Unit 8 Last Assignment

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 patterns and substitut- ing constructive ones. continued Reality Therapy reality therapists do not make use of psychological testing and traditional diagnosis. instead, through the use of skillful questioning, the therapist helps clients make an assessment of their current behavior. this informal assessment encourages clients to focus on what they want from life and to determine whether what they are doing is working for them. Feminist Therapy feminist therapists have criticized the DSM classification system, claiming it emphasizes the individual’s symptoms and ignores the social factors that cause dysfunctional behavior. the feminist assessment process emphasizes the cultural context of clients’ problems, especially the degree to which clients possess power or are oppressed. they contend that as tradition- ally practiced, diagnostic systems such as the DSM reflect the dominant culture’s definitions of psychology and health. Misdiagnosis and blaming the victim may occur when sociopolitical factors are minimized or ignored. Postmodern Approaches solution-focused brief therapy and narrative therapy are two examples of postmodern ther- apies that do not emphasize formal diagnosis or categorization of individuals. Postmodern approaches do not highlight a client’s deficits, problems, failures, and what is wrong with people. instead, emphasis is placed on an individual’s competencies, accomplishments, skills, strengths, and successes. the therapist’s assessment and provisional diagnosis are generally arrived at by collaborative conversations with a client. Systemic Therapies family systems therapists believe that many symptoms stem from problems within the system, rather than originating in the individual. in most systemic approaches, both therapist and client are involved in the assessment process. some systemic therapists assist clients in tracing the key events of their family history and identifying issues in their family of origin. as a part of the assessment process, individuals may be asked to identify what they learned from inter- acting with their parents, from observing their parents’ interactions with each other, and from observing how each parent interacted with each sibling. source: Case Approach to Counseling and Psychotherapy (corey, 2013b). DSM-5 Assessment Although you may not yet have had to face the practical task of diagnosing a cli- ent, you will need to come to terms with this reality at some point in your work. Many state licensing boards require applicants to demonstrate competence in the use of diagnostic tools including the DSM-5. Regardless of your theoretical ori- entation, you will most likely be expected to work within the DSM framework if you are practicing in a community mental health agency or in any other agency in which insurance companies pay for client services. Because you will need to think within the framework of assessing and diagnosing clients, it is important that you become familiar with the diagnostic categories and the structure of the DSM-5. The Council for Accreditation of Counseling and Related Educational Pro- grams (CACREP, 2016) emphasizes the need for counseling students to acquire the competencies that will enable them to effectively use DSM-5 assessment in their practices. Important advances in neurology, genetics, and the behavioral sciences over the past two decades have increased our understanding of mental illness. In the DSM-5, considerable attention has been given to developmental issues, gaps in the current system, disability and impairment, neuroscience, and cross-cultural issues (American Psychiatric Association, 2012a, 2013a). Cultural factors are included in assessment by using the Cultural Formulation Interview, a semistructured inter- view with 16 questions. Comas-Diaz and Brown (2016) contend that this cultural formulation is limited because “the American Psychiatric Association’s cultural for- mulation is medically oriented and is, consequently, based on clients’ deficits and psychopathology instead of focusing on clients’ strength and resilience” (p. 250). The DSM-5, like its predecessors, has attracted broad criticism and debate (Pickersgill, 2014). Vanheule and Devisch (2014) point out that the DSM-5 lacks an operational framework for assessing distress when diagnosing a mental dis- order. Other scholars have also been critical of the contents of the DSM-5, but Cosgrove and Wheeler (2013) focus on the firestorm of controversy surrounding DSM-5 panel members’ ties to the pharmaceutical industry. It was reported that 69% of task force members who oversaw development of the revised manual had ties to the pharmaceutical industry, an increase of 21% over previous edi- tion task force members who had such relationships (Cosgrove & Krimsky, 2012). Blumenthal-Barby (2014) believes this emphasis will have consequences: an increasing number of phenomena that were previously considered “clinically unremarkable” (p. 531) are now labeled as mental disorders and are likely to be treated pharmacologically. “The authors of the DSM-IV have critiqued the authors of the DSM-5 for expansions that they believe will cause harm from over-diagnosis and false- positives in practice” (Blumenthal-Barby, 2014, pp. 531–532). Reflecting on lessons they learned from working on the previous edition of the manual, the authors of that edition cited examples of diagnoses such as Asperger’s and bipolar II, which were added to the DSM-IV, that ultimately were “wildly overused in ways that were never intended” (p. 532). They expressed their concerns that the DSM-5 could potentially provoke several more epidemics. Another controversy emerged prior to publication of the DSM-5 when the National Institute of Mental Health (NIMH) announced plans to develop its own psychiatric nosology, the Research Domain Criteria (RDoC), which would classify mental disorders based on specific functional analysis of certain cells, genes, neu- ral circuits, and behaviors (Pickersgill, 2014; Sisti, Young, & Caplan, 2013). With the aim of informing future editions of the DSM and the International Classifica- tion of Diseases (ICD), another widely used classification system, the RDoC rests on the premise that the only objective way to classify disorders is to start with biology and work back to symptoms. The NIMH hopes to create biosignatures for mental conditions and, through the creation of the RDoC, suggests that mental disorders can be explained through a value-neutral combination of genetics, imag- ing, and neuroscience. Advocates of an exclusively biomedical model strive to minimize the role of values in a classification of psychiatric conditions, but some argue that values infuse medical categories in a variety of ways: Values can drive practical considerations about where and how to divide up constella- tions of already agreed upon symptoms. Or they might operate at a more fundamental level and influence what is considered to be dysfunctional or disordered behavior in the first place. (Sisti et al., 2013, p. 2) Sisti and colleagues (2013) concluded that values and objectivity are compatible, as can be seen in many psychiatric cases. The idea that the RDoC classification system “will be somehow value-free and objective because it begins with genes instead of behavior is to impose a value on crude reductionism that will not lead to any more objectivity than can be found in the pages of the DSM-5” (p. 4). The Case For Psychodiagnosis LO5 Practitioners who favor the use of diagnostic procedures argue that such proce- dures enable the therapist to identify a particular emotional or behavioral dis- order, which helps in designing an appropriate treatment plan. Diagnosis stems from the medical model of mental health, which holds that different underlying causal factors, some of which are biological, produce different types of disorders. Proponents of traditional diagnosis often make the following points: • Therapists have a legal, professional, and ethical obligation to assess whether clients may pose a danger to themselves or to others. They also need to screen for disorders that might respond best to a combination of medication and psy- chotherapy. Diagnosis may alert them to the need for a referral to a physician or a psychiatrist for a medical diagnosis, or for the treatment of a possible neuropsychological problem. • Practitioners must be skilled in understanding and utilizing diagnostic proce- dures in order to function effectively in most mental health agencies. • In working with a professional team, diagnosis is essential so that all team members have a common language and a common frame of reference. • A diagnosis may be helpful to the therapist who wants to consult with other therapists about a given client. • Diagnosis can assist in conceptualizing a case. • It may be difficult to formulate a meaningful treatment plan without clearly defining the specific problems that need to be addressed. Diagnosis can help clinicians identify treatment possibilities, as they clearly specify particular symptoms and difficulties the client is experiencing. • Diagnosis can provide information about possible causal factors associated with different types of mental disorders. • Diagnosis can provide a framework for research on diagnostic categories and into various treatment approaches. • A diagnosis may be critical to determine therapeutic success, which can be defined as the reduction of symptoms or the absence of the disorder as a con- sequence of treatment. • Practitioners who work in an agency seldom have a choice about diagno- sis. In many cases, they are required to make a diagnosis, often in the first session. • Diagnosis may be a minimum standard of care for some licensed profession- als. The failure to formulate a diagnosis may result in legal and credential consequences. • There often is no insurance reimbursement without an acceptable diagnosis. • Diagnosis can help to normalize a client’s situation. Some clients find reassur- ance in knowing they are not alone and that there is a name for their condition. The Case Against Psychodiagnosis LO6 Some mental health professionals believe DSM diagnosis has many limitations and that it can harm clients. Some voices in the field have been critical of the broader philosophy behind this diagnostic and medical model, and we include their concerns here. Carl Rogers (1961) consistently maintained that diagnosis was detrimental to counseling because it tended to pull clients away from an inter- nal and subjective way of experiencing themselves and to foster an objective and external conception of themselves. The result was an increased tendency toward dependence, with clients acting as if the responsibility for changing their behavior rested with the expert and not with themselves. Feminist therapists have challenged the DSM system and proposed alterna- tives for making meaningful assessments. Therapists who question the usefulness of traditional diagnosis make these observations: • Diagnosis is typically done by an expert observing a person’s behavior and experience from an external viewpoint, without reference to what they mean to the client. • Diagnostic categories can minimize the uniqueness of the client. When clients are categorized, it can lead to imposing labels on them in such a way as to not see their complexity or individuality. • Reducing people to the sum of their symptoms ignores natural capacities for self-healing. • Because the emphasis of the DSM model is on pathology, deficits, limitations, problems, and symptoms, individuals are not encouraged to find and utilize their strengths, assets, competencies, and abilities. • Diagnosis can lead people to accept self-fulfilling prophecies or to despair over their condition. • Diagnosis can narrow therapists’ vision by encouraging them to look for behavior that fits a certain disease category. A diagnostic framework is based on a medical model that is not congruent with many counselors’ core values and beliefs (Zalaquett et al., 2008). • DSM diagnoses do not adequately consider contextual, social, and cultural factors. • DSM