paranoid, NOS) 2 (2) 5.5
Substance-related disorders
Alcohol abuse 7 9.6
Alcohol dependence (4) 5.5
3 Substance-induced mood disorder 1 1.4
5 Substance-induced psychotic disorder 1 1.4

Note: The research team reached consensus in ranking the severity of reported diagnoses. Diagnoses are ranked
in level severity from 1 to 6, with 1 being least severe and with 6 being the most severe or pervasive. Data
presented in parentheses represent provisional diagnoses of which participants would like additional informa­
tion to potentially rule out. Percentages reported are approximate. NOS = not otherwise specified. Substance-
related disorders, alcohol abuse, and alcohol dependence were not included in ranking process since these do not
represent mental health disorders.

a specifier (e.g., atypical features, mixed Information variance. Participants ack­

episode). For those participants who reported
an Axis III designation (n = 37), 31 (84%)
stated that there were no concerns whereas 3
(8%) deferred a decision, regarding medical
issues contributing to the presenting problem.
Identified Axis IV categories of issues (i.e.,
psychosocial or environmental problems)
included occupational (n = 30), legal (n = 27),
financial (n = 21), social (n = 10), family/
primary support group (n = 7), trauma history
(n = 4), and grief/loss (n = 3). The median
global assessment of functioning was 45
(SD = 10.04, range = 44). Subthemes, or
forms of diagnostic variance, included infor­
mation variance, observation variance, and
criterion variance.
nowledged information variance per case;
that is, they noted that the amount and type
of data available were limited to what the
client presented. Specifically, a client’s pre-
senting problems limited the accuracy and
detail of symptoms presented, or the client
intentionally minimized the amount and
severity of symptoms. Several participants
(n = 19) perceived clients as being unable or
unwilling to disclose, owing to psychosis,
substance abuse, or overall symptomology.
In addition, a majority (n = 26) noted inten-
tional client resistance: The client was
minimizing or lying about the severity of
symptoms, was defensive or resistant, or was
contradicting himself or herself. Participants
10    Measurement and Evaluation in Counseling and Development
stated that given the client’s inability or
unwillingness to report data, there were
insufficient data available from the intake
regarding treatment history (n = 23); onset,
duration, and frequency of symptoms (n =
16); current social and occupational func-
tioning (n = 10); psychosis (n = 10); family
history of mental illness (n = 9); trauma (n =
7); and degree of urgency for clinical intake
(n = 1).
Observation variance. Another form of
diagnostic variance present in this study
was observation variance, or variability in
the way that data are interpreted. Participants
interpreted data differently; some stated this
was a result of the client’s not sitting in front
of them. Others reported it to be a function
of their experience level or perceived incom-
petence when compared to other profession-
als. Although some mentioned that different
professionals interpret data differently, many
preferred to defer to professionals whom
they perceived as being more competent
(e.g., psychiatrists, psychologists), and many
viewed themselves as being incompetent
(based on their experience level). This atti-
tude was apparent in participants’ reported
levels of certainty regarding their clinical
judgments. For example, 25 participants
stated they were uncertain about their
assigned diagnosis or diagnoses, with 11
noting that they became more uncertain as
they were interviewed. Only 4 participants
reported that they became more certain
about their assigned diagnosis or diagnoses.
Criterion variance. Several participants
(n = 14) alluded to the subjective nature of
the diagnostic process—that individuals use
different criteria to diagnose. For example,
participants noted that diagnosing was an
imprecise process, that there was never
enough information available for an accurate
diagnosis, and that criteria, as presented, fit
multiple diagnoses. Relatedly, several par-
ticipants (n = 16) described changing the
severity of the assigned diagnosis during
their decision-making process owing to
the subjectivity of diagnosing. In addition,
imprecision was evident in ratings for level
of functioning. Many participants (n = 15)
were inconsistent for their Axis V and
Global Assessment Scale ratings, with an
average difference of 9.13 points between
the two assigned ratings. Moreover, other
participants (n = 7) demonstrated inconsis-
tencies between their assigned ratings for
level of functioning and their descriptions
of functioning.
Cognitive Tools
Participants employed a variety of tools in
the clinical decision-making process. These
tools influenced their degree of diagnostic
variance.
