Assessment and diagnosis are integrally related to the practice of counseling and psychotherapy, and both are often viewed as essential for planning treat- ment. Regardless of their theoretical orientation, therapists need to engage in assessment, which is generally an ongoing part of the therapeutic process.
Assessment should not precede and dictate intervention; rather, it is woven in and out of the therapeutic process as a pivotal component of therapy itself (Duncan, Miller, & Sparks, 2004). This assessment may be subject to revision as the clinician gathers further data during therapy sessions. Some practitioners consider assessment as a part of the process that leads to a formal diagnosis.
Assessment consists of evaluating the relevant factors in a client’s life to identify themes for further exploration in the counseling process. Diagnosis, which is sometimes part of the assessment process, consists of identifying a specifi c mental disorder based on a pattern of symptoms that leads to a specifi c diagnosis. Both assessment and diagnosis can be understood as providing di- rection for the treatment process.
Psychodiagnosis is the analysis and explanation of a client’s problems. It may include an explanation of the causes of the client’s diffi culties, an account
of how these problems developed over time, a classifi cation of any disorders, a specifi cation of preferred treatment procedure, and an estimate of the chances for a successful resolution. The purpose of diagnosis in counseling and psycho- therapy is to identify disruptions in a client’s present behavior and lifestyle.
Once problem areas are clearly identifi ed, the counselor and client are able to establish the goals of the therapy process, and then a treatment plan can be tailored to the unique needs of the client. A diagnosis provides a working hy- pothesis that guides the practitioner in understanding the client. The therapy sessions provide useful clues about the nature of the client’s problems. Thus diagnosis begins with the intake interview and continues throughout the dura- tion of therapy.
The classic book for guiding practitioners in making diagnostic assess- ments is the fourth edition of the American Psychiatric Association’s (2000) Diagnostic and Statistical Manual of Mental Disorders, Text Revision (also known as the DSM-IV-TR). Clinicians who work in community mental health agencies, private practice, and other human service settings are generally expected to as- sess client problems within this framework. This manual advises practitioners that it represents only an initial step in a comprehensive evaluation and that it is necessary to gain information about the person being evaluated beyond that required for a DSM-IV-TR diagnosis.
Although some clinicians view diagnosis as central to the counseling pro- cess, others view it as unnecessary, as a detriment, or as discriminatory against ethnic minorities and women. Irvin Yalom (2003), who is a psychiatrist, recom- mends that therapists avoid diagnosis based on his belief that “diagnosis is often counterproductive in the everyday psychotherapy of less severely impaired patients” (p. 4). Yalom contends that diagnosis limits vision, diminishes a ther- apist’s ability to relate to a client as a person, and may result in a self-fulfi lling prophecy.
CONSIDERING ETHNIC AND CULTURAL FACTORS IN ASSESSMENT AND DIAG- NOSIS A danger of the diagnostic approach is the possible failure of counsel- ors to consider ethnic and cultural factors in certain patterns of behavior. The DSM-IV-TR emphasizes the importance of being aware of unintentional bias and keeping an open mind to the presence of distinctive ethnic and cultural patterns that could infl uence the diagnostic process. Unless cultural variables are considered, some clients may be subjected to erroneous diagnoses. Certain behaviors and personality styles may be labeled neurotic or deviant simply be- cause they are not characteristic of the dominant culture. Counselors who work with African Americans, Asian Americans, Latinos, and Native Americans may erroneously conclude that a client is repressed, inhibited, passive, and unmoti- vated, all of which are seen as undesirable by Western standards.
ASSESSMENT AND DIAGNOSIS FROM VARIOUS THEORETICAL PERSPEC- TIVES The theory from which you operate infl uences your thinking about the use a diagnostic framework in your therapeutic practice. Many practitio- ners who use the cognitive behavioral approaches and the medical model place heavy emphasis on the role of assessment as a prelude to the treatment process.
The rationale is that specifi c therapy goals cannot be designed until a clear picture emerges of the client’s past and present functioning. Counselors who base their practices on the relationship-oriented approaches tend to view the process of assessment and diagnosis as external to the immediacy of the client- counselor relationship, impeding their understanding of the subjective world of the client. As you will see in Chapter 12, feminist therapists contend that traditional diagnostic practices are often oppressive and that such practices are based on a White, male-centered, Western notion of mental health and mental illness. Both the feminist perspective and the postmodern approaches (Chap- ter 13) charge that these diagnoses ignore societal contexts. Therapists with a feminist, social constructionist, solution-focused, or narrative therapy orienta- tion challenge many DSM-IV-TR diagnoses. However, these practitioners do make assessments and draw conclusions about client problems and strengths.