diagnoses are based on the assumption that distress in a family or social context is the result of individual pathology, whereas a systemic approach views the source of the distress as being within the entire system. • The best vantage point for understanding another person is through his or her subjective world, not through a general system of classification. • Some disorders, especially those associated with children, depend on adults in homes and schools to give subjective reports that are often self-serving in terms of trying to control the child or to protect themselves. • A diagnosis assigned to clients can have implications for their employment and future employability status. • Many of the warnings against diagnosis speak to social justice issues. Often the person with the least power is the one being labeled, which can further silence oppressed clients and communities. Carlos Zalaquett, a counselor educator, contends that some professionals assume they understand a particular person by knowing his or her diagnosis (personal communication, January 29, 2009). In reality, DSM diagnoses do not cap- ture the uniqueness of the individual. A diagnosis is a label with no capacity to describe the totality of a human being. Therefore, it is always important to learn how the specific diagnosis is expressed in a particular client. Zalaquett adds that, once formulated, a diagnosis can follow an individual even if the assigned diag- nosis no longer fits the person. For example, a college student diagnosed with a major depressive disorder associated with difficulties in college may not be accepted in a work-related position at some later time. Even though the person is no longer depressed, he or she may still carry the stigma of being labeled as depressed, which could have long-term implications. Our Position on Assessment and Psychodiagnosis Both assessment and diagnosis, broadly construed, are legitimate parts of the ther- apeutic process. The kind of diagnosis we have in mind is the result of a collabo- rative effort by the client and the therapist, also referred to as co-diagnosis. Both should be involved in discovering the nature of the client’s difficulty, a process that commences with the initial sessions and continues until therapy is terminated. Even practitioners who oppose conventional diagnostic procedures and terminol- ogy unavoidably make an assessment of clients based on questions such as these: • What brought the client into therapy? • What are the client’s resources for change? • What are the client’s strengths and vulnerabilities? • Has the client had previous success in dealing with a similar problem? • What does the client want from therapy, and how can it best be achieved? • What should be the focus of the sessions? • What environmental factors are contributing to the client’s problems, and what can be done to alleviate these external factors? • In what ways can an understanding of the client’s cultural background shed light on developing a plan to deal with the client’s problems? • What role does the client’s spirituality play in assessing and treating the problem? • What specific family dynamics might be relevant to the client’s present strug- gles and interpersonal relationships? • What kind of support system does the client have? • What are the prospects for meaningful change? From our perspective, assessment and diagnosis (either formal or informal) help the practitioner conceptualize a case, implement treatment, and evaluate out- comes. The clinician and the client can discuss key questions as part of the ther- apeutic process. Clinicians will develop hypotheses about their clients, and they can talk about these conjectures with them. Diagnosis does not have to be a mat- ter of categorizing clients; rather, practitioners can think more broadly, describe behavior, and think about its meaning. In this way, diagnosis becomes a process of thinking about the client with the client. Diagnosis can be viewed as a general descriptive statement identifying a client’s style of functioning. The therapist can develop hunches about a client’s behavioral style and perhaps even share these observations with the client as a part of the therapeutic process. Comas-Diaz and Brown (2016) suggest that a process-oriented clinical assessment can be appropriate for culturally diverse clients. The first task in this assessment is to engage clients in treatment by inviting them to tell their story. Comas-Diaz and Brown recommend “that cultural similarities and differences be explored during the initial stages of assessment and then continuously throughout treatment” (p. 249). As we emphasized earlier, we favor a collaborative approach to assessment that includes the client as a therapeutic partner. After the initial assessment of the client is completed, a decision can be made whether to refer the individual for alternative or additional treatment. The assessment information can be used in exploring the client’s difficulties in thinking, feeling, and behaving and in estab- lishing treatment goals. Assessment and diagnosis can be linked directly to the therapeutic process, forming a basis for developing methods of evaluating how well the therapist’s procedures are working to achieve the client’s goals. Using diagnostic nomenclature is a reality that most practitioners must accept, especially if they work within a managed care system or with a third-party reim- bursement system. For therapists who are required to work within a diagnostic framework, the challenge is to use diagnosis as a means to the end of providing quality service to clients rather than as an end in itself that leads to a justification for treatment. We concur with Herlihy, Watson, and Patureau-Hatchett (2008) that it is possible to work within a diagnostic framework in an ethical and diversity- sensitive manner. They offer the following suggestions for diversity-sensitive diagnosis. Reflecting on their recommendations can be a useful route to avoiding bias in one’s diagnostic practices. • Counselor self-awareness is the starting point for culturally sensitive diagnosis. • Rather than assess only symptoms of behavior, strive to gather informa- tion about the context in which clients live and the meaning of their life experiences. • Do not assume that differences between the counselor and the client are nec- essarily barriers to effective counseling. • If symptoms are identified, consider reframing them as coping mechanisms as opposed to signs of pathology. • Consider the benefits of making diagnosis a collaborative process. issues in theory and Practice / 381 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/o Herlihy, Watson, and Patureau-Hatchett conclude that the DSM system is here to stay, at least for the foreseeable future. The question for mental health practi- tioners is not whether to use the DSM system but how to use it while being cultur- ally sensitive in a way that can benefit clients. Clarifying Your Position What is your position on diagnosis? The following questions may help you clarify your thinking on this issue: • After reviewing the cases for and against psychodiagnosis, what position makes the most sense to you and why? • Some contend that clients have a right to know their diagnoses as part of informed consent. What do you think of this practice? What client variables would you consider when discussing a diagnosis with a client? • Some maintain that clients should not be told their diagnoses because of the possibility of their living up to a self-fulfilling prophecy. What is your thinking on this matter? • If you were working for an agency that relied on managed care programs, how would you deal with the requirement of quickly formulating a diagnosis and a treatment plan, generally within the initial session? How would you work with the limitations of being able to see clients for no more than six visits? • What are your thoughts about the right of clients to decide whether informa- tion will be released to third-party payers? • Do you agree or disagree that therapists who do not accept the medical model, yet who provide diagnoses for reasons of third-party payments, are compro- mising their integrity? • What ethical, legal, and professional issues can you raise pertaining to diagno- sis? In your view, what is the most critical issue? • What cultural critique can you offer about the diagnostic system and thera- pists being expected to diagnose clients? Diagnosis Within an Insurance Context Ethical dilemmas are often created when diagnosis is done strictly for insurance purposes, which often entails arbitrarily assigning a client to a diagnostic classi- fication, sometimes merely to qualify for third-party payment. Some practition- ers who are opposed to a diagnostic framework take the path of least resistance and give every client the same diagnosis. Clients who consult therapists regard- ing problems that do not fit a standard “illness” category may not be reimbursed for their psychotherapy. Some therapists may agree to see a couple or a family but submit a claim for an individual as the “identified patient,” using an acceptable DSM diagnosis. Although it may be tempting for a clinician to present an “acceptable” but inaccurate diagnosis, this is both unethical and fraudulent. Braun and Cox (2005) note that the intentional misdiagnosis of mental disorders for the purpose of seeking insurance reimbursement constitutes health care fraud, which can lead to legal censure and court action at the local, state, and federal level. Many insurance carriers will not pay for treatment that is not defined as an “illness” for which treatment is medically necessary. If a therapist treats a couple 382 / chaPter 10 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, sc for marital difficulties and submits a claim to a managed care organization for couples therapy, chances are that the claim will be rejected. Although some fam- ily and couples counselors may view assigning certain diagnoses antithetical to their practice because they believe dysfunctional behaviors are manifestations of a faulty family system, they are aware that “utilization reviews typically require DSM diagnoses of individuals rather than of relationships” (Braun & Cox, 2005, p. 428). Practitioners must always be cognizant of their ethical responsibilities and use their best clinical judgment when making decisions involving diagnosis. With some managed care mental health companies, a therapist may call the company with a diagnosis. A technician may then look up “appropriate” treat- ment strategies to deal with the identified problem (if, indeed, the diagnosis meets the criteria for reimbursement). This raises significant ethical issues as important treatment decisions may be made by a nonprofessional who has never seen the client and who lacks a depth of understanding of mental health issues. Ethical and Legal Issues in Diagnosis LO7 Under no circumstances should clinicians compromise themselves regarding the accuracy of a diagnosis to make it “fit” criteria accepted by an insurance company. If therapists do not understand how to work within some kind of diagnostic and assessment framework, and if they do not have a clear picture of the client’s prob- lem, it is possible that they will not help the client. We also think it is an ethical (and sometimes legal) obligation of therapists to be mindful that a medical evaluation is many times indicated. This is especially true in dealing with problems such as dementia, schizophrenia, bipolar disorder, and depression with suicidal ideation. Students need to learn the clinical skills necessary to do this type of screening and referral, which is a form of diagnostic thinking. Practitioners may cause harm to clients if they treat them in restrictive ways because they have diagnosed them on the basis of a pattern of symptoms. Thera- pists may then behave toward clients in ways that make it very difficult for clients to change. If practitioners do not possess the competence to use DSM diagnosis appropriately, this raises an ethical issue. Practitioners who use the DSM-5 must be trained in its use. This training