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1. What if you worked in an agency that required you to formulate a diagnosis and treatment plan based on your impressions at the time of the initial session?  How would this influence your practice? How would you try to maintain your own integrity within this agency?

2. Samuel has a private practice and he receives most of his income from clients covered by managed care companies.  He is completing the paperwork to get both reimbursement and approval of the number of sessions for two new clients. Samuel is aware that the diagnosis he gives will affect the responses of the managed care reviewer. The first client, Charlie, has experienced a recent interpersonal loss and has some behaviors that meet the criteria for major depression. The second client, Amanda, has also experienced a recent interpersonal loss and has some behaviors that meet the criteria for a personality disorder. For Charlie, Samuel knows that if he gives a diagnosis of bereavement he will likely be told that the client does not need treatment and he will not be reimbursed, but if the client has Major Depressive Disorder, then the client may be given six or eight sessions. Similarly, if Samuel gives Amanda a diagnosis of Major Depressive Disorder, she will likely be approved for several sessions. However, if he assigns a diagnosis of a personality disorder, then she will not be approved for counseling. Samuel truly believes that both individuals could benefit from counseling with him.

Regarding the case study above, what diagnosis should Samuel give Charlie and Amanda?  Why?  Do you think it is unethical or illegal for Samuel to give Charlie or Amanda one diagnosis or another?  Is it unethical that an insurance company, who has not yet met the client can determine whether they will have services paid for, or how many sessions they can have? Why/why not?

3. Your textbook identifies a characteristic of a social justice counselor as being a courageous risk-taker. How courageous do you consider yourself to be when faced with opposition from others? Do you think of yourself as a risk-taker? What can you do to prepare yourself to be a social justice advocate for your clients?

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chapter 10 Issues in Theory and Practice Introduction Ethical practice requires a solid theoretical framework. Therapists’ theoretical positions and conceptual views influence how they practice. Ideally, theory helps practitioners make sense of what they hear in counseling sessions. In this chap- ter we address a variety of interrelated ethical issues, such as why a theory has both practical and ethical implications, the goals and techniques that are based on a theoretical orientation, the role of assessment and diagnosis in the therapeutic process, issues in psychological testing, and issues surrounding evidence-based practices (EBPs). Clinicians must be able to conceptualize what they are doing in their coun- seling sessions and why they are doing it. Sometimes practitioners have difficulty explaining why they use certain counseling interventions. When you first meet a new client, for example, what guidelines would you use in putting into a the- oretical perspective what clients tell you? What do you want to accomplish in this initial session? Can you explain your theoretical understanding of how peo- ple change in a clear and straightforward way? Think about how your theoretical viewpoint influences your decisions on questions such as these: • What are your goals for counseling? • What techniques and interventions would you use to reach your goals? • What value do you place on evidence-based treatment techniques? • What is the role of assessment and diagnosis in the counseling process? • How do you make provisions for cultural diversity in your assessment and treatment plans? • Does the client’s presenting problem influence the specific assessments you choose to use? • How does your theoretical viewpoint influence the specific assessment mea- sures you choose to use with clients? • How flexible are you in your approach? • What connections do you see between theory and practice? • Do you consult with colleagues on matters pertaining to theory and practice? LO1 Developing a Counseling Style Theories of counseling are based on worldviews, each with its own values, biases, and assumptions of how best to bring about change in the therapeutic process. Contemporary theories tend to be oriented toward individual change and are grounded in values that emphasize choice, the uniqueness of the individual, self-assertion, and ego strength (see Chapter 4). Many of these assumptions are inappropriate for evaluating clients from cultures that focus on interdependence, de-emphasize individuality, and emphasize being in harmony with the universe. In some cultures, basic life values tend to be associated with a focus on inner expe- rience and an acceptance of one’s environment. Within cultures that focus more on the social framework than on development of the individual, a traditional therapeutic model has limitations. In addition, it is not customary for many client populations to seek professional help, and they will typically turn first to informal