Representativeness. Some participants
(n = 18) strictly followed DSM criteria,1
stating that for a particular diagnosis, a
symptom is either a necessary criterion or
not, thus referring to the idea of expected
frequencies and base rates for a diagnosis,
given a cluster of symptoms. This subtheme
also refers to a more rigid adherence to the
DSM in making a diagnostic decision. With
respect to criteria, participants focused on
how a cluster of symptoms or criteria cor-
responded with a diagnosis or with several
diagnoses. Some participants used the deci-
sion trees in the DSM manual. Three partici-
pants noted prevalence of symptoms per
gender, based on DSM information.
Availability bias. Rather than strictly using
the DSM in diagnostic decision making,
participants (n = 29) viewed symptoms or
criteria as belonging to a diagnosis because
of their personal/clinical experiences or

academic training or as a common response
to environmental stressors. Some partici-
pants integrated a range of symptoms in
making a diagnosis. The most salient aspect
of this subtheme is that a majority of these
participants attributed their diagnostic deci-
sion to their seeing many similar cases
within their work settings. Relatedly, par-
ticipants’ clinical interests were often con-
nected to their clinical decision-making
processes. Examples include (a) having an
interest in family therapy and thus wanting
additional information on family/support
systems and recommending family therapy,
(b) having an interest in substance abuse
and thereby giving a substance abuse diag-
nosis, and (c) having an interest in attention-
deficit/hyperactivity disorder and therefore
considering a likewise diagnosis. Only one
participant noted being familiar with cul-
tural bias in diagnosing.
Vividness criterion. Most participants
found certain criteria as being more intense
and as more heavily influencing the diag-
nostic decision-making process. The most
frequently cited vividness criterion was the
presence of psychosis. Additional vivid
criteria included the following (from most
to least frequently cited): depressive symp-
toms, impulsivity, mood swings, mania,
recent suicide attempt, substance abuse,
self-injury, trauma history, and extreme
stressors. Eleven participants stated that no
vivid or salient symptoms were useful for
the decision-making process.
Anchoring. Several participants (n = 15)
described their final diagnosis as being
based on clinical data presented early in the
clinical intake and narrative summary. Most
of these data were noted as vivid criteria.
Furthermore, they described a decision-
making process in which they searched to
confirm support for initial clinical data (i.e.,
Hays et al. / Diagnostic Variance in Counseling    11
confirmation bias), during which time they
deferred or ruled out diagnoses that did not
fit their initial clinical impressions.
Locus of attribution. Participants attrib-
uted the cause or manifestation of symptoms
as a result of external factors (situational) or
internal/biological factors (dispositional).
Of the 33 participants who discussed locus
of attribution, 22 identified symptoms as a
response to external factors, and 5 attributed
symptoms to a predisposition to disorders,
based on family history of mental illness;
only 6 participants identified situational and
dispositional loci as being responsible for
symptom expression.
Discussion
This study provides support for the notion
that various forms of diagnostic variance
are evident in the clinical decision-making
process between counselors and counselor
trainees. Even though participants reviewed
one of six cases that presented identical
information regarding symptomology and
external stressors, they reported 73 diag­
noses (with varying levels of severity and
specificity), seven categories of psychosocial
or environmental problems, and differing
opinions regarding whether personality
disorder symptoms and medical concerns
should be considered. This variation was a
result of perceived diagnostic variance per
case, the degree of which was predomi­
nantly affected by participants’ adherence to
various cognitive tools.
Three subthemes were noted for diagnostic
variance: information variance, observation
variance, and criterion variance. Although
information variance refers to the limited
availability of data based on client reports
and the degree to which counselors seek
data, participants in this study acknowledged
12    Measurement and Evaluation in Counseling and Development
only that their assigned client failed to
provide sufficient data, intentionally or unin­
tentionally. Participants discussed several
categories of missing data and noted that
clients more often minimized their amount
and severity of symptoms as a form of inten­
tional resistance than as a result of symp­
tomology (e.g., paranoia, substance abuse).
Findings for this subtheme demon­strate
that counselor educators and super­visors
should discuss with trainees and practitioners
how the possibility of infor­mation variance
is related not just to clients’ insufficient
reporting but also to counselors’ unwilling­
ness or inability to ask for pertinent infor­
mation. In addition, clients may not report
clinical data because of their mistrust of
the counseling relationship, an aspect not
discussed in this study.