requires learning more than diagnostic categories; it involves knowing personality theory, psychopathology, and seeing how they relate to therapeutic practice. Zalaquett and colleagues (2008) recommend reframing the way counselors are trained to use the DSM model. They write about the benefits that can be derived from building a collaborative relationship with clients in ways that result in meaningful case formulations, diagnoses, and treatment planning. Now let us look at two specific cases where diagnosis and treatment options had to be evaluated. The Case of Irma irma has just accepted her first position as a counselor in a community agency. an agency policy requires her to conduct an intake interview with each client, determine a diagnosis, and establish a treatment plan—all in the first session. Once a diagnosis is established, clinicians have a maximum of five more sessions with a given client. after 3 weeks, she lets a colleague know that she is troubled by this timetable. her colleague reassures her that what she is doing is acceptable and that the agency’s aim is to satisfy the requirements of the hMO. irma does not feel reassured and cannot justify making an assessment in so short a time. • What are your reactions to irma’s concern? are there ethical difficulties with this agency’s policies? explain. • is it justified to provide a person with a diagnosis mainly for the purpose of obtaining third- party payment? explain. • if irma retains her convictions, is she ethically obliged to discontinue her employment at this agency? What other alternatives, if any, do you see for her situation? • in the course of a client’s treatment, if the original diagnosis no longer applies, would you continue to use that diagnosis simply because your client wishes to see you? Commentary. before accepting the position, irma should have done some research and assessed whether the expectations of the agency were congruent with her beliefs about the helping process. irma cannot simply take the opinion of a colleague as an answer to her con- cerns now and should contact the hMO administration to see whether other options are open to her, such as requesting additional sessions. although irma may take issue with the require- ment to diagnose each client, she will need to balance this theoretical concern with the ethical and legal standards requiring professionals to carefully assess and accurately diagnose clients before commencing any intervention. in addition to advocating for her clients if more time is required for diagnoses and treatment in some cases, irma has an obligation to recognize the limits of her own competence. as a relatively new counselor, irma may require more time to arrive at accurate diagnoses. she must take the initiative to request supervision of her work, allow more senior clinicians to conduct intake and diagnostic interviews, or consider working in a different agency. • The Case of Bob bob displays symptoms of insomnia, sadness, lethargy, and hopelessness. he has also been diagnosed with a substance abuse disorder. after 12 weeks of treatment, felicita realizes that her client has all the symptoms of a major depression and that he is showing no improvement. she is inclined to double the number of weekly sessions to accelerate her client’s progress. • What do you think of felicita’s plan? is it justified? • should she have done a more thorough assessment earlier in the treatment? What assessment strategies could she have used? Might the results have indicated alternative treatments? • is felicita obligated to refer bob for a psychiatric evaluation to determine whether antide- pressant medication is indicated? is she obliged to refer him if he so desires? explain. • What are her ethical obligations if he refuses to see a psychiatrist? • What other ethical issues do you see in this case? Commentary. felicita is limited in her scope of practice, and bob may need more help than she can provide. she cannot prescribe medication, which may be indicated in this case. because of her assessment of bob as being seriously depressed, it is important that she con- duct an assessment for suicidality. felicita should refer bob for a medical and psychiatric eval- uation as well. because of his problems with substance abuse and his depression, bob may benefit from an intensive outpatient treatment program. felicita may help her client most by exploring adjunct treatment options with bob and making any informed and clinically neces- sary referrals. • Cultural Issues in Assessment and Diagnosis LO8 The DSM system tends to pathologize clients, perpetuating the oppression of cli- ents from diverse groups (Remley & Herlihy, 2016). Durodoye (2013) notes that “because of biases in mental health treatment, diverse populations have been psychiatrically mislabeled and treated on the basis of mainstream definitions of what is normal” (pp. 299–300). La Roche, Fuentes, and Hinton (2015) argue that the DSM is based on Western American assumptions (such as individualism and universalism), which limits its usefulness among different cultural groups. They also contend that the cultural contexts of clients must be included in the assess- ment process to prevent misconstruing the meaning of symptoms. For example, it is a mistake to assume that a Mexican American woman who resides at home with her parents until she marries is enmeshed. Instead, her living situation may be a result of gender-role expectations in her family. Zalaquett and colleagues (2008) acknowledge that cultural biases exist in both traditional helping models and the DSM model, yet they do not suggest that either should be discarded from a counselor’s practice. Instead they emphasize the responsibility of counselors to use these models in more culturally competent ways. Cultural sensitivity is essen- tial in making a proper diagnosis, and a range of factors need to be considered in interpreting the assessment process. See the Ethics Codes box titled “Cultural Sensitivity in Assessment” for some professional guidelines regarding culturally sensitive diagnosis. Clearly, it is important to consider cultural and other diversity factors in both the assessment process and when formulating a diagnosis. If clinicians fail to con- sider ethnic and cultural factors in certain patterns of behavior, a client may be sub- jected to an erroneous assessment, diagnosis, and course of treatment. Failure to give adequate weight to cultural factors can result in misdiagnoses that perpetuate stereotypes based on race, ethnicity, gender, and sexual orientation (Comas-Diaz & Brown, 2016). Culturally diverse clients may prematurely drop out of treatment during the assessment process. Rather than focusing on pathology during the assessment phase, Comas-Diaz and Brown suggest using the initial session as a consultation meeting with the aim of negotiating mutually satisfactory goals for treatment and engaging clients in treatment. The goal should be to promote client agency and foster a collaborative therapeutic relationship. Nystul (2016) believes that it is critical that therapists be aware of the cultural context of language when differentiating mental health from mental illness. What is considered healthy can vary greatly from one culture to the next. Nystul maintains that a comprehensive assessment helps therapists better understand clients in terms of cultural, gender, religion or spirituality, and other aspects of diversity. Barnett and Johnson (2015) suggest that practitioners think twice before they render a diagnosis. They point out that accurate assessment and diagnosis involves taking into consideration the realities of discrimination, oppression, and racism in society and also in the mental health disciplines. Barnett and Johnson caution counselors to give extra attention to avoid misdiagnosing and patholo- gizing certain cultural groups who have traditionally been disadvantaged by the mental health system. They emphasize carefully considering the ways in which clients’ socioeconomic and cultural experiences can influence behavior, including the presentation of symptoms. Whenever clinicians assess clients from culturally diverse populations, it is important for them to be aware of unintentional bias and to keep an open mind to the possibility of distinctive ethnic and cultural patterns. Kress, Eriksen, Rayle, and Ford (2005) maintain that clinicians need to strive toward diversity-sensitive diagnostic practices because doing so is ethically required and integral to effec- tively delivering services to diverse client groups. They encourage counselors to conduct a thorough assessment of their clients’ cultural realities and to acquire an understanding of the complexity of the nature of the DSM-5. La Roche and colleagues (2015) point out that we all live in cultural contexts that shape our way of being in the world, so it is essential for all of us to assess and address cultural meanings and contextual variables. LO9 Using Tests in Counseling Testing is different from assessment, although tests may be used in the process of assessment. A test generates a score that represents a sample of behavior on a particular day. An assessment is an integrated process that yields a comprehensive picture of the client’s functioning using multiple measures in multiple settings. Clinicians do not interpret test scores; rather, they interpret assessment batteries to produce a comprehensive, holistic picture of the client’s psychological functioning as it applies to the referral question. It is important to understand the common assessment tools used in your profession, even if you choose not to use these tools in your practice. As is true of diagnosis and assessment, the proper use of psychological test- ing in counseling and therapy is the subject of some debate. Generally, those who use therapeutic approaches that emphasize an objective view of counseling are inclined to use testing procedures as tools to acquire information about clients or as resources that clients themselves can use to help them in their decision making. Therapists who employ person-centered and existential approaches tend to view testing in much the same way that they view diagnosis—as an external frame of reference that is of little use to them in counseling situations. We think the core issue is not whether you will use tests but rather under what circumstances and for what purposes. Tests are available that measure apti- tude, ability, achievement, intelligence, values and attitudes, vocational interests, or personality characteristics. Unfortunately, these tests are often misused, and when this occurs, ethical concerns are raised. Tests may be given routinely, given without providing feedback to clients, used for the wrong purposes, interpreted without consideration for cultural factors, or given by unqualified testers. Clini- cians may choose measures based on what is available or easy to give rather than on which measure will best provide information to address the referral question or the reason for the testing in the first place. Here are some guidelines that will help you think about the circumstances under which you might want to use tests for counseling purposes and how to use them in an ethical manner. • It is important for clinicians to be familiar with any tests they use and prefera- bly to have taken these tests themselves. It is essential to know the purpose of each test and how it measures what it purports to measure. Sometimes mental health workers find that they are expected to give and interpret tests as a basic function of their job. If they have not had adequate training in this area, they are in an ethical bind. In-service training and continuing education programs are ways of gaining competence in using some psychological assessment devices. • Familiarize yourself with the standards pertaining to testing in the ethics code of your profession. Recognize the limits of your competence to use and inter- pret tests. Know when you need to refer clients to a specialist in testing. • Select tests that are appropriate for your client given his or her unique cul- tural, social, and cognitive factors. If others