systems such as family, friends, and the community. Developing a counseling approach is more complicated than merely accepting the tenets of a given theory. Ideally, the theoretical approach you use to guide your practice is the result of intensive study, reflection, and clinical experience. Fur- thermore, because a theory of counseling is often an expression of the personality of the theorist and of the therapist, it is worthwhile to take a critical look at the theorist who developed it and try to understand why it appeals to you. Uncriti- cally following any single theory can lead you to ignore some of the insights that your life and your work open up to you. This is our bias, of course, and many would contend that providing effective therapy depends on following a given the- ory. Ultimately, your counseling orientation and style must be appropriate for the unique needs of your clients and for the type of counseling you do. Developing an approach to counseling is an ongoing and fluid process. It is common for counsel- ors in training to be drawn to a particular theory initially but to modify it as they gain more experience and evaluate what seems to be working or not working with their clients. When developing or evaluating a theory, a major consideration is the degree to which that perspective helps you understand and organize what you are doing with clients. Does your framework provide a broad base for working with diverse clients in different ways, or does it restrict your vision and cause you to ignore variables that do not fit the theory? Does your theory address all types of prob- lems? Does your theory take into consideration how cultural differences operate? It is important to evaluate what you emphasize in your counseling work. The fol- lowing questions may help you make this evaluation: • At this point in your training, how would you describe your theory? • Do you anticipate that your theoretical approach will change as you gain clin- ical experience? • What does your approach emphasize and/or de-emphasize, and why does it appeal to you? • What are some of the techniques associated with your theoretical approach? • To what extent does your theory address multicultural and diversity factors? • Does your theory have research to support its effectiveness? • Is your theory a good fit with the community standards where you practice? • How would you present your theoretical model in your informed consent document? • Have your life experiences caused you to modify your theoretical viewpoint in any way? • How does your theory explain how change happens? • Does your theory view client’s problems as being more individually or more systemically based? • How does your theory affect how power is used in sessions and in the counselor–client relationship? • In what ways does your theory influence the way you see the roles of counselor and client? Your assumptions about the nature of counseling and the nature of people have a direct impact on the way you practice. The goals you think are important in ther- apy, the techniques and methods you employ to reach these goals, the way in which you see the division of responsibility in the client–therapist relationship, your view of your role and functions as a counselor, and your view of the place of assessment and diagnosis in the therapeutic process are all largely determined by your theo- retical orientation—and all of these factors have implications for ethical practice. Practicing counseling without an explicit theoretical rationale is somewhat like trying to sail a boat without a rudder. Just as a good sailor can adjust to the move- ment of the wind, a good therapist goes along with the movement of the client. A theoretical orientation is not a rigid structure that prescribes specific steps of what to do in a counseling situation; rather, it is a set of general guidelines that coun- selors can use to make sense of what they are hearing and what needs to change. Some practitioners favor an integrative approach rather than relying on a single theoretical model (Corey, 2013a, 2017). An integrative approach is not a “catch all” style but a purposeful and intentional integration of theoretical models that reso- nate with you (Kristin Vincenzes, personal communication, October 14, 2016). The Division of Responsibility in Therapy Beginning mental health practitioners often burden themselves with too much responsibility for client outcomes. They may be critical of themselves for not knowing enough, not having the necessary skill and experience, or not being sen- sitive enough. Overly anxious counselors frequently fail to include clients in the therapeutic work, focusing too much on the interventions, treatment plans, and goals rather than being present with their clients during sessions (Kristin Vincen- zes, personal communication, October 14, 2016). The question of responsibility is an integral part of the initial sessions and includes involving clients in thinking about their part in their own therapy. One way to clarify the shared responsibility in a therapeutic relationship is by a contract, which is based on a negotiation between the client and the therapist to define the therapeutic relationship. A contract (which can be an extension of the