Regardless of the particular theory espoused by a therapist, both clinical and ethical issues are associated with the use of assessment procedures and pos- sibly a diagnosis as part of a treatment plan.
A COMMENTARY ON ASSESSMENT AND DIAGNOSIS Is there a way to bridge the gap between the extreme view that diagnosis is an essential part of therapy and the extreme view that it is a detrimental factor? Most practitioners and many writers in the fi eld consider assessment and diagnosis to be a continuing process that focuses on understanding the client. The collaborative perspective that involves the client as an active participant in the therapy process implies that both the therapist and the client are engaged in a search-and-discovery process from the fi rst session to the last. Even though some practitioners may avoid formal diagnostic procedures and terminology, making tentative hypoth- eses and sharing them with clients throughout the process is a form of ongoing diagnosis. This perspective on assessment and diagnosis is consistent with the principles of feminist therapy, an approach that is critical of traditional diag- nostic procedures.
Ethical dilemmas may be created when diagnosis is done strictly for insur- ance purposes, which often entails arbitrarily assigning a client to a diagnostic classifi cation. However, it is a clinical, legal, and ethical obligation of thera- pists to screen clients for life-threatening problems such as organic disorders, schizophrenia, bipolar disorder, and suicidal types of depression. Students need to learn the clinical skills necessary to do this type of screening, which is a form of diagnostic thinking.
It is essential to assess the whole person, which includes assessing dimen- sions of mind, body, and spirit. Therapists need to take into account the bio- logical processes as possible underlying factors of psychological symptoms and work closely with physicians. Clients’ values can be instrumental resources in the search for solutions to their problems, and spiritual and religious values often illuminate client concerns. For an excellent discussion of the role of spiri- tual and religious values in the assessment and treatment process, see Integrat- ing Religion and Spirituality Into Counseling (Frame, 2003).
For a more detailed discussion of assessment and diagnosis in counseling practice as it is applied to a single case, consult Case Approach to Counseling and
Psychotherapy (Corey, 2009b), in which theorists from 11 different theoretical orientations share their diagnostic perspectives on the case of Ruth.
The Value of Evidence-Based Practice
Mental health practitioners must choose the best therapeutic approach or inter- ventions with a particular client. For many practitioners this choice is based on their theoretical orientation. In recent years, however, practitioners have begun promoting specifi c interventions for specifi c problems or diagnoses based on empirically supported treatments (Cukrowicz et al., 2005; Deegear & Lawson, 2003). Increasingly, clinicians are encountering the concept of evidence-based practice (McCabe, 2004). The central aim of evidence-based practice (EBP) is to require psychotherapists to base their practice on techniques that have empiri- cal evidence to support their effi cacy. Research studies empirically analyze the most effective and effi cient treatments, which then can be widely implemented in clinical practice (Norcross, Beutler, & Levant, 2006). Evidence-based practice requires clinicians to be accountable to their clients and to have up-to-date in- formation on effective treatments (Edwards, Dattilio, & Bromley, 2004).
Evidence-based practice is a potent force in psychotherapeutic practice to- day, and it may mandate the types of treatments therapists can offer in the future (Wampold & Bhati, 2004). Although it may seem that there is universal agreement that practitioners should rely on evidence as a guide in determining what works, deciding what qualifi es as evidence is no simple matter (Norcross et al., 2006).
The managed health care system is a driving force in promoting empiri- cally supported treatments (Deegear & Lawson, 2003). In many mental health settings, clinicians are pressured to use interventions that are both brief and standardized. In such settings, treatments are operationalized by reliance on a treatment manual that identifi es what is to be done in each therapy session and how many sessions will be required (Edwards et al., 2004). Edwards and his colleagues point out that psychological assessment and treatment is a business involving fi nancial gain and reputation. In seeking to specify the treatment for a specifi c diagnosis as precisely as possible, health insurance companies are concerned with determining the minimum amount of treatment that can be expected to be effective. This raises ethical questions about whether the insur- ance company’s need to save money is being placed above the needs of clients.
Many practitioners believe this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process and individual variability. Indeed, relying exclusively on standardized treat- ments for specifi c problems may raise another set of ethical concerns because the reliability and validity of these empirically based techniques is question- able. Human change is complex and diffi cult to measure beyond such a sim- plistic level that the change may be meaningless. Furthermore, not all clients come to therapy with clearly defi ned psychological disorders. Many clients have existential concerns that do not fi t with any diagnostic category and do not lend themselves to clearly specifi ed symptom-based outcomes. EBP may have something to offer mental health professionals who work with individuals with
specifi c emotional, cognitive, and behavioral disorders, but it does not have a great deal to offer practitioners working with individuals who want to pursue more meaning and fulfi llment in their lives.