who are similar to your client in terms of demographics are not included in the standardization sample of the instrument you have chosen to use, it is highly probable that the test you have chosen is inappropriate for your client. • Clients from culturally diverse backgrounds may react to testing with sus- picion if tests have been used to discriminate against them in schools and employment. To minimize such negative reactions, it is a good practice to explore a client’s views and expectations about testing and to work with him or her in resolving attitudes that are likely to affect the outcome of a test. • Involve your clients in the selection of tests. Clients need to understand what information the tests are designed to provide. Before administering tests, obtain your client’s informed consent. • Know why you want to use a particular test. Does your agency require that you administer certain tests? Are you giving tests because they will help you understand a client better? Do you administer tests mainly when clients request them? • Assume a stance of critically evaluating tests you may use. Know their limita- tions, and keep in mind that a test can be useful and valid in one situation but inappropriate in another. • Explore why clients want to take a battery of tests, and teach clients the values and limitations of testing. If that is done, there is less chance tests will be under- taken in a mechanical fashion or that unwarranted importance will be attrib- uted to the results. Clients need to be aware that tests are merely tools that can provide useful information they can then explore in their counseling sessions. • In general, it is best to give clients test results, not simply test scores. In other words, explore with your clients the meaning the results have for them. Inte- grate the test results with other information, such as clients’ developmen- tal, social, and medical history. Evaluate your clients’ readiness to receive and accept certain information and be sensitive to the ways in which clients respond to the information provided. • How well do your assessment results parallel what the client is reporting in his or her own subjective experience? Have you adequately investigated all salient areas of the client’s life in your current assessment process? • It is critical to maintain the confidentiality of test results. Results may be han- dled in different ways, depending on the purpose and type of each test or on the requirements of the agency where you work. Nevertheless, your clients need to feel that they can trust you and that test results will neither be used against them nor revealed to people who have no right to this information. Paying attention to the above points when considering administrating or interpreting testing is one way to increase the likelihood that you are practicing in a culturally sensitive manner. From a social justice perspective, clinicians can use their power to bring to light the misuses and inaccurate applications of assess- ment, especially with those from underserved and oppressed communities. Clients being tested should know what the test is intended to discover, how it relates to their situation, and how the results will be used. Perhaps the most basic ethical guideline for using tests is to keep in mind the primary purpose for which they were designed: to provide objective and descriptive measures that can be used by clients in making better decisions. It is wise to remember that tests are tools that should be used in the service of clients. LO10 Evidence-Based Therapy Practice Mental health practitioners are frequently expected to make decisions about what they believe to be the best therapeutic approaches or interventions with a particu- lar client. Clinical practice should be based on the best available research integrated with a practitioner’s expertise within the context of a particular client (Norcross, Hogan, & Koocher, 2008). For many therapists the choice of interventions they make in their practice is based on their theoretical orientation. Over the past cou- ple of decades, however, a shift has occurred toward promoting the use of specific interventions for specific problems or diagnoses based on empirically supported treatments (APA Presidential Task Force, 2006; Cukrowicz et al., 2005; Deegear & Lawson, 2003; Edwards, Dattilio, & Bromley, 2004; Lazarus & Rego, 2013; McCloskey, 2011; Tarvydas, Addy, & Fleming, 2010). Treatment manuals were developed for a wide range of psychological disorders, and they yielded impres- sive research results. Lazarus and Rego (2013) state that this success ushered in the movement toward empirically supported treatments and evidence-based practice. Increasingly, clinicians who practice in a behavioral health care system are encountering the concept of evidence-based practice (Bride, Kintzle, Abraham, & Roman, 2012; Norcross et al., 2008). Evidence-based practice (EBP) is “the integra- tion of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force, 2006, p. 273). This idea encompasses more than simply basing interventions on research. Norcross and colleagues (2008) advocate for inclusive evidence-based practices that incorporate each of the three pillars of EBP: best available evidence, clinician expertise, and client characteristics. Evidence-based practice is often associated with cognitive-behavioral approaches. These approaches are the most extensively researched psychother- apies, with hundreds of studies supporting their effectiveness for a wide range of emotional and behavioral problems (Antony, 2014). Hollon and Beck (2013) report that cognitive-behavioral interventions have generated powerful evidence of success in treating depression, anxiety disorders, panic disorders, social pho- bia, posttraumatic stress disorders, eating disorders, substance abuse, personality disorders, and childhood depression and anxiety disorders. Although abundant research has been conducted on cognitive-behavior therapies, it is a mistake to con- clude that these approaches have a monopoly on evidence-based therapy practice. In their extensive review of research on humanistic psychotherapy from 1990 to 2015, Angus and colleagues (2015) concluded that “humanistic psychotherapy researchers have made significant contributions to innovative advancements in the field of psychotherapy methods and research findings over the past 25 years” (p. 338). Angus and colleagues also contend that humanistic psychotherapies “ are supported by multiple lines of scientific evidence and should therefore be included in clinical guidelines and lists of evidence-based psychotherapy” (p. 339). Elliott, Greenberg, Watson, Timulak, and Freire (2013) compiled a com- prehensive review of the humanistic-experiential psychotherapies and report that a substantial and rapidly growing body of data supports these approaches with a wide range of client problems including depression, relationship problems, anx- iety disorders, eating disorders, coping with chronic medical conditions, psychotic disorders, and substance abuse. The movement toward grounding psychotherapy practice on a scientific foun- dation led to the concept of empirically supported treatments (EST). “Proponents of ESTs believe that each form of therapy needs to be tested in carefully controlled experimental research. The results would show which therapies actually worked and which, though well intended, did nothing to help the patient or, worse, were harmful” (Pope & Wedding, 2014, p. 576). Managed care companies and other third-party insurance companies embrace the concept of ESTs and tend to restrict payments to therapies that demonstrate evidence of being effective and efficient (Pope & Wedding, 2014). Increasing the availability and use of ESTs has become a focus of public policy, and some individ- uals have concentrated their efforts on discovering the best ways to train practi- tioners in the use of these treatments and to disseminate this information (Godley, Garner, Smith, Meyers, & Godley, 2011; McCloskey, 2011; Vismara, Young, Stahmer, Griffith, & Rogers, 2009). However, there is another side to the EST issue. In his extensive review of the efficacy and effectiveness of psychotherapy, Lambert (2013) states that identifying lists of empirically supported treatments for specific disorders is controversial and puts too much emphasis on small differences in outcomes associated with certain treatments. Lambert concludes, “to advocate empirically supported therapies as preferable or superior to other treatments is probably premature” (p. 205). Basing one’s psychotherapeutic practices on interventions that have been empirically validated may seem to be the ethical path to take, but business consid- erations do enter into this picture. In seeking to specify the treatment for a specific diagnosis as precisely as possible, health insurance companies are concerned with determining the minimum amount of treatment that can be expected to be effec- tive. There is a pressure for ESTs to be both short and standardized. Treatments are operationalized by reliance on a treatment manual that identifies what is to be done in each therapy session and how many sessions will be required (Edwards et al., 2004). Bolen and Hall (2007) note that organizations competing for managed care contracts are assessed by their capacity to manage programs and costs as well as by their skill in implementing focused and brief methodologies. Some practitioners believe that this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process. Indeed, relying exclusively on standardized treatments for specific problems may raise another set of ethical issues. One of these issues is the reliability and validity of these empirically based techniques. Human change is complex and difficult to measure unless researchers operationalize the notion of change at such a simplistic level that the change may be meaningless. Not all clients come to therapy with clearly defined psychological disorders. Many clients have existential concerns that do not fit in any diagnostic category and do not lend themselves to clearly specified symptom-based outcomes. Evidence-based practice has significant lim- itations for practitioners working with individuals who want to pursue meaning and fulfillment in their lives. Lazarus and Rego (2013) raise this key question: What should therapists do when clients do not respond to manualized treatments or present with a problem for which no treatment manual exists? Treatment manuals focus on methods and procedures but lack consideration of the client–therapist relationship as a basic element in therapy. If there is not a working alliance, which calls for the genuine meeting of client and therapist, then the effects of the application of empirically established methods and the best of manuals will be diluted, if not erased (Lazarus & Rego, 2013). Norcross, Beutler, and Levant (2006) remind us that many aspects of treatment— the therapy relationship, the therapist’s personality and therapeutic style, the cli- ent, and environmental factors—contribute to the success of psychotherapy and must be taken into account in the treatment process. Proponents of the common factors approach point out that EBPs tend to emphasize only one of these aspects: interventions based on the best available research. Bohart and Wade (2013) argue that substantial research supports the position of the client accounting for more of the treatment outcome than either the relationship or the method employed. “There is evidence that clients make the single strongest contribution to outcome” (p. 219). Norcross and his colleagues (2006) acknowledge that mental health profes- sionals are challenged by the mandate to demonstrate the efficiency, efficacy, and safety of the services they provide. Although the goal of EBP is to enhance the effectiveness of client services and to improve public health, Norcross and his col- leagues show that there is a great deal of controversy and discord when it comes to EBP. They stress the value of informed dialogue and respectful debate as a way to gain clarity and to make progress. Elmore (2016) reports that ESTs