informed consent process discussed in Chapter 5) encourages both client and therapist to specify the goals of the therapy and the methods likely to be employed in obtaining these goals. For clients who have little or no knowledge of what the counseling process involves, this discussion may be limited. Legal and ethical considerations need to be taken into account in designing the contract and the treatment plan, and this is especially true when dealing with vulnera- ble populations such as children, the elderly, and clients with disabilities. A con- tract can be written, or it may be part of an ongoing discussion between therapist and client regarding treatment goals, progress, and outcomes. Therapists who work within a managed care context need to discuss with clients how managed care will influence the division of responsibility between the health management organization (HMO), the client, and the therapist. These providers may deter- mine what kinds of problems are acceptable for treatment, how long treatment will last, the number of sessions, and the focus of the work. Under this system, practitioners must be accountable to the managed care company by demonstrat- ing that specific objectives have been met. From our own perspective, therapy is a collaborative venture of the client and the therapist. Both have serious responsibilities for the direction of therapy, and this needs to be clarified from the very beginning of counseling. Lambert (2013) notes that “learning how to engage the client in a collaborative process is more central to positive outcomes than which process (theory of change) is provided” (p. 202). Most probably the therapist has the greater responsibility in the initial phase of therapy, especially in exploring the presenting problem and designing the treatment plan. In essence, the therapist has the responsibility to create the environment that allows change to take place. However, as therapy progresses, the responsibility generally shifts more to the client. Clinicians who typically decide what to discuss and are overdirective run the risk of imposing their own views and perpetuating their clients’ dependence. Clients should be encouraged to assume responsibility from the beginning of the relationship. This is especially true of the cognitive-behavioral approaches, which emphasize client-initiated contracts and homework assignments as ways in which clients can fulfill their commitment to change. These devices help to keep the focus of responsibility on clients by challenging them to decide what they want from therapy and what they are willing to do to get what they want. It also keeps the therapist more active in the process. As you consider the range of viewpoints on the division of responsibility in therapy, think about your own position on this issue. How has your position changed over time? What are the ethical implications of taking responsibility for the direction of the therapy process? Deciding on the Goals of Counseling Therapy without a goal is unlikely to be effective, yet practitioners may fail to devote enough time to thinking about the goals they have for their clients and the goals clients have for themselves. The initial task of therapy is to identify a client’s problems and concerns, which leads directly to establishing goals with the client. The therapist’s theory will greatly influence the types of goals established as well as the methods used to reach those goals. Both the therapist and the client should clearly understand the goals of their work together and the desired outcomes of their relationship. In this section we discuss possible aims of therapy, how goals are determined, and who should determine them. When considering therapeutic goals, it is important to keep in mind the cul- tural determinants of therapy. The aims of therapy may be specific to a partic- ular culture’s definition of psychological health. An effective theory considers the person-in-relation and the cultural context as essential aspects in developing appropriate goals for the helping process (see Chapter 4). Clinicians should not impose goals, but some practitioners may persuade their clients to accept certain goals. Others are convinced that the specific aims of counseling ought to be determined entirely by their clients. Who sets the goals of counseling is best understood in light of the theory you operate from, the type of counseling you offer, the setting in which you work, the problems of the client, and the characteristics of your clients. Your theoretical orientation influences gen- eral goals, such as insight versus behavior change. If you are not clear about your general goals, your techniques and approach may be random and arbitrary. Other factors can also affect the determination of goals. For example, if you work with clients in a managed care system, the goals will need to be highly spe- cific, limited to reduction of problematic symptoms, and often aimed at teaching coping skills. When you work in crisis intervention, goals are likely to be short term and functional, and you may be much more directive. Working with children in a school, you may combine educational and therapeutic goals. As a counselor to the elderly in an assisted living facility, you