C Clients give so much about themselves verbally and non-verbally in counseling sessions that it overwhelms clinicians who do not organize the information and use it to create a structured plan for their joint work, argues Nathaniel N. Ivers , Associate Professor and Chair of the Department of Counseling at Wake Forest University.
Fully understanding a client's situation, symptoms and needs and then comparing them with a diagnosis (if appropriate) and a treatment plan that will help them heal, grow and thrive are core aspects of professional counseling. Consultants learn these skills, at least conceptually, in the graduate school, but gain a real understanding of them through their direct work with clients.
This knowledge is put to practical use "where the rubber comes on the street," says Ivers, a member of the American Counseling Association. Thoroughly investigating a client's concerns – going beyond superficial questions like "How did this week go?" Or "What do you want to talk about?" – is the most inclusive and effective way to develop a comprehensive treatment plan and set a goal for the client and practitioner working together in therapy.
Ivers admits that full-cased counselors may be reluctant to spend time devising a comprehensive, inclusive plan for each client. But as he says to his students: The more you do, the easier it becomes.
"At some point, you don't have to write a complete, multi-step case conceptualization plan for every client," says Ivers, a licensed professional advisor in Texas and a licensed clinical mental health advisor in North Carolina. "But if at some point … you have trouble figuring it out, you have to go back to it – put a pen on paper and come up with a complete plan."
In teaching these concepts to students, Ivers often shares a quote from psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo in Canada and one of the founders of cognitive behavioral therapy: “A clinician without a conceptual case model is like a captain of a ship without one Oars, drifting around aimlessly with little or no direction. "
An important responsibility
The three components of assessment, diagnosis and treatment planning are inextricably linked and provide counselors with a “map” to offer an evidence-based treatment that best suits the client, says Shannon Karl, ACA member, professor and field clinical coordinator in the Department of Counseling at Nova Southeastern University in Florida. The process is not only critical in creating a basis for counseling work with a client, but also creates a way for the individual to obtain appropriate treatment services from counselors and interdisciplinary professionals.
Assessment, diagnosis, and treatment planning are important tasks, and mastering these skills is often closely related to the clinician's confidence, Karl says, so it is understandable that new professionals should be concerned when things get right do. She urges counselors who feel this way to remember that their mentors are there to advise and support them. Similarly, counselor training and supervision programs are designed to help trainees through this learning curve, she says.
Even so, beginners and experienced counselors alike should seek further training, peer counseling and mentoring throughout their careers in these areas, emphasizes Karl, co-author of the ACA-published book DSM-5 Learning Companion for Counselors. It is essential for counselors to keep these skills up to date, not only because they are an integral part of the counseling process, but also because diagnoses and the associated criteria are constantly changing and developing.
Karl was a member of an ACA working group that was formed to study the updates and changes introduced in 2013 to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). until many counseling practices updated their procedures to reflect changes made between the fourth and fifth editions of the DSM.
Karl encourages clinicians to stay informed and up-to-date by attending workshops, conferences and other training events; regular consultation with specialist colleagues; Looking for mentor or supervision; Joining professional list servs; and reading counseling magazines and other publications. Working actively with state and local advisory organizations will also help practitioners keep up with criteria and processes that vary from state to state, she notes. Leadership within the counseling profession must ensure that funding for advanced training in diagnostics, diagnosis and treatment planning is prioritized, especially for counselors in economically disadvantaged or rural areas and environments where practices or clinics are scarce, Karl adds.
“One thing that we can do at all levels is to ensure that clinicians have access to free or inexpensive training courses, workshops, and seminars. Accessibility is important, ”says Karl, a licensed psychologist who specializes in childhood trauma and DSM-5 disorders. “Regardless of the work environment, it is important for professional consultants to be able to serve their customers in the best possible way. We cannot help others to heal in isolation. "
Danica Hays, author of the ACA-published book Assessment in Counseling: Procedures and Practices, notes that postgraduate counseling students often only take one class on assessment and diagnosis. In order to complete the knowledge of the consultants, in addition to the competence acquired through experience, continuous further training is necessary.
