Testing then treating a client?

[mypointlesspov]

What's the consensus on completing psychological or psychoeducational testing then being the one to treat that same client? This came up at my practice this week as we are in the process of starting our testing program. I've heard from other colleagues that they don't do this and I'm not sure if that's a personal boundary or an ethical issue. There wasn't anything specific in the APA ethics code about this (I checked sections 3, 9, and 10), but I'm inclined to not treat anybody that I've evaluated based on what I've heard past colleagues do and based on my experiences doing testing during graduate school. At one of my placements, we were expressly not allowed to treat anyone we evaluated. Granted, this was a forensic/hospital-based setting so I'm not sure if that would apply elsewhere.

That being said, one of my colleagues at the practice who comes from school psychology background said she prefers to be the one to treat anyone she tests because she has the most information about them going into it. I can see her reasoning there. I'm also from a school psychology background, but in a largely non-traditional role so I never ended up working with the few kids I evaluated.

Side note: I forgot how much goes into testing. I'm getting back into the swing of things for the first time in 4 years and I'm finding myself feeling overwhelmed by the prospect of writing a report when I used to churn out about two per month during grad school.

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[WisNeuro]

Testing and treating, yes. But I would always also offer them providers as referrals, as long as such services were present in the community and legit. Treating, then testing. Nope.

 

[Mama Bear]

Dual relationship stuff. I would examine the context/purpose to determine if it would become a problematic dual relationship. Diagnostic test as part of their treatment for the sole purpose of aiding in my understanding of the client and how to best treat them? Maybe ok. An assessment battery that may impact eligibility for outside services and the client is heavily invested in the diagnosis and results? I’m going to refer that out.

 

[Therapist4Chnge]

In a clinical setting (workers comp only), I'll do the intake and testing and then have them follow-up with counseling (with one of my counselors); the testing informs treatment. I agree with WisNeuro about not doing treatment and THEN assessment. For pre-surgical and pain psych assessment, I view those as congruent with follow-up psychoeducation and/or counseling. Sometimes I'll refer out the neuro cases after testing, it really depends on the referral question(s) and vibes of the patient. I used to be an assessment only practice, but so many of my referring providers wanted to be able to refer to one office for both, I made the adjustment. Anything remotely related to forensic/legal work or differential diagnosis is strictly an assessment and then refer out.

 

[AcronymAllergy]

Agree with the above--test then treat is generally okay, depending on the nature of the initial assessment. Treating then testing is where things get sticky, unless the assessment is limited and essentially solely for the purpose of informing treatment/tracking progress.

 

[BuckeyeLove]

Greenberg, S. A., & Shuman, D. W. (1997). Irreconcilable conflict between therapeutic and forensic roles. Professional Psychology: Research and Practice, 28(1), 50–57.

 

[mypointlesspov]

Thanks for the input, everyone. Our concensus was that treatment then testing is explicitly a no, but we weren't sure about the opposite.

The evaluations we're doing at our practice are for ADHD or autism and usually with psychoed components as they're being given to schools and colleges to potentially get access to SPED services/accommodations. We just got our first person who came in asking for both testing and treatment which is why this came up. My concern was the dual relationship aspect, so I'll just stick to referring anyone I test to other providers and let my colleague use their clinical judgment to decide what's right for them.

 

[Pragma]

Agree with the above--test then treat is generally okay, depending on the nature of the initial assessment. Treating then testing is where things get sticky, unless the assessment is limited and essentially solely for the purpose of informing treatment/tracking progress.

This also reflects my attitude on this issue. But even when testing first then treating, should be thoughtful and purposeful about it.

 

[AcronymAllergy]

Thanks for the input, everyone. Our concensus was that treatment then testing is explicitly a no, but we weren't sure about the opposite.

The evaluations we're doing at our practice are for ADHD or autism and usually with psychoed components as they're being given to schools and colleges to potentially get access to SPED services/accommodations. We just got our first person who came in asking for both testing and treatment which is why this came up. My concern was the dual relationship aspect, so I'll just stick to referring anyone I test to other providers and let my colleague use their clinical judgment to decide what's right for them.

In that case, yeah, I'd probably refer out. Especially as they may need further documentation and/or assessment from you in the future.

 

[PsyDr]

Thanks for the input, everyone. Our concensus was that treatment then testing is explicitly a no, but we weren't sure about the opposite.