may stress coping skills and ways of relating to others in this environment. Working with veterans, you may intertwine career counseling, psychoeducation, and therapeutic goals. What your goals are and how actively you involve your client in determining them will depend to a great extent on the type of counseling you provide and the type of client you see. The Case of Leon Leon, a 45-year-old aeronautical engineer, has been laid off after 20 years of employment with the same company. he lives with his partner of 10 years, and they have three children together. Leon shows signs of depression, has lost weight, and was referred to you by his primary care physician. he has had no previous history of depression, but his father committed suicide at age 50. Leon is not close to his mother or siblings and describes his relationship with his partner as lackluster at best. he expresses, without much affect, feelings of abandonment at being termi- nated after so many years of dedicated service. how would you assess and work with Leon if he were your client? consider these questions: • What specific goals would you have in mind as you develop a treatment plan for Leon? • What theoretical approach would you use and why? • Would your approach include a suicide assessment? Why or why not? • Would you recommend a medical evaluation? Why or why not? • Would you assess Leon’s use of alcohol and other substances? • Would you explore Leon’s support system, and how significant would that be in setting goals? explain. • Would you consider bringing Leon’s partner in for some couples sessions? Why or why not? • to what degree would you involve Leon in creating goals? • Would you consider Leon’s unemployment a significant factor in this case? Would your goals include dealing with that reality? • how would you assess the outcomes of your work with Leon? What would need to change for you to deem your work with Leon successful? in what ways could you involve Leon in assessing outcomes? Commentary. Leon shows signs of having serious emotional problems that he is not fully expressing. some indicators are his lackluster relationship, depression, the suicide of his father, and his lack of affect. in Leon’s case, assessment is crucial to the process of identifying goals for therapy. an initial goal is to discover Leon’s purpose in seeking therapy. One of our imme- diate goals would be to assess for possible suicidal ideation, especially because of his father’s suicide. We suspect that Leon’s low affect is an indicator of much unexpressed emotional pain, which we would want to pursue with him. as part of the assessment process, we would ask about his use of alcohol or other substances to gauge whether these may be contributing to or exacerbating his presenting issue. Leon was referred by his physician, so we might ask for a release of information to learn of any medical conditions that may be contributing to Leon’s presenting problems. Our theoretical orientation will guide how we conceptualize Leon’s case and the interventions we make with him. • LO2 The Use of Techniques in Counseling Your use of techniques in counseling is closely related to your theoretical model. What techniques, procedures, or intervention methods would you use, and when and why would you use them? Out of anxiety, counselors may feel pressured to try technique after technique in an indiscriminate fashion. Practitioners must have a clear understanding of the techniques they use and why they are using them. From an ethical perspective, practitioners should have a rationale for using a particular technique and have training in the interventions they use. In a legal proceeding, a counselor may be required to provide an explicit rationale and evidence-based documentation to substantiate the interventions used with a particular client. Empirical research consistently supports the centrality of the therapeutic rela- tionship as a primary factor contributing to the psychotherapy outcome (Angus, Watson, Elliott, Schneider, & Timulak, 2015; Cain, 2016; Crits-Christoph, Gibbons, & Mukherjee, 2013; Elkins, 2016; Lambert, 2011, 2013; Norcross, 2010). The therapeutic alliance enhances the quality of the working relationship, and this alliance is the product of the collaborative efforts of both client and therapist (Cain, 2016; Keenan & Rubin, 2016). Researchers have repeatedly confirmed that a positive alliance and a collaborative therapeutic relationship are the best predictors of a positive therapy outcome (Elkins, 2016; Keenan & Rubin, 2016; Kottler & Balkin, 2017; Miller, Hubble, Duncan, & Wampold, 2010). Practitioners would do well to pay attention to the way they interact with clients and the manner in which they participate in the ther- apy, providing high levels of empathy, respect, and collaboration. Lambert (2013) believes too much attention is sometimes devoted to studying techniques rather than focusing on therapists as people and their interactions with clients. The tech- niques counselors employ, although important, are less crucial to therapy outcomes than are the interpersonal factors operating in the client–counselor relationship. Your techniques cannot be separated from your personality and your rela- tionship with your client. When