"With the amount of material to be covered, [counselor graduate education] lessons often focus on case conceptualization and treatment planning by simply following a prescription," says Hays, professor and dean of the College of Education at the University of Nevada , Las Vegas. Gaining extensive knowledge, which includes “other types of knowledge – often by scholars and practitioners of color – can be incredibly helpful in ensuring that customers are not harmed by an incomplete and / or distorted story told on their behalf she adds.
Customer-controlled
Tracie Keller, a licensed professional clinical counselor and supervisor in Ohio, has found that working directly with the client to identify goals and create a treatment plan builds trust and the relationship between clinician and client which in turn improves treatment outcomes. She emphasizes this collaborative approach on the website of her group practice in Columbus, Ohio by including the following statement: "We believe that treatment planning is a process that both the therapist and the client jointly determine."
Keller tries to look at the process from the client's perspective. She notes that when she went to a doctor and the doctor prescribed a treatment plan and medication without bothering to tell her she had the flu, she was questioning what was going on and whether the doctor was hers Post estimated.
Keller, who specializes in treating clients with eating disorders and trauma-related problems, says a prescriptive approach never really worked for her. “[Clients know] even the best,” she says. “For me it is [collaborative treatment planning] something that creates a lot of trust. It's not just about dictating “this is what I want you to do”, but instead [clients] walking alongside to achieve the goals they want. … If the customer does not buy, [counseling] will not be successful. "
Hays notes that involving clients in case design and treatment planning also enables better cultural understanding and better responsiveness. Counselors have a great responsibility for getting a client's story right, she says, and "to get the story right, it must be constructed with the client in a way that takes into account their cultural experiences as well as trauma and resilience issues."
“A really good assessment is to commit to collecting a client's story with that client, using basic helping skills to confirm what the client is sharing as they share it, several qualitative and quantitative tools involved in the process and suggesting a treatment and evaluating it with the customer, ”says Hays. "The assessment may therefore not include many questions, but [rather] more space within the sessions for the client to share their stories with the power and voice to confirm or refute an evolving conceptualization of these stories."
When Keller starts working with a new client, she listens carefully as they discuss their history and symptoms. Keller often notices possible diagnoses and topics to be dealt with in counseling while listening, but she keeps these ideas for the time being. Instead, she encourages the client to reflect on treatment goals and asks questions such as "If you could change something in your life by working together, what would that be?" Or "What would you like to be different in your life after our relationship has ended?"
Clients who show symptoms of an eating disorder may respond with statements like "I don't want to fight my body anymore" or "I'm sick of hating my body," says Keller. In this example, Keller and the client could work together to develop a goal of improving the client's body image in counseling. Later, when the client has made progress towards this goal and has developed a stronger therapeutic relationship with Keller, she will return to some of the problems revealed in the first assessment session and try to relate those problems to the client's treatment goals. For example, if the client mentioned cleaning behaviors or restrictive eating in the first session, Keller could gently suggest that this behavior could be something to achieve the client's goal of achieving healthy body image.
Since Keller accepts insurance in her practice, she diagnoses all of her clients in order to submit them for reimbursement. Keller tells each customer that she will share his diagnosis with his insurance company and she takes time to explain the diagnosis to the customer and how she came to that decision. Depending on the client, she sometimes takes out her copy of the DSM-5 in the session and goes through the diagnostic criteria with them.
"I talk about it from the start because you are in a very vulnerable area [at intake] and it is important to be really transparent about what your diagnosis is and what it means," says Keller. She never progresses with a treatment plan or diagnosis unless a client agrees.
After discussing the diagnosis with the client, she explains the methods and tools she uses (such as cognitive behavioral therapy or desensitization and reprocessing of eye movements) to treat this particular diagnosis and how she will adapt her approach, to help the client meet the treatment goals they have identified.