The evaluations we're doing at our practice are for ADHD or autism and usually with psychoed components as they're being given to schools and colleges to potentially get access to SPED services/accommodations. We just got our first person who came in asking for both testing and treatment which is why this came up. My concern was the dual relationship aspect, so I'll just stick to referring anyone I test to other providers and let my colleague use their clinical judgment to decide what's right for them.

Chance that someone loses it, when you don't dx ADHD or ASD: high.

 

[AcronymAllergy]

Chance that someone loses it, when you don't dx ADHD or ASD: high.

It wasn't even for formal testing accommodations, but I still remember the mother of a college underclassman calling our psych services clinic in grad school to yell at me when my eval said her son didn't have ADHD.

 

[BuckeyeLove]

Where this gets real weird is if its a super circumscribed area of practice (and one without a ton of actual research support). I had a supervisor who ran a VERY successful sex offender assessment and treatment practice. He did psycho-sexual risk evals (not bad ones by any stretch) and then if the risk was there, recommended treatment (usually group but individual if needed). He was the ONLY provider in a 100 mile radius. So...one stop shop. Never got called to task for it either. Which...if you're the only one available, it is what it is i guess. At the end of the day the literature is pretty meh about if we can actually treat these guys anyway, but he still makes a boatload.

 

[Therapist4Chnge]

Where this gets real weird is if its a super circumscribed area of practice (and one without a ton of actual research support). I had a supervisor who ran a VERY successful sex offender assessment and treatment practice. He did psycho-sexual risk evals (not bad ones by any stretch) and then if the risk was there, recommended treatment (usually group but individual if needed). He was the ONLY provider in a 100 mile radius. So...one stop shop. Never got called to task for it either. Which...if you're the only one available, it is what it is i guess. At the end of the day the literature is pretty meh about if we can actually treat these guys anyway, but he still makes a boatload.

I knew a guy who would do "fly in" forensic work, a great gig if you set it up right. He covered CA and a state or two in the midwest. The guy makes/made a killing because he did it direct and not through a 3rd party, as the pass-through companies take a chunk for basically having the prison contract. I casually talked with some recruiters (pre-COVID), and the locations are in the middle of nowhere and some of the file review can be rough. Being forensic-trained (i.e. to do NGRI, risk assessments, etc) is a blank check if you enjoy doing assessment work and you have a decent amount of business sense. If you don't, you can still work with your local courts, but some pay really poorly.

 

[BuckeyeLove]

I knew a guy who would do "fly in" forensic work, a great gig if you set it up right. He covered CA and a state or two in the midwest. The guy makes/made a killing because he did it direct and not through a 3rd party, as the pass-through companies take a chunk for basically having the prison contract. I casually talked with some recruiters (pre-COVID), and the locations are in the middle of nowhere and some of the file review can be rough. Being forensic-trained (i.e. to do NGRI, risk assessments, etc) is a blank check if you enjoy doing assessment work and you have a decent amount of business sense. If you don't, you can still work with your local courts, but some pay really poorly.

You ain't kidding. It's almost offensive in some counties (including my home one currently). For reference, Courts (really it's delegating agencies who handle the contracts) pay between 55-60 dollars an hour for contract forensic work. I want you to think about that. 55-60 bucks an hour. From what i can tell, these rates have not increased with inflation the last 10-15 years. How they get away with it i have no idea. Meanwhile I make significantly more than that per hour at my ACTUAL W2 job. Let's not even talk about what i charge for private cases. I just don't get how these Courts have justified keeping these rates so low. While like you said, if you're willing to put in the work, you can make a total killing going out of state - usually ones no one wants to live in - to help with backlog (a few years ago i did this in Alabama).

 

[WisNeuro]

You ain't kidding. It's almost offensive in some counties (including my home one currently). For reference, Courts (really it's delegating agencies who handle the contracts) pay between 55-60 dollars an hour for contract forensic work. I want you to think about that. 55-60 bucks an hour. From what i can tell, these rates have not increased with inflation the last 10-15 years. How they get away with it i have no idea. Meanwhile I make significantly more than that per hour at my ACTUAL W2 job. Let's not even talk about what i charge for private cases. I just don't get how these Courts have justified keeping these rates so low. While like you said, if you're willing to put in the work, you can make a total killing going out of state - usually ones no one wants to live in - to help with backlog (a few years ago i did this in Alabama).

Yeah, I see some of the court mandated fees in some places and wonder what kind of evaluators they're able to procure at those rates. I'll stick with my PI/WC/FAA/etc cases.