practitioners fall into a pattern of mechanically employing techniques, they are not responding to the particular individuals they are counseling. To avoid this pitfall, you must pay attention to the ways you use techniques. The purpose in using a technique is to facilitate movement. You may try a technique you have observed someone else using very skillfully only to find that it does not work well for you. In essence, your techniques need to fit your therapeutic style, your level of training, and the specific needs of your client. When working with culturally diverse client populations, it is clinically and eth- ically imperative that you use interventions that are consistent with the values of your client. With all clients, it is best to adapt your techniques to the needs of your clients rather than expecting your clients to fit your techniques. Assessment and Diagnosis as Professional Issues Assessment and diagnosis are an integral part of the practice of mental health coun- seling and psychotherapy. No matter what their theoretical orientation, all compe- tent mental health practitioners use some type of assessment to arrive at a client’s diagnosis. This assessment is subject to revision as the clinician gathers further data during the therapy sessions; assessment is an ongoing part of the therapeutic process. Assessment consists of evaluating the relevant factors in a client’s life to identify themes for further exploration. Diagnosis, which is sometimes part of the assessment process, consists of possibly identifying a specific mental disorder based on a pattern of symptoms that leads to a specific diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychi- atric Association, 2013a), the official guide to a system of classifying psychological disorders and generally referred to as the DSM-5. Both assessment and diagnosis are intended to provide direction for the treatment process. Psychodiagnosis (or psychological diagnosis) is a general term covering the process of identifying an emotional or behavioral problem and making a state- ment about the current status of a client. Psychodiagnosis might also include identifying a syndrome that conforms to a diagnostic system such as the DSM-5. This process involves identifying possible causes of the person’s emotional, cogni- tive, physiological, and behavioral difficulties, leading to some kind of treatment plan designed to ameliorate the identified problem. The clinician must carefully assess the client’s presenting symptoms and think critically about how this partic- ular conglomeration of symptoms impairs the client’s ability to function in his or her daily life. Practitioners often use multiple tools to assist them in this process, including clinical interviewing, observation, psychometric tests, and rating scales. They also may make a referral for a medical evaluation. Differential diagnosis is the process of distinguishing one form of mental disorder from another by determining which of two (or more) disorders with sim- ilar symptoms the person is suffering from. The DSM-5 is the standard reference for distinguishing one form of mental disorder from another; it provides specific criteria for classifying emotional and behavioral disturbances and shows the dif- ferences among the various disorders. The DSM-5 deals with a variety of disorders pertaining to developmental stages, learning and cognition, trauma, personality, substance abuse, moods, anxiety, sex and gender identity, eating, sleep, impulse control, and adjustment. Some dispute that diagnosis should be part of the psychotherapeutic pro- cess; others see diagnosis as an essential step leading to a treatment plan. Some approaches stress the importance of conducting a comprehensive assessment of the client and see it as the initial step in the therapeutic process. The rationale is that specific counseling goals cannot be formulated and appropriate treatment strategies cannot be designed until a thorough picture of the client’s past and pres- ent functioning is formed. Furthermore, evaluation of progress, change, improve- ment, or success may be difficult without an initial assessment. Those who oppose a diagnostic model claim that the DSM labels and stigmatizes people. In performing psychodiagnosis of any type, it is crucial that clinicians consider cultural factors and how these may influence the client’s current behaviors, feel- ings, thoughts, and symptom presentation. Dadlani, Overtree, and Perry-Jenkins (2012) emphasize the importance of addressing clinicians’ and clients’ experiences with privilege and oppression as a basic aspect of diagnostic assessment. They call for a reformulation of diagnostic assessment that puts culture at the center of the assessment process. The multicultural and social justice perspective on assess- ment and treatment focuses on client strengths within a cultural and historical framework. Later in this chapter we address more fully the cultural dimensions of diagnosis. Nystul (2016) believes the clinical interview is a useful tool in the assessment and diagnostic process because it provides a structure for organizing information. The clinical interview serves many purposes, some of which are providing infor- mation on a client’s