A large part of the initial goal setting and therapeutic work with clients is often aimed at reducing symptoms, says Keller. As treatment progresses, she works with clients to postpone or change treatment goals in order to go beyond symptom management and focus on the problems that are below their original concern.
For example, a client with chronic depression might first identify goals that are to improve their mood and alleviate their symptoms. Later, when their symptoms subside and the client feels better, they may be ready to focus on past trauma or relationship problems that they previously did not have the bandwidth to address, says Keller.
She finds that this process often happens organically; The "win" in symptoms subsiding often motivates clients to identify additional goals. "It's cool because you have a lot of trust and previous success in therapy [at that point] and the client often wants to dig deeper and make bigger changes," says Keller.
The clients' treatment plans must evolve and remain flexible as the needs of the clients change during the therapy. Keller notes that it is common for people with eating disorders to experience periods when their symptoms worsen, sometimes leading to hospitalization or inpatient treatment. Whenever this happens, Keller works with the client to change their treatment plan and identify various goals for the near future, and then repeat the process after the client has been discharged or otherwise improved.
The assessment should not be limited to the first and final sessions with a client. As Keller points out, an important part of this process is aligning with the client's needs and integrating the assessment work into each session. She says that she constantly listens to short and long term treatment goals.
"During the course of treatment, you will receive information with every session," says Keller. “When you go with them, you learn more and more: how they relate to you, how they relate to other people. You cannot ignore this information. It will guide you. I constantly evaluate this information and record it. "
Keller admits that her understanding of the treatment planning process has expanded over time. "Now it's a process that comes to mind every single session – not just at the intake and exit," she says. “Even if I don't talk to the customer about it, I think of every conversation through the lens of its goals. It becomes an unspoken but omnipresent aspect of the work and moves it further. ”
Diagnosis: A love-hate relationship
Many professional advisors have mixed feelings about the diagnosis. On the one hand, it can be a tool that connects clients with the mental health care they need. On the other hand, it can be viewed (by both clinicians and clients) as a “label” that accompanies clients throughout their treatment and in some cases for life.
Keller says she understands both sides; However, she values diagnosis and finds it useful. Diagnosis is a tool that enables her to understand how to help her clients initially, and she guides her interventions and therapeutic approach as treatment progresses. It can also remove financial barriers to mental health care. Consultation can be expensive and insurance companies usually require a diagnosis for reimbursement. Keller therefore sees the diagnosis as a way of giving patients access to treatment who could not afford advice without insurance cover.
The key, says Keller, is to be completely transparent to clients and to involve them in the diagnostic process, especially with diagnoses that can carry a stigma such as personality disorders, substance use disorders, and eating disorders. In some cases counselors may have to offer psycho-education in order to dispel inaccuracies or stereotypes about a diagnosis.
"With that I can sometimes have a love-hate relationship [diagnosis]", admits Keller. “It can have a stigma and a burden to share with the insurance company. … Often in the end of the therapy we have to process and unpack a lot, [including] what you [clients] heard and experienced while carrying this diagnosis. If I can be involved with them in this process and recognize the stigma, I can help them. "
Ivers says that the diagnosis can be limited, even if clients develop a feeling of dependence on their diagnosis or use it as a "crutch". But overall, he notes that the diagnostic process generally encourages counselors to seek best practice, research, and resources to help and support their clients.
"We have to be careful not to reduce people to their diagnosis," warns Ivers. “But for others, it can be a relief to finally get a name for the collection of symptoms they are experiencing. It can also open you up for treatment and put you through to you [their counselor] or other doctors who can help with your specific concern, [including] prescribe medication. ”
Karl agrees that a benefit of diagnosis is that it often helps to connect clients to interdisciplinary treatment. Even if a counselor does not have to assign diagnoses to clients, he must have “comfortable awareness” and basic knowledge of the diagnostic process and be able to carry clients so that they can be linked to further treatment if necessary, says Karl. Screening skills and diagnostic skills are also a prerequisite for admission as a counselor in many states, and therefore something that one needs to keep up to date through further training, she adds.