 

[borne_before]

I test and treat all the time!

But, I do kiddo evaluations only. Usually once testing is done, I know the kid and family pretty well. My process can be very therapeutic as well. I also split testing up over multiple days (usually three with a separate feedback) because I want to get the best information and most of my patients can't handle a neurobattery over multiple hours. Neither can I.

Referrals are usually doctors, parents, etc. A main purpose of my evals is to qualify for services OR to figure out what is going on (ADHD v. Anx, ODD vs ASD, Dyslexia Vs Intellectual disability, etc).

Lets say a kiddo has:

• autism - then I will offer the family parent training (loving the RUBI manual lately) as they get plugged into ABA (can take months).
• ADHD/Oppositionality - Usually some flavor of parent training (personal peeve: clinicians who waste a lot of time/money doing individual therapy on kiddo with ADHD when that is the only issue).
• Anxiety - parent mediated interventions like SPACE if warranted; individual therapy (CBTish) if cognitively able and motivated (usually teenage girls lol).
• Depression - PMT/individual therapy.

I don't really see it as a conflict, but I also don't do forensic or divorce junk either.

 

[borne_before]

Chance that someone loses it, when you don't dx ADHD or ASD: high.

Fun fact: my first and only board complaint is relevant here. Most people would just get a second opinion. The joys of working with the public, I guess. The same parent made a complaint against another provider at my work but their board actually has a stronger screening process than mine. Apparently that complainer parent has made at least three other complaints around town.

The whole process sucked and was one of the most stressful things of my life. But, work forked over for a good lawyer (Psychologist/JD) and circled the wagons around me (physicians get sued all the time).

The situation kind of validated my process and I used my lawyer to tighten things up even more. For instance, they suggest setting up a formal monthly case consultation. My work eagerly agreed, even though we're constantly consulting each other. (boards love consultation and when you practice within competencies and adhere to best practices). The screening committee basically had two questions and a unanimous dismissal.

Now I do lot's of "let's say it isn't autism, how would you feel about that? when a parent seems a little attached to a certain diagnosis." and "this eval might reveal a different conclusion."

 

[mypointlesspov]

You ain't kidding. It's almost offensive in some counties (including my home one currently). For reference, Courts (really it's delegating agencies who handle the contracts) pay between 55-60 dollars an hour for contract forensic work. I want you to think about that. 55-60 bucks an hour. From what i can tell, these rates have not increased with inflation the last 10-15 years. How they get away with it i have no idea. Meanwhile I make significantly more than that per hour at my ACTUAL W2 job. Let's not even talk about what i charge for private cases. I just don't get how these Courts have justified keeping these rates so low. While like you said, if you're willing to put in the work, you can make a total killing going out of state - usually ones no one wants to live in - to help with backlog (a few years ago i did this in Alabama).

My grad school research in the late 10s was focused on assessing the content and quality of state funded forensic evals. This was a HCOL state and they'd maybe get $1200 for a full eval, twice that for a neuro. It was one of the big factors that put me off of forensics. The state wanted to make sure they were getting the best bang for their buck, but a lot of the evals were poorly done because psychologists seemed to be rushing through them.

 

[BuckeyeLove]

My grad school research in the late 10s was focused on assessing the content and quality of state funded forensic evals. This was a HCOL state and they'd maybe get $1200 for a full eval, twice that for a neuro. It was one of the big factors that put me off of forensics. The state wanted to make sure they were getting the best bang for their buck, but a lot of the evals were poorly done because psychologists seemed to be rushing through them.

It's the same with SSDI evals (which pay i believe 165 per report, and a bit of a bump up for testing). The only way people make it financially make sense is to do as many as possible in as little amount of time as possible. I knew a dude who would schedule 13 SSDI evals in a 4 hour period. He accurately estimated a 66 percent show rate. He would have a psych assistant do the majority of the interview and then lay eyes on the claimant. At the end of the day he was still making his 300/hr hourly rate by doing this. Same goes for some people i see doing state/county forensic work. Psych assistant, schedule a ton of people, template report, bing bang boom submit. I just can't get myself to do this. If I'm doing an evaluation I make sure it is essentially un-impeachable, which requires time. But not worth my time for those rates.

 

[cara susanna]

66% show rate for SSDI evals?? I would think people would have high motivation to show up for those.

 

[BuckeyeLove]

66% show rate for SSDI evals?? I would think people would have high motivation to show up for those.