have come to represent an accepted standard of care in many circles, but the EST movement has been the source of much con- troversy since its inception. Proponents of the common factors perspective have argued that the narrow focus of the EST movement neglects key dimensions of effective psychotherapy, including the emphasis on the therapeutic alliance and an accurate explanation of the client’s presenting difficulties. Miller, Duncan, and Hubble (2004) are critical of the EST movement and argue that the best hope for integration of the field is a focus on using data generated during treatment to inform the process and outcome of treatment. “Significant 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 EBP, ther- apists tailor their work through practice-based evidence” (p. 2). One private prac- titioner collected data on his own effectiveness over 45 years of practice. Clement (2013) analyzed outcome data on 1,599 cases and demonstrated that his effective- ness did not improve across the years. In addition, he found that the “years with the largest patient caseloads or the greatest proportion of patients with managed care insurance tended to show the poorest outcomes” (p. 23). Clement’s goal in publishing his own practice-based evidence was to encourage his colleagues to follow suit. In his own words, “I have shown you my practice-based evidence. Now you show me yours” (p. 42). EBP involves far more than simply employing interventions based on the best available research. The APA Presidential Task Force on Evidence-Based Practice (2006) emphasize that psychotherapy is a collaborative venture in which clients and clinicians develop ways of working together that are likely to result in positive outcomes. The involvement of an active, informed client is crucial to the success of therapy services. Based on their clinical expertise, therapists make the ultimate judgment regarding particular interventions, and they make these decisions in the context of considering the client’s values and preferences. Bohart and Wade (2013) found that research on clients’ perspectives supports the idea of the client as an active agent in the therapy process. For further reading on the topic of EBPs, we recommend APA Presidential Task Force (2006), Duncan, Miller, Wampold, and Hubble (2010), Norcross, Beutler, and Levant (2006), and Norcross, Hogan, and Koocher (2008). Findings From Psychotherapeutic Research Just as clinicians sometimes underuse theory, some do not see the practical value of understanding how psychotherapy research can enhance their practice. Without understanding how to translate current research findings into their practices, thera- pists limit themselves in their ability to help clients. Clinicians need to understand how theory and research contribute to more effective and therefore more ethical practice. Most of the questions we have raised in this chapter have a direct relation- ship to a therapist’s therapeutic approach. Specialized techniques, the balance of responsibility in the client–therapist relationship, the functions of the therapist, and the goals of treatment are all tied to a therapist’s theoretical orientation. But at some point you will probably ask: Does my psychotherapeutic approach or these specific techniques work? To answer this question, you may need to rely on the findings of psychotherapeutic research. Boisvert and Faust (2003) examined leading international psychotherapy researchers’ views on psychotherapy outcome research. Participants in the study rated level of research evidence for or against various assertions about psycho- therapy process and outcomes. Their study revealed some interesting conclusions. Experts showed strong agreement that research did support the following assertions: • Therapy is helpful to the majority of clients. • Most people achieve some change relatively quickly in therapy. • People change more due to “common factors” than to “specific factors” asso- ciated with therapies. • In general, the various therapeutic approaches achieve similar outcomes. • The relationship between therapist and client is the best predictor of treatment outcome. • Most therapists learn more about effective therapy techniques from their expe- rience than from the research. • Approximately 10% of clients get worse as a result of therapy. Experts showed strong agreement that research does not support the following assertions: • Placebo control groups and waitlist control groups are as effective as psychotherapy. • Therapist experience is a strong predictor of outcome. • Long-term therapy is more effective than brief therapy for the majority of clients (p. 511). In his review of the effectiveness of psychotherapy, Lambert (2013) supports most of the conclusions of the Boisvert and Faust study. Lambert notes that the theme derived from meta-analyses of the large body of psychotherapy research clearly shows that “psychotherapy has proven to be highly beneficial” (p. 176). What are the primary determinants of the effectiveness of psychotherapy? Elkins (2012, 2016) cites evidence showing that personal and interpersonal factors are the major determinants of effectiveness. The humanistic elements of psycho- therapy, which include the client, the therapist, and the therapeutic alliance, are powerful factors in psychotherapy outcome. Although specific theories and tech- niques are important, they are not the crucial factors that account for outcome. Most psychotherapy research, training, and practice are based on the assumption that a therapist’s theory and techniques—not personal and interpersonal factors—are the primary instruments of change. Elkins (2012) proposes a change in the focus of training students to provide less emphasis on theory and techniques and more emphasis on the therapist as a person. The aim of this training is to cultivate the trainee’s capacity to connect with clients on a deep level so clients will feel under- stood, supported, and accepted. In short, Elkins asserts that we need to rethink many of our assumptions and beliefs about clinical research, training, and practice and make significant changes in these areas to bring the profession into alignment with the findings of contemporary science. Angus and colleagues (2015) also point to ample evidence to suggest that therapeutic training should emphasize the person of the therapist and “the development of empathic communication skills, the capac- ity to enhance clients’ emotional expression and self-regulation, and the capacity to develop a secure and productive therapeutic alliance for the facilitation of client narrative disclosure and productive meaning-making in therapy sessions” (p. 340). Angus and colleagues emphasize that the collaborative nature of the therapeutic relationship is key to the process of therapy unfolding. It is clear that the authentic personal relationship is central to effective therapeutic practice.

Chapter 13. Community and Social Justice Perspectives Introduction When the community mental health movement came into existence, it took the family systems perspective discussed in Chapter 11 a step further to include the entire community as the focus of treatment. By looking at the whole community, it is possible to discover strengths within the community and to develop ways to bring these strengths to work for the community and the individual. Feminist therapy likewise addresses the need to consider the social, cultural, historical, political, and economic context that contributes to a person’s problems in order to understand and help that person. Working with people in individual, couples, family, and group therapy are some key ways for professionals to promote mental and emotional health. Working in the community requires an expansive focus that embraces the total milieu of people’s lives and fosters real and lasting community change. Making a Difference in the Community To be effective and practice ethically, we must be aware of the broader context of human problems no matter what setting we choose for our work. In much the same way family therapists think beyond the child to the needs and strengths of the whole family, we must think beyond the needs of the individual to the needs and strengths of the community at large. As we lean into our discomfort to exam- ine systemic issues in the larger context of the community, we will face tough choices regarding changes in our profession and our role. Chung and Bemak (2012) view courage in dealing with fear as a cornerstone of doing multicultural social justice work and point out that “social change and improvements in human rights have never taken place without individuals taking risks” (p. 164). For social transformation to occur, Waller (2013) feels he must be willing to get out of the office and get involved with the community: “My social justice action tends to focus on changing policies within a system that impact the community rather than just an individual” (p. 93). Bemak and Conyne (2018) dis- cuss the issue of transforming roles in their book Journeys to Professional Excellence: Stories of Courage, Innovation, and Risk-taking. The authors document the impor- tance and challenges of incorporating innovation, risk-taking, and courage in the lives of well-known mental health professionals. To illustrate how a counselor might work with both an individual client and also address societal factors that are exacerbating a personal problem, consider this scenario: A school counselor begins working with a young teen struggling with depression and suicidal ideation. Upon further questioning, it becomes evident that his anxiety is related to “coming out” to his friends and family. His fear of discrimination and bul- lying are being expressed as feelings of hopelessness and isolation. As the counselor works with the teen on his emotions and suicidal ideation, she also works to create an environment in the school that makes it safer for all LGBTQ teens to be who they are without fears of retaliation or bullying. To create this supportive environment, the counselor creates safe spaces for open dialogue, imparts information, gives voice to the LGBTQ community within the school, and invites guest speakers to various classes. The Community as Client LO1 The foundation of all ethical practice is promoting the welfare of clients. Overlook- ing the abilities, strengths, and resources within the community does a great dis- service to the individuals we serve. If we hope to bring about significant changes for individuals and communities, Homan (2016) believes we need to change the conditions that affect people rather than change the people affected by these conditions. Many homeless veterans of war struggle to function in society due to immobilizing PTSD symptoms, substance abuse, and low social support. Not only have they experienced trauma related to combat during their military service, but they continue to experienced traumatic events outside of the mil- itary (Carlson, Garvert, Macia, Ruzek, & Burling, 2013). Consider Tommy’s circumstances: Stressed to the maximum after having a leg amputated, Tommy is plagued with survi- vor’s guilt and nightmares after witnessing friends being killed in Afghanistan. Upon returning home, Tommy found it difficult to get through each day without drinking heavily and lashing out angrily at his family. Frightened by the intensity of his anger, Tommy’s wife took their two small children and filed for divorce, which was devas- tating to him. Tommy knew he needed help and understandably felt disillusioned, disappointed, and frustrated when he was unable to get the mental health services that he desperately needed through the local VA hospital. As his mental health deteriorated and his PTSD symptoms spiraled out of control, Tommy could not handle simple tasks and ended up homeless. What community-level interventions could help veterans and spouses and chil- dren of returning veterans feel supported and accepted in their communities? What community changes are needed to help those who are struggling to thrive? How might community members benefit from these interventions even though they are not the primary focus of