With respect to the second subtheme,
observation variance, participants discussed
two potentially overlapping variables—
namely, feelings of incompetence and
uncertainty with their diagnostic decisions.
Perceived incompetence refers to their
lacking experience or the right type of
experience—that is, a belief that other profes­
sionals, such as physicians and psychologists,
were more competent. In addition, a majority
of participants reported uncertainty in their
clinical decision making and, in several
cases, became more uncertain as they were
interviewed about their assigned diagnosis
or diagnoses. These predominant aspects of
observation variance are alarming, for two
reasons: First, counselors and counselor
trainees may feel incompetent as a result of
their chosen profession; second, they may
question their ability to accurately diagnose
clients partly as a function of their feelings
of incompetence. Counselor educators and
supervisors are encouraged to process, with
trainees and practitioners, reasons why
similar data and criteria are interpreted
differently among professionals, even when
formal methods and behaviorally based
criteria for clinical decision making are
available. Furthermore, they should address
the beliefs held among professionals regard­
ing ability and competence in clinical deci­
sion making.
The third subtheme, criterion variance,
relates to the subjective nature of making
clinical decisions, which leads to changes in
diagnosis and inconsistency in rating levels
of functioning. For example, participants
described selecting a diagnosis that differed
in severity from their initial diagnostic
considerations. Changes in ratings regarding
level of functioning were also evident when
comparing the Axis V rating (the global
assessment of functioning) with the Global
Assessment Scale rating, assigned after par­
ticipants were interviewed and had com­
pleted the survey packet. The subjectivity
and imprecision related to changing diag­
noses, ratings of functioning, and descrip­
tions of functioning should be addressed in
counselor education and supervision.
Adherence to cognitive tools was the
second major theme of this study, with par­
ticipants demonstrating five specific cogni­
tive tools, or subthemes: representa­tiveness,
availability bias, vividness criterion, ancho­r-
ing, and locus of attribution.
With respect to the information process­
ing tools of representativeness and availabi­
lity bias as used the clinical decision-making
process, participants utili­zed information
readily available to them (availability bias;
n = 29) more so than they did criteria as
predominantly outlined in the DSM (repre­
sentativeness; n = 18). Furthermore, only one
participant mentio­ned cultural bias as being
part of the diag­nostic decision, without
being asked directly what cultural factors
influence a client’s presenting problem or
diagnosis (i.e., avoi­dance of a schizophrenia
diagnosis for an African American client,
given the potential overdiagnosis in African

Americans). Hence, counselor trainees and
practitioners should be informed of ways in
which criteria set forth in the DSM for
particular diagnoses may be used in the
clinical decision-making process with
increased attention to cultural factors; that
is, despite the limitations of using the DSM
among all cultural groups (Eriksen & Kress,
2005), misdiagnosis or diagnostic variance
may be minimized by using a variety of
cognitive tools.
Themes related to the vividness criterion
and anchoring subthemes highlight that
salient and intense information, as presented
early in clinical assessment, biases final
diagnoses in that clinicians may defer or
rule out certain diagnoses as they confirm
the presence of their initial clinical impres­
sions. Although certain aspects of diagnoses
do provide increased evidence for particular
impressions, counselor trainees and practi­
tioners should be encouraged to monitor
their tendency to “look for what they want
or expect to see,” to avoid possible misdiag­
nosis. The final subtheme, locus of attri­
bution, points out that most participants
noted problems as being situational, yet few
focused on external stressors in the clinical
decision-making process. In addition, the
either/or position—that problems are inter­
nal or external—may hinder conceptuali­
zations of client symptomology as a result
of the interaction between biology and
environ­ment. Although the DSM does not
speak to the etiology of mental disorders,
counselor trainees and practitioners should
consider how external factors influence the
presen­tation and manifestation of symptoms,
particularly given their preference to conce­
ptualize problems using a situational locus
of attribution.
In sum, findings indicate an evolving
theory of what factors (in the form of cogni­
tive tools) influence variance (of three forms)
among counselors and counselor trainees.
Hays et al. / Diagnostic Variance in Counseling    13
Attending to these factors could improve
the clinical decision-making process, inclu­
ding the acquisition of more thorough
and accurate clinical data within the coun­
seling session and the minimization of
misdiagnosis—all of which could also
lead to more accurate treatment referrals
and better treatment outcomes for clients
across cultural identities (e.g., gender, race/
ethnicity, SES).