I know right? You'd think it would have been higher. I did them for a bit when i was bored and that matched my number as well. I have a feeling the show rate is a lot higher for a vet going in for a CP exam (and hoping for continued service connection).

 

[WisNeuro]

66% show rate for SSDI evals?? I would think people would have high motivation to show up for those.

As far as I know, besides just needing to wait longer for an evaluation, there is no penalty for the no-shows, similar to the VA.

 

[cara susanna]

As far as I know, besides just needing to wait longer for an evaluation, there is no penalty for the no-shows, similar to the VA.

Right, but the longer you wait for the eval, the longer you wait before you get money.

 

[WisNeuro]

Right, but the longer you wait for the eval, the longer you wait before you get money.

Motivation and organization are a struggle for a lot of people. But yeah, low pay and difficult patients is a good reason I don't do this work. I do screen out a decent number of referrals in which physicians refer patients to me for a "disability eval." And then I remind them about how insurance fraud is generally frowned upon, especially when you've documented it.

 

[ClinicalABA]

I test and treat all the time!

But, I do kiddo evaluations only. Usually once testing is done, I know the kid and family pretty well. My process can be very therapeutic as well. I also split testing up over multiple days (usually three with a separate feedback) because I want to get the best information and most of my patients can't handle a neurobattery over multiple hours. Neither can I.

Referrals are usually doctors, parents, etc. A main purpose of my evals is to qualify for services OR to figure out what is going on (ADHD v. Anx, ODD vs ASD, Dyslexia Vs Intellectual disability, etc).

Lets say a kiddo has:

• autism - then I will offer the family parent training (loving the RUBI manual lately) as they get plugged into ABA (can take months).
• ADHD/Oppositionality - Usually some flavor of parent training (personal peeve: clinicians who waste a lot of time/money doing individual therapy on kiddo with ADHD when that is the only issue).
• Anxiety - parent mediated interventions like SPACE if warranted; individual therapy (CBTish) if cognitively able and motivated (usually teenage girls lol).
• Depression - PMT/individual therapy.

I don't really see it as a conflict, but I also don't do forensic or divorce junk either.

Similar situation in my clinic (though treatment is limited to ABA services). While I mostly do testing, I do at times get involved in the treatment of the children I diagnosis with ASD. I occasionally perform billed ABA treatment services (billed as BCBA codes under my ABA license rather than my psych license), and pretty frequently provide clinical consultation (non-billed) as the senior clinician in my region.

The big ethical concern would be providing an invalid diagnosis in order to be able to provide (and be paid for) treatment services. This can be an issue in ABA treatment, where A) the diagnosis is required to access ABA services; and B) the the treatment services can be quite extensive, especially relative to the relatively small number of (generally 1x) assessment hours that are provided.

As far a providing invalid diagnoses, I address any concerns there by being relatively conservative and "by the book" when reaching diagnostic conclusions. If I don't see the symptom (or have multiple sources of reports of symptoms that I wouldn't see in office, such as overly negative reactions to certain food textures or loud sounds), I don't endorse that symptom as present. In my summary section on the report, I make sure to list all symptoms that met criteria for the diagnosis, and their source (e.g., direct observation, formal testing, or parent/other therapist report). Basically, if not enough symptoms are present to meet DSM-5 criteria, I don't make an "it's close enough" ASD (or other) diagnosis, even if subjectively I think it is ASD.

When I do make a diagnosis and recommend ABA services, I specifically say that "there are several agencies in the area that provide such services, and we are one of them. I encourage you to look at as many agencies as you can and pick the one that you feel will work best for your family." In my written recommendations, I make no mention of any specific agency or "our services". This issue is somewhat ameliorated in that I almost exclusively see children under three who are receiving Early Intervention Services (my state's birth-to-three program). In such cases, the EI case coordinator helps with the referral and must provided at least some information on each ABA agency. Furthermore, any ABA agency doing services with children in EI has to respond to an RFR from the state (detailing all the services they provide, including diagnosis) and be selected by the state.

TLDR- original poster is wise to be thinking about such things. Always err on the side of being more ethical. However, treating individuals you diagnose is not explicitly prohibited by the general APA ethics code. As other posters have mentioned, there may be more consideration if you are doing forensic evals. The goal of the eval should be to provide an empirically justified diagnosis within a recognized diagnostic criteria system (e.g., DSM-5), and you should have the data to justify that diagnosis, whether you treat or not.