the interventions? The ethical issues we discuss in this chapter are faced by many workers in community agency settings. We use the term community agency broadly to include any institution—public or private, nonprofit or for-profit—designed to provide a wide range of social and psychological services to the community. Likewise, when we speak of a community worker, we refer to a diverse pool of human-service workers whose primary duties include serving individuals within the community in a variety of community groups. Community workers include social workers, community organizers and developers, clinical mental health counselors, psychologists, psychiatrists, nurses, counselors, couples and family therapists, artists, activists, clergy persons, human-service workers with vary- ing degrees of education and training, and residents involved in the community. Examine your own commitment to working in the community by thinking about these questions: • Which communities that you belong to are most important to you? What makes you regard these communities as special or meaningful? • What are the key problems or issues facing each of these communities? What forces within or surrounding these communities exacerbate the issues individ- uals and groups are experiencing? • What are some resources available to empower people in these communities? • In what ways have historical or current issues of oppression, discrimination, and poverty affected these communities? • Who holds the power in each of these communities? Who are the decision makers? Who is most likely to support or thwart change? This chapter also examines how the system affects the counselor, the eth- ical dimensions of practice, and how to survive and thrive while working in the system. If practitioners are limited in their ability to adapt their roles to the needs of the community, they are not likely to be effective in reaching those who most need assistance. Likewise, if the community does not understand what community mental health workers can do, they are less likely to use their services. LO2 Why a Community Perspective Is a Concern for Counselors Chung and Bemak (2012) suggest that by adhering to traditional roles, practition- ers are maintaining and reinforcing the status quo, which results in passively sup- porting the social injustices, inequalities, and discriminatory treatment of certain groups of people. Chung and Bemak contend that advocacy is an ethical and moral obligation for an effective mental health professional. The community approach is relevant to all communities, but it is particularly relevant to underserved commu- nities. By addressing the cause of the problem within the community, we can help change the lives of many individuals—not just the one person sitting in our office or clinic—as the following story demonstrates. Moving Upstream While walking along the banks of a river, a passerby notices that someone in the water is drowning. After pulling the person ashore, the rescuer notices another person in the river in need of help. Before long the river is filled with drowning people, and more rescuers are required to assist the initial rescuer. Unfortunately, some people are not saved and some people fall back into the river after they have been pulled ashore. At this time, one of the rescuers starts walking upstream. “Where are you going,” the other rescuers ask disconcerted. The upstream rescuer replies, “I’m going upstream to see why so many people keep falling into the river.” As it turns out, the bridge leading across the river upstream has a hole through which people are falling. The upstream rescuer realizes that fixing the hole in the bridge will prevent many people from ever falling into the river in the first place. (Cohen & Chehimi, 2010, p. 5) We rarely look beyond the individual in examining how the community and the system contribute to the client’s problem, and this individual focus may limit our effectiveness. How would you answer these questions: • In what ways are your own struggles a by-product of societal ills? • What social justice issues do you feel passionate about or have a particular interest in supporting? • What is your sphere of influence? To what groups or communities do you belong, and what kind of power or influence do you have in those arenas? • What role would you like to play in improving your community? What are the first steps you might take in this role as a social change agent? If we narrowly define what it means to be a counselor, we limit ourselves and the assistance we can provide to our clients. Advocating for systemic changes can bring about positive changes in the lives of our clients. A colleague, who is a social justice advocate and counseling practitioner, often observed overt and or covert racist practices in the elementary school system. She had noticed that the same few African American boys were consistently being sent to the principal’s office for disciplinary reasons. She found this troubling and brought it to the attention of the school psychologist. She used her knowledge as a clinician, along with being a member of the school community, to engage in a dialogue that led to systemic change, increased awareness, and more effective interventions. This is an illus- tration of how we can use our professional knowledge and skills to advocate for changes that help others in our community. Ethical Practice in Community Work The ethics codes of professional practice reinforce the practitioner’s responsibility to the community and to society (see the Ethics Codes box titled “Responsibilities to Community and Society”). It is left to community workers to identify strategies for becoming more responsive to the community. 456 / chaPter 13 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. ETHICS CODES: Responsibilities to Community and Society National Organization for Human Services (2015) Human service professionals stay informed about current social issues as they affect the client and the community. They share that information with clients, groups and community as part of their work. (Standard 13.) Human service professionals provide a mechanism for identifying unmet client needs, calling attention to these needs, and assisting in planning and mobilizing to advocate for those needs at the individual, community, and societal level when appropriate to the goals of the relationship. (Standard 15.) Human service professionals advocate for social justice and seek to eliminate oppression. They raise awareness of underserved populations in their communities and with the legislative system. (Standard 16.) American Mental Health Counselors Association (2015) Mental health counselors recognize they have a moral, legal, and ethical responsibility to the com- munity and to the general public. Mental health counselors are aware of the prevailing community and cultural values, and the impact of professional standards on the community. (V.) ETHICS CODES: Responsibilities to Community and Society continued American School Counselor Association (2016) School counselors attempt to establish a collaborative relationship with outside service providers to best serve students. School counselors request a release of information signed by the student and/or parents/guardians before attempting to collaborate with the student’s external provider. (A.6.f.) One of the primary objectives of community practice is constituency self- determination. Community organizers must first determine the primary recipient of their interventions. Is the client an individual, a group of people, or society in general? Practitioners need to acquire adequate skills to deal effectively with the ethical challenges unique to community work. For instance, suppose a program is established to nurture the abilities of bright students from disadvantaged back- grounds and to assist them in getting into top colleges. On the surface this seems straightforward, but a number of assumptions underlie the stated goal. Donors are placing a high value on attendance at a top-ranked school and discounting as trivial any inconvenience travel to a distant city may cause these students and their families. Students and their families may place a high value on keeping the family intact and so would prefer the student attend the nearby college and con- tinue to live at home. The community worker might be concerned that the best interests of certain students would not be optimally served by encouraging them to leave home to attend a college far away from their families. Although some students might adapt well, others might not for any number of reasons. This could result in them dropping out of school and returning home. On the other hand, the worker might also be concerned that the donors would stop funding the program if students forfeited the opportunity to study at a top-ranked univer- sity. Without the funding, those students who could potentially be well served by the program would lose out on this opportunity. If you were in this community worker’s position, how might you navigate this ethical dilemma? In talking about social justice, community activism, and outreach, our students are sometimes uncertain about where to begin or how they can make a difference. A good starting place is to list the communities to which you belong and describe your spheres of influence within these various systems. For example, you may be a member of a religious organization, a book club, an athletic team, or a creative arts circle. Pay attention to the issues that arise in the organizations to which you belong and ask yourself these questions: • What sociocultural issues can you identify within the systems, organizations, groups, and communities you belong to or have frequent contact with? (Some examples might be discriminatory practices, poverty, lack of support, lack of diver- sity, negative influence of media, crime, and lack of access to power or resources.) • What roles can you take in bringing about awareness, change, or confirmation of these issues? • What do you see as potential barriers to raising awareness or bringing about change? • What is one thing (at the macro or micro level) that you could actively do to bring about awareness of the issues harming the members of these communi- ties? How willing are you to do this? • What do you tell yourself that keeps you from acting as a change agent? One of our students talked about his work as a high school football coach and how his own multicultural training helped him to identify changes that needed to be made in the language coaches and team players used. After learning about heterosexism firsthand from his college classmates, this student used his position as coach to model less sexist and homophobic language in the locker rooms. His goal was to create an environment in which a team member who might be gay would not be subject to constant verbal assaults and daily microaggressions. This seemingly small change opened the door to other important conversations among his players. What began with a change in language later was integrated into cul- tural sensitivity training with the staff and athletic team at the school. The Community Mental Health Orientation The community orientation is based on the premise that the community itself is the most appropriate focus of attention, rather than the individual, and the com- munity also is the most potent resource for solutions. Even when counseling indi- viduals, consider how these individuals have been influenced by the community, how they might draw on community resources to help meet their goals, and ways that the community is presently influencing them. Homan (2016) reminds us: “Just like an individual or a family, a community has resources and limitations. Com- munities have established coping mechanisms to deal with problems. To promote change in a community, the community must believe in its own ability to change and must take responsibility for its actions or inactions” (p. 27). The need for diverse and readily accessible treatment programs has been a key factor in the development of the community mental health orientation. Envi- ronmental factors cause or