To further the inquiry, future research in
the area of diagnostic variance could provide
support for, and therefore confirm, these
propositions by expanding the design to
include participants from a variety of settings
and geographical regions, by presenting
client cases in different modalities (e.g.,
videotaped intake session, clients with
different symptoms), and by increasing the
type of data source (e.g., focus group inter­
views, quantitative surveys).
Note
1. That is, criteria were based on the Diagnostic
and Statistical Manual of Mental Disorders (fourth
edition, text revision; American Psychiatric Associa­
tion, 2000).
References
American Psychiatric Association. (2000). Diagnostic
and statistical manual of mental disorders (4th
ed., text rev.). Washington, DC: Author.
Dumont, F., & LeComte, C. (1987). Inferential pro-
cesses in clinical work: Inquiry into logical errors
that affect diagnostic judgments. Professional
Psychology: Research and Practice, 18, 433–438.
Ellis, M. V., Robbins, E. S., Schult, D., Ladany, N., &
Banker, J. (1990). Anchoring errors in clinical
judgments: Type I error, adjustment, or mitigation?
Journal of Counseling Psychology, 37, 343–351.
Eriksen, K. P., & Kress, V. E. (2005). Beyond the
DSM story: Ethical quandaries, challenges, and
best practices. Thousand Oaks, CA: Sage.
Gigerenzer, G. (2002). Calculated risks: How to know
when numbers deceive you. New York: Simon &
Schuster.
14    Measurement and Evaluation in Counseling and Development
Kahneman, D., & Tversky, A. (1973). On the psychol-
ogy of prediction. Psychological Review, 80(4),
237−251.
Lawson, W., Hepler, N., Holladay, J., & Cuffel, B.
(1994). Race as a factor in inpatient and outpatient
admissions and diagnosis. Hospital and Community
Psychiatry, 45, 72–74.
Lopez, S. R. (1989). Patient variable biases in clinical
judgment: Conceptual overview and methodolo­
gical considerations. Psychological Bulletin, 106,
184–203.
Miles, M. B., & Huberman, A. M. (1994). Qualitative
data analysis: An expanded sourcebook (2nd ed.).
Thousand Oaks, CA: Sage.
Paniagua, F. A. (2005). Assessing and treating cultur-
ally diverse clients: A practical guide (3rd ed.).
Thousand Oaks, CA: Sage.
Patton, M. Q. (2002). Qualitative research and evalu-
ation methods (3rd ed.). Thousand Oaks,CA: Sage.
Rosenthal, D. A. (2004). Effects of client race on
clinical judgment of practicing European American
vocational rehabilitation counselors. Rehabilitation
Counseling Bulletin, 47, 131–141.
Strauss, A., & Corbin, J. (1998). Basics of qualitative
research: Techniques and procedures for develop-
ing grounded theory (2nd ed.). Thousand Oaks,
CA: Sage.
Trierweiler, S. J., Muroff, J. R., Jackson, J. S.,
Neighbors, H. W., & Munday, C. (2005). Clinician
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journals
Permissions.nav.
race, situational attributions, and diagnoses of
mood versus schizophrenia disorders. Cultural
and Ethnic Minority Psychology, 11(4), 351–364.
Danica G. Hays, PhD, LPC, NCC, is an Assistant
Professor in the Department of Educational Leader­
ship and Counseling at Old Dominion University.
Dr. Hays’ research interests include qualitative
methodology, assessment and diagnosis, trauma and
gender issues, and multicultural and social justice
concerns in counselor preparation and community
mental health.
Amy L. McLeod, PhD, LPC, NCC, is an Assistant
Professor at Argosy University in Atlanta, Georgia.
She currently serves as Secretary for the Association
for Assessment in Counseling and Education (AACE).
Dr. McLeod’s research interests include multicultural
issues in counselor education and supervision, wom-
en’s issues, and assessment and diagnosis.
Elizabeth Prosek, MSEd, is a doctoral student in the
Department of Educational Leadership and Coun­
seling at Old Dominion University. Her research
interests include assessment models for co-occurring
disorders, diagnosis and treatment planning, and best
practice for counseling individuals with intellectual
disabilities.