presenting problems, giving glimpses of historical factors that may be contributing to the client’s condition, and providing a framework for mak- ing a differential diagnosis to determine whether an individual suffers from a par- ticular mental disorder. Because most therapy settings require a clinical interview, familiarity with this form of assessment is essential. Nystul claims that the clinical interview can be structured to suit both the counselor’s theoretical orientation and the unique needs of the client. Theoretical Perspectives on Assessment and Diagnosis LO4 Depending on the theory from which you operate, a diagnostic framework may occupy a key role or a minimal role in your therapeutic practice. Practitioners using a cognitive-behavioral approach and the medical model may place heavy emphasis on the role of assessment as a prelude to the treatment process. Many practitioners using relationship-oriented approaches view the process of assess- ment and diagnosis as external to the immediacy of the client–counselor relation- ship. They feel that it distracts the therapist from concentrated attention on the subjective world of the client. The developmental, multicultural, and social justice theoretical model empha- sizes client strengths (Ivey, Ivey, Meyers, & Sweeney, 2005; Zalaquett et al., 2008). The individual develops within a family in a community and cultural context, and this model places greater attention on environmental and contextual issues. By establishing an egalitarian therapeutic relationship, clients can be actively involved in diagnosis and case formulation, with the goal of fostering their psy- chological liberation (Crethar, Torres Rivera, & Nash, 2008; Duran et al., 2008). Understanding differences among theoretical models has relevance for ethi- cal practice because the way in which diagnosis is practiced rests on theoretical foundations. Regardless of the particular theory espoused by a therapist, both clin- ical and ethical issues are associated with the use of assessment procedures and diagnosis as part of a treatment plan. Practitioners within the same theoretical model often differ with respect to the degree to which they employ a diagnostic framework in their clinical practice. The box titled “Assessment and Diagnosis and Contemporary Theories of Counseling” provides a summary of the way each model addresses assessment and diagnosis. Assessment and Diagnosis and Contemporary Theories of Counseling issues in theory and Practice / 375 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-202 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Psychoanalytic Therapy some psychoanalytically oriented therapists, though certainly not all, favor psychodiagnosis. this is partly due to the fact that for a long time in the United states psychoanalytic practice was largely limited to people trained in medicine. Adlerian Therapy assessment is a basic part of adlerian therapy. the initial session focuses on developing a relationship based on a deeper understanding of the individual’s presenting problem. a com- prehensive assessment involves examining the client’s lifestyle. the therapist seeks to ascertain the faulty, self-defeating beliefs and assumptions about self, others, and life that maintain the problematic behavioral patterns the client brings to therapy. Existential Therapy the main purpose of existential clinical assessment is to understand the personal meanings and assumptions clients use in structuring their existence. this approach is different from the traditional diagnostic framework because it focuses on understanding the client’s inner world, not on understanding the individual from an external perspective. Person-Centered Therapy Like existential therapists, person-centered practitioners maintain that the best vantage point for understanding another person is through his or her subjective world. they believe that traditional assessment and diagnosis are detrimental because they are external ways of understanding the client. Gestalt Therapy gestalt therapists attend to interruptions in the client’s here-and-now awareness and encour- age clients to explore what they are experiencing in the present. the emphasis on the present moment is viewed as being more important than interpretations or any diagnosis. Behavior Therapy the behavioral approach begins with a comprehensive assessment of the client’s present functioning, with questions directed to past learning that is related to current behavior. Prac- titioners with a behavioral orientation generally favor a diagnostic stance, valuing observation and other objective means of appraising both a client’s specific symptoms and the factors that have led up to the client’s malfunctioning. such an appraisal, they argue, enables them to use the techniques that are appropriate for a particular disorder and to evaluate the effectiveness of the treatment program. Cognitive-Behavioral Approaches the assessment used in cognitive-behavioral therapy is based on getting a sense of the client’s pattern of thinking using a collaborative approach. Once self-defeating beliefs have been identified, the treatment process involves examining specific thought pattern

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