contribute to the problems of many groups in society, and a process that considers both the individual and the environment is likely to benefit everybody. The focus of community work is on preventing rather than remediating problems. Types of Client and Community Interventions LO3 Community counseling is “a comprehensive helping framework that is grounded in multicultural competence and oriented toward social justice” (Lewis, Lewis, Daniels, & D’Andrea, 2011, p. 9). A comprehensive community counseling model described by Lewis and colleagues is based on two activities: • facilitating human development by providing direct interventions with clients and community members, and • facilitating community development through advocacy interventions that break down external barriers to client well-being. Human development activities include both focused strategies (such as outreach activities) and broad-based strategies (such as developmental and preventive pro- grams aimed at educating members of the community). Community development activities also include both focused strategies (such as advocating for clients and preparing clients to be their own advocates) and broad-based interventions (such as counselors acting as change agents in systems through social and political advocacy). Another way of conceptualizing the community counseling model is through the various forms of services provided to clients: direct client services, indirect cli- ent services, direct community services, and indirect community services (Lewis et al., 2011). Direct Client Services These service providers focus on outreach activities to a population that might be at risk for developing mental health problems. Commu- nity counselors provide help to clients either facing crises or dealing with ongoing stressors that overwhelm them. By reaching out to schools and communities that are receptive to help, community workers can offer a variety of personal, career, family, and counseling services to at-risk groups. This population also would include referrals from the courts, churches, mosques, synagogues, probation departments, VA centers, and drug and alcohol treatment centers. Direct client service providers empower clients with skills, knowledge, and understanding that will help them cope with external stressors (Toporek et al., 2009). Indirect Client Services Client advocacy and consultation are at the heart of these services, and community workers create partnerships by working with groups in a collaborative way rather than merely providing services for these groups. Coun- selors identify factors that negatively affect their clients and take action, often in collaboration with others, to bring about needed changes (Lewis et al., 2011). If a community worker is advocating on behalf of clients with physical disabilities who are constantly overlooked for jobs they are capable of performing, the com- munity worker might organize a campaign to educate employers and raise their awareness about people with physical disabilities. If the client community con- ducts the research, prepares the materials to be distributed, participates in pre- sentations, and evaluates the success of the campaign, their abilities and strengths will be showcased to employers. In addition, the client population will be empow- ered by participating in their own advocacy. Direct Community Services Community counselors serve their communities by offering preventive education programs geared to the population at large. Examples of these programs include life planning workshops, value clarification seminars, interpersonal skills training, and teaching parents about their legal rights and responsibilities. Because the emphasis is on prevention, these programs help peo- ple develop a wider range of competencies. The focus of preventive programs is on teaching effective living and problem-solving competencies. Indirect Community Services Community workers strive to change the social environment to reduce the mental and physical health problems of the popula- tion as a whole by influencing public policy. The focus is on promoting systemic change by working closely with those in the community who develop public pol- icy. For example, a community worker might focus on helping to shape policies at the local, state, or national level that support people with disabilities in finding satisfactory employment and that safeguard their rights in the workplace. Another community agent might work closely with stakeholders to develop effective com- munity interventions and new public policies to assist people suffering with an opiate addiction in getting the treatment they need to recover. Community work is not easy; there are institutional obstacles to getting mean- ingful work done. Bemak (2013) comments that “being effective in community work requires a rigorous focus on the goals of the work and a profound under- standing that the process of achieving these goals may be fraught with challenges and complications” (p. 193). He believes that a main challenge for counselors is to take action and do what is necessary to meet their goals by drawing on their pas- sion and commitment to make the world a better place. LO4 Social Justice Perspective Broadly constructed, “social justice involves access and equity to ensure full par- ticipation in the life of a society, particularly for those who have been system- atically excluded on the basis of race/ethnicity, gender, age, physical or mental disability, education, sexual orientation, socioeconomic status, or other character- istics of background or group membership” (Lee, 2013a, p. 16). Counseling from a social justice perspective involves addressing the realities of oppression, privilege, and social inequities. Social justice and advocacy have become areas of major concern for all coun- selors, and indeed, social justice is referred to as a fifth force that entails a par- adigm shift beyond the individual. The fifth force represents a proactive concern with advocacy and social change and focuses on changing systems and policies on multiple levels (Chung & Bemak, 2012). “Social justice counseling with marginal- ized groups in our society is most enhanced (a) when mental health professionals can understand how individual and systemic worldviews shape clinical prac- tice and (b) when they are equipped with organizational and system knowledge, expertise, and skills” (Sue & Sue, 2013, pp. 108–109). From this perspective, the helping professional’s role includes advocate, consultant, psychoeducator, change agent, and community worker. Counselors with a community orientation are committed to making society a better place by challenging systemic inequities. Although not all counselors will have the time or energy to effect major institutional change, all have the capability of working toward some kind of social change. For example, counselors might strive for social change by challenging colleagues who have made erroneous assump- tions regarding marginalized client populations. Hogan (2013) believes we need to recognize that our own cultural framework is the starting point for how we engage the world. Understanding ourselves as cultural beings powerfully influences our perceptions, as well as the methods we use in our professional work. Social Justice Advocacy as an Ethical Mandate Counselors who base their practice on aspirational ethics oppose all forms of dis- crimination and oppression. Some of the ethics codes refer to the role of social justice advocacy as an ethical mandate (see the Ethics Codes box titled “Social Justice Advocacy”). Ethical dilemmas may arise when the cultural values of the community are not congruent with the values of the community worker. Practitioners need to think about the cultural values of the community where they work and the degree to which their intervention strategies are likely to advance the mental health of clients in the community (Pack-Brown, Thomas, & Seymour, 2008). What is the practitioner to do when there is a conflict between a community agency’s program and the personal values of the practitioner? Reflect on the following case of a social worker who is seeking advice. The Case of Lupe Lupe is a social worker in a community mental health agency that is sponsoring workshops aimed at preventing the spread of hiv. the agency has attempted to involve the local churches in these workshops. One church withdrew its support because the workshops encouraged “safer” sexual practices, including the use of condoms, as a way of preventing hiv. a church official contended that the use of condoms is contrary to church teachings. being a member of this church, Lupe finds herself struggling with value conflicts. she believes the teachings of her church and thinks the official had a right to withdraw his support of these workshops. but she also is aware that many people in the community she serves are at high risk for contracting hiv because of both drug use and sexual practices. in an attempt to resolve this value conflict, Lupe seeks out several of her colleagues, each of whom provides some advice. Colleague A: i hope you tell your clients and others in the community that you have value conflicts between agency practice and your religious beliefs and, for that reason, you are voluntarily resigning from the agency. Colleague B: be up front with the people you come in contact with by telling them of your values and providing them with adequate referrals so they can get information about pre- vention of this disease. you do owe it to them not to steer them in the direction you think they should move. Colleague C: it is best that you not disclose your values or let clients know that you agree with the church’s views. instead, focus on the underlying causes of their behaviors and work toward helping clients become more aware of how they are engaging in self-destructive behaviors. if Lupe were to seek you out and ask for your advice, consider what you would say to her. in formulating your position, answer these questions: • Which of her colleagues comes closest to your thinking, and why? • With which colleague do you find yourself disagreeing the most, and why? • Would it be ethical for Lupe not to disclose her values to her clients? Why or why not? • What are the potential consequences if Lupe imposes her moral beliefs on the population she is serving? is it her ethical and moral duty to the community to develop a program aimed at prevention of hiv? explain. Commentary. this case highlights a conflict between the social worker’s personal values and her agency’s requirements in a community context. Lupe should identify any conflicts between her ethical duty to avoid harm and promote her clients’ best interests and the church’s teachings, and then abide by the ethical mandate. We would remind Lupe that just as in individual counsel- ing, she is committed to working for the best interests of her client, in this case, the community as a whole. Lupe’s failure to provide necessary information to members of the community puts the community at risk of harm. because the teachings of the church prevent such a partnership, Lupe may need to enlist other community groups in her efforts to provide outreach regarding methods of safer sex. even though Lupe’s values are congruent with the church’s position, eth- ically she cannot replace community values with her personal values. johnson, barnett, elman, forrest, and Kaslow (2012) have encouraged the profession to modify and amplify the principle of beneficience to incorporate qualities of caring and compassion. this case illustrates the need for practitioners to demonstrate care and compassion in their work in the community. • The Goals of Social Justice and Advocacy LO5 Advocacy can help create a better world that goes beyond an individual client (Chung & Bemak, 2012). The goal of counseling from a social justice perspective is to promote the empowerment of people who are marginalized and oppressed in our society (Herlihy & Watson, 2007). Stone and Dahir (2016) claim that “the basic principles of advocacy are helping socially devalued groups gain the tools, confi- dence, political