Counseling is not merely a technique that needs to be empirically validat- ed. Many aspects of treatment—the therapy relationship, the therapist’s per- sonality and therapeutic style, the client, and environmental factors—are vital contributors to the success of psychotherapy. Evidence-based practices tend to emphasize only one of these aspects. Norcross and his colleagues (2006) argue for the centrality of the therapeutic relationship as a determinant of therapy outcomes. They add, however, that the client actually accounts for more of the treatment outcome than either the relationship or the method employed. Sub- stantial research supports these contentions (see Lambert & Barley, 2002).
Norcross and his colleagues (2006) believe the call for accountability in mental health care is here to stay and that all mental health professionals are challenged by the mandate to demonstrate the effi ciency, effi cacy, and safety of the services they provide. They emphasize that the overarching goal of EBP is to enhance the effectiveness of client services and to improve public health and warn that mental health professionals need to take a proactive stance to make sure this goal is kept in focus. They realize there is potential for misuse and abuse by third-party payers who could selectively use research fi ndings as cost-containment measures rather than ways of improving the quality of ser- vices delivered. Norcross and his colleagues stress the value of informed dia- logue and respectful debate as a way to gain clarity and to make progress.
Miller, Duncan, and Hubble (2004) are critical of the EBP movement and ar- gue that “signifi cant improvements in client retention and outcome have been shown where therapists have feedback on the client’s experience of the alliance and progress in treatment. Rather than evidence-based practice, therapists tai- lor their work through practice-based evidence” (p. 2). Practice-based evidence involves using data generated during treatment to inform the process and out- come of treatment. This topic is discussed in more detail in Chapter 15.
Dual and Multiple Relationships in Counseling Practice
Dual or multiple relationships, either sexual or nonsexual, occur when coun- selors assume two (or more) roles simultaneously or sequentially with a cli- ent. This may involve assuming more than one professional role or combining professional and nonprofessional roles. The term multiple relationship is more often used than the term dual relationship because of the complexities involved in these relationships. In the latest revision of the ACA Code of Ethics (ACA, 2005) both of these terms have been replaced with the term nonprofessional interactions to indicate additional relationships other than sexual ones. Many forms of nonprofessional interactions or nonsexual multiple relationships pose a challenge to practitioners. Some examples of nonsexual dual or multiple rela- tionships are combining the roles of teacher and therapist or of supervisor and therapist; bartering for goods or therapeutic services; borrowing money from a client; providing therapy to a friend, an employee, or a relative; engaging in a social relationship with a client; accepting an expensive gift from a client; or
going into a business venture with a client. Some multiple relationships are clearly exploitative and do serious harm both to the client and to the profes- sional. For example, becoming emotionally or sexually involved with a current client is clearly unethical, unprofessional, and illegal. Sexual involvement with aformer client is unwise, can be exploitative, and is generally considered un- ethical.
Because nonsexual dual and multiple relationships are necessarily complex and multidimensional, there are few simple and absolute answers to resolve them. It is not always possible to play a single role in your work as a counselor, nor is it always desirable. You may have to deal with managing multiple roles, regardless of the setting in which you work or the client population you serve.
Give careful thought to the complexities of multiple roles and relationships be- fore embroiling yourself in ethically questionable situations.
Ethical reasoning and judgment come into play when ethics codes are ap- plied to specifi c situations. The revised edition of the ACA Code of Ethics (ACA, 2005) stresses that counseling professionals must learn how to manage multiple roles and responsibilities in an ethical way. This entails dealing effectively with the power differential that is inherent in counseling relationships and training relationships, balancing boundary issues, addressing nonprofessional relation- ships, and striving to avoid using power in ways that might cause harm to cli- ents, students, or supervisees.
Although dual and multiple relationships do carry inherent risks, it is a mistake to conclude that these relationships are always unethical and neces- sarily lead to harm and exploitation. Some of these relationships can be benefi - cial to clients if they are implemented thoughtfully and with integrity (Lazarus
& Zur, 2002; Zur, 2007). An excellent resource on the ethical and clinical dimen- sions of multiple relationships is Boundaries in Psychotherapy: Ethical and Clinical Explorations (Zur, 2007).