The diagnosis also requires that counselors know how to use the DSM. Karl advises clinicians to familiarize themselves with looking up things in the manual and knowing where to turn if they have questions or need more information, rather than trying to memorize the contents.
In addition, the DSM mentions certain conditions where counselors are not involved in the diagnosis, such as: B. Neurodevelopmental Disorders. However, because counselors are often included in treatment plans for clients with these diagnoses, they still need to be competent enough to understand each DSM diagnosis and its best treatment practices, even if they are not diagnosing the client themselves. Karl noted.
Trying to remember all the nuances of the diagnoses in the DSM means “adjusting to failure”, says Karl. The DSM-5 contains more than 1,000 pages and hundreds of diagnoses. Even though doctors have been able to remember everything in the manual, the information is regularly revised and updated. Because of this, Karl urges the consultants to focus on having a core knowledge of the manual, getting used to it, using it as a resource, and adapting to it as it changes.
Potential bias
Consultants are people with individual personalities and world views, so there is always the possibility that potential biases creep into the assessment, diagnosis and treatment planning. To avoid this, clinicians need to think carefully about their biases and really think about their assessment questions and diagnostic processes, says Ivers, who presented the "Using Case Conceptualization to Navigate the Turbulent Waters of the Human Condition" session at ACA Conference & Expo 2018 .
Ivers emphasizes that consultants must critically question why they ask what they ask – and what not. "If a client acknowledges some of the cultural struggles he is facing and we circumvent these problems and do not focus on them," he says, "we tell him that it is not therapeutically important."
"Case design is a tool and when used effectively it can be extremely helpful," notes Ivers. “But when used ineffectively, it can be hurtful and harmful. In the case of culture, it can actively discriminate and misdirect. It can [cause a clinician to] try to bring a customer into a form. "
Clinicians must also bear in mind that assessment and diagnostic tools can have an innate bias. Models often have “cultural tastes” and are based on what is traditional (or westernized) rather than what is deviant or non-dominant, says Ivers. He teaches Jon and Len Sperry's case conceptualization method to his students at Wake Forest. One of the advantages of the model, according to Ivers, is that it allows flexibility and customization based on the client's cultural factors. (For more information, see the article by Jon and Len Sperry in Counseling Today, "Case Conceptualization: Keys To Highly Effective Counseling.")
“There are proven differences in the way symptoms are expressed from culture to culture, and therefore individuals do not exactly fit into diagnosis or treatment boxes.
She points out that research shows that there are disproportionately many psychological problems in people with marginalized status. "The question was whether differences in diagnosis rates – based on case conceptualizations – are actual differences between cultural groups or whether they can be traced back to incorrect assessment and diagnosis processes on the part of the counselor," says Hays. “The answer is probably a bit of both. The cultural bias of counselors significantly shapes the assessment and treatment, and experiences of privilege, oppression, trauma and resilience shape the symptoms presented. "
Keller admits that the potential bias of doctors in assessment, diagnosis and treatment planning is one of the most confusing aspects of professional advice. The search for feedback through regular consultations with specialist colleagues and participation in the counseling itself is of inestimable value in this area.
Personal advice and professional advice enable Keller to process things, identify their “blind spots” and work through their own prejudices, “so that they don't come out of the counseling room,” she says. "The last thing I want is that my things [my client’s] influence things."
Ivers admits that it is "inherently reductionist" to structure all information a counselor receives from a client during the therapeutic relationship into a treatment model and plan. A loss of data cannot be prevented because the consultant processes all information, he says.
"It is therefore important to remain flexible and to be aware that there can be blind spots," advises Ivers. “You will never get it 100 percent right, and that's why we [counselors] keep reviewing and modifying a treatment plan. But hopefully you are on the right track. "
An extra-occupational learning curve
It is not easy to competently assess what a client needs and then meet those needs with an accurate and responsive treatment plan that will help the person heal. For this reason, consultants continuously develop and strengthen these skills throughout their careers.
Keller says her goal remains to expand her assessment, diagnosis, and treatment planning skills over the coming decades to better serve her clients. "To be an effective advisor means to trust and agree to always learn and grow ourselves," says Keller. “If I stop doing that, I should probably stop practicing. Consulting is a process that I have to be ready to grow and change and develop with – just like clients do. [Counselors should] Trust that it is okay – and even good – to learn wherever you are on your professional path. "
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Wrestling with the previous diagnosis of a client
It is not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes through a referral, the counselor may have case notes with the diagnosis in writing. In other situations, a client can tell the counselor that they have been told they have a particular diagnosis. This means that there is a possibility that the client has misunderstood or incorrectly remembered clinical terms that he heard from another doctor or found on the Internet.
So what happens if the counselor does not agree with the previous diagnosis after getting to know the client? It's a common scenario, says Shannon Karl, a licensed mental health advisor and professor at Nova Southeastern University. She asks counselors to remember that people grow and change, so a diagnosis should not be static. An earlier diagnosis may no longer be relevant or applicable to a client, especially if it is older than a few years.
Counselors have to come to their own conclusions about a client without a previous diagnosis coloring their assessment, says Karl.
Danica Hays, professor and dean of the College of Education at the University of Nevada, Las Vegas, suggests that practitioners ask the client questions to get additional information about a previous diagnosis, including how (and by whom) it was made was asked how the client perceives the diagnosis, to what extent the client still identifies with the diagnosis and how or whether he has the feeling that the diagnosis has led to finding support to address his symptoms.
"Given the inevitable role of bias in clinical decision-making, counselors should always be careful when a client presents a treatment history in which they have been diagnosed in a particular way," says Hays. “It is important that counselors not rush to jump to a diagnosis based on what was previously diagnosed. This is a clear example of the inadequate way in which cognitive tools are used to provoke misdiagnosis and abuse of clients. ”
The role of a counselor also includes ensuring that a client feels heard and trusted when discussing previous diagnoses or conditions he believes have but are yet to be diagnosed, adds Tracie Keller , a licensed professional clinical advisor, added.
"I try to keep this [information] with respect and honor, but at the same time I make my own assessment and treatment plan based on what I hear," says Keller, who owns a counseling practice in Columbus, Ohio. "I use that as a starting point to ask further questions, [as] as a starting point to dig deeper."
Karl arbeitete einst als Berater für psychische Gesundheit in einer Schmerzklinik, wo sie die Freiheit hatte, eine erste Sitzung mit Kunden zu führen, bevor sie die Patientenakten öffnete und überprüfte. „Die Kunden schätzten es sehr, dass ich mir ein paar Minuten Zeit nehmen wollte, um es [their mental health history] von ihnen zu hören“, sagt Karl. „Sie wussten, dass sie die Chance hatten, ihre Geschichte ohne Filter mit mir zu teilen.“
Karl räumt ein, dass dies den meisten Beratern nicht möglich sein wird. Sie fordert die Kliniker jedoch auf, Wege zu finden, die Hintergrundgeschichte eines Klienten in ihren eigenen Worten zu hören, selbst wenn sie die Diagnose und die Krankengeschichte des Klienten kennen, bevor die Person die Tür betritt.
„Wir müssen die Möglichkeit bewahren, die Geschichten der Kunden von ihnen zu hören“, sagt Karl. „Denken Sie daran, dass wir nicht durch unsere Diagnosen definiert werden; wir wachsen und entwickeln uns in positive richtungen. Was vorher geschah, bedeutet nicht, dass es jetzt passiert. Seien Sie sich bewusst, dass die Beurteilung ein kontinuierlicher, fortlaufender Prozess ist und eine Diagnose niemals in Stein gemeißelt wird. Wenn wir aus dieser Perspektive kommen, hilft es uns, die Kunden so zu sehen, wie sie sind, im Gegensatz zu dem, womit sie gekennzeichnet sind.“
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Bethany Bray ist eine leitende Autorin und Social-Media-Koordinatorin für Counseling Today. Kontaktieren Sie sie unter [email protected].
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