clout, and skills needed to move away from oppression” (p. 125). Chung and Bemak (2012) state that “being an advocate requires the core counsel- ing skills and multicultural competencies, along with energy, commitment, motiva- tion, passion, persistence, tenacity, flexibility, patience, assertiveness, organization, resourcefulness, creativity, a multisystems and multidisciplinary perspective, and the ability to deal with conflict and negotiate and access systems” (p. 175). Counselors must be willing to work outside of traditional school and agency settings to lower societal barriers that impede optimum human functioning (Steele, 2008; Stone & Dahir, 2016). Some of these societal barriers include limited access to health care and a quality education, poverty, segregation, racism, sexism, and discrimination, all of which are conditions that contribute to oppressive societal practices and create barriers to participating fully in society. Tensions in American society related to social injustice have increased in recent years. Although some progress has been made, society remains polarized. Stories about police brutal- ity directed toward Black males, mass shootings and acts of terrorism both on American soil and abroad, xenophobia, and intolerance toward the LGBTQ com- munity, religious minorities, and other vulnerable populations abound. Global issues such as terrorism, war, radicalization, political dissension, and economic instability may have an impact on our lives and on the lives of our clients in ways that we cannot yet imagine. Through the ubiquitous presence of technology and social media in our lives today, we can access news anywhere in the world as it is occurring, which certainly makes the world seem smaller. Some may find the sheer amount of information available to be overwhelming and stressful. In this age of globalization, counselors and other helping professionals need to be prepared to deal with demands that previously may have seemed to be beyond the scope of their training. For instance, a counselor working with refugees who escaped unthinkable conditions in war-torn countries may be dealing with the trauma of experiencing or witnessing atrocities in the client’s country of origin as well as the trauma of leaving one’s home and loved ones behind; finding appro- priate housing and employment; learning a new language and navigating a new culture; and dealing with xenophobic attitudes from others in the community. Working on issues such as self-actualization must, by necessity, take a backseat to these higher priorities. Refugees and other clients who have been oppressed may need assistance with a variety of tasks, and it is imperative that the counselor and the client establish goals in a collaborative manner. Community-oriented counselors must adopt a flexible approach and be willing to assist clients in finding resources that will help them make a positive adjustment. During my (Cindy’s) work with Sudanese ref- ugees, it was not uncommon for me to conduct home visits. Although I provided mental health services, my clients often needed basic information such as how to get a driver’s license, apply for college classes, find jobs, use kitchen appliances, and sort through mail that was important versus “junk.” Although this may not seem like counseling, it was a basic part of establishing trust and was necessary in order for my clients to feel ready to begin to talk about the deeper issues of trauma that accompanied them when they entered the country. Social justice and advocacy competencies are necessary for counselors to work effectively on a systemic level. Counselor education programs must include skills training to intervene effectively on both individual and community levels. Lewis, Toporek, and Ratts (2010) point out that “more and more counselors have begun to use the wide-angle lens in their work. The counseling profession has come to accept the idea that advocacy strategies and a social justice perspective belong at the center of good practice” (p. 243). LO6 Advocacy Competencies Counselors function as advocates when they use their skills in helping clients chal- lenge institutional barriers that impede their personal, social, academic, or career goals (Lee & Hipolito-Delgado, 2007). Counselors who have a social justice advo- cacy perspective demonstrate leadership abilities and understand the importance of speaking out to empower individuals, families, and their community (Ratts & Hutchins, 2009). A primary focus for school counselors who assume an advocacy role is to become the voice for students who lack educational opportunities. All stu- dents deserve equal access to a quality education (Stone & Dahir, 2016), and Lee and Rodgers (2009) point out that school counselor advocates are risk-takers and often take on causes that are unpopular. They assert that it takes courage “to intervene not only into the lives of clients but also into the larger social/political arena for the benefit of an individual client as well as to foster social justice for all” (p. 286). Ethical practice requires counselors to assume an advocacy role that is focused on affecting public opinion, public policy, and legislation (ACA, 2014; Lee & Rodgers, 2009). Practitioners also need to develop an awareness of their own beliefs and attitudes regarding social issues and marginalized populations, the scope of their knowledge, and their level of skill at intervening within the differ- ent domains of advocacy. Finally, multicultural competence is essential in under- standing the cultural relevance and appropriateness of advocacy interventions as counselors bring their own attitudes and beliefs to the sociopolitical history of their communities. For comprehensive discussions of social justice and systems changes as applied to working with diverse client populations, see ACA Advocacy Competencies: A Social Justice Framework for Counselors (Ratts et al., 2010) and Social Justice Counseling: The Next Steps Beyond Multiculturalism (Chung & Bemak, 2012). Social Justice Advocacy in School Counseling The role of school counselors is expanding to include advocating for social justice on a broader scale (Lee & Rodgers, 2009). Stone and Dahir (2016) devote a chap- ter to the topic of school counselors as advocates, and their ideas are represented in this discussion. Raising hopes and expectations and empowering students are critical roles for school counselors to play in supporting a better future for stu- dents. However, a proactive stance goes beyond working with individual students to advocating for change throughout the school system when inequities and dis- criminatory practices are found. Stone and Dahir list some guiding principles for effective advocacy: • Counselors demonstrate a willingness to be passionate advocates and risk- takers who assist students in finding a voice. • Counselors believe that they can make a significant difference by relentlessly and collaboratively pursuing an advocacy role. They recognize that they can affect change, and they accept and celebrate their small successes. • Counselors believe in their students and do not allow others to sidetrack them with negativity. School counselors can help foster a vision and a belief in the development of high aspirations for every student. LO7 Roles of Helpers Working in the Community As we indicated in Chapter 4, to meet the needs of many ethnic and culturally diverse clients, traditional counselors must have a different vision and master dif- ferent skills. Providing services in nontraditional settings outside the office may be clinically and ethically indicated and may be most beneficial to clients. Outreach Interventions The outreach approach may include both developmental and educational efforts, such as skills training, stress management, and consultation. Outreach activities also include family preservation services, the goal of which is to develop a treatment plan with a family to maintain children’s safety in their own homes. For instance, during a series of home visits to a parent with poor coping skills, an outreach worker teaches, models, and reinforces parenting strategies that can be used to effectively navigate challenging parent–child interactions. Community counselors also attempt to change the dysfunctional system that is producing problems for individuals, fam- ilies, and communities. The focus is on looking at the problem in its community context rather than dealing only with the problem within the individual. MacLeod and McMullen (2016) suggest that counselors also can reach out to the community outside of the counseling setting by volunteering at nonprofit organizations in their local area. Providing outreach beyond the counseling setting is one way to combat stigma and stereotypes regarding mental health concerns; outreach interventions can teach people about wellness and the benefits of coun- seling. “Outreach and volunteer work allows counselors to use their skills in new and useful ways, while providing the public with an experience of what counsel- ors do and what they value” (p. 78). Alternative Counselor Roles LO8 Community-oriented counseling emphasizes the necessity for recognizing and dealing with environmental conditions that often create problems for ethnically diverse client groups. In this psychosocial approach, community workers focus on alternative ways of helping clients that embody fundamental principles of social justice and activism aimed at client empowerment. Atkinson (2004) suggests these alternative roles for counselors who work in the community: advocate, change agent, consultant, adviser, facilitator of indigenous support systems, and facilitator of indige- nous healing methods. Counselors who adopt these alternative roles base their work on a developmental foundation rather than on a service approach. The role of community workers as advocates and change agents has been described; now let’s take a look at some other alternative counselor roles. Consultant Operating as consultants, counselors encourage clients from diverse cultures to learn skills they can use to interact successfully with various forces within their community. In this role, client and counselor cooperate in addressing unhealthy forces within the system. Consultants work with clients from diverse racial, ethnic, and cultural backgrounds to design preventive programs aimed at eliminating the negative impacts of racism and oppression. The role of consultant can be seen as the role of a teacher. Adviser The counselor as adviser initiates discussions with clients about ways to deal with environmental problems that contribute to their personal problems. In many ways, this is a social work approach that considers the person-in-the- environment rather than simply addressing problems within the individual. For example, recent immigrants may need advice on immigration paperwork, coping with problems they will face in the job market, or problems that their children may encounter at school. Veterans transitioning out of the military also may need help finding a job, accessing education benefits, finding a place to live, and identifying local supports for their family. Facilitator of Indigenous Support Systems Many ethnically diverse clients, people in rural environments, and older people would not consider seeking professional help in the traditional sense. However, they may be willing to put their faith in family members or close friends, or turn to other social support systems within their own communities. Community workers need to be aware of cultural factors that may be instrumental in contributing to a client’s prob- lem or resources that might help alleviate or solve the client’s problem. Coun- selors can play an important role by encouraging clients to make full use of indigenous support systems (such as family and friendship networks) within their own communities. Facilitator of Indigenous Healing Systems Mental health practitioners need to learn what kinds of healing resources exist within a client’s culture. In many cul- tures, individuals with problems are more likely to put their trust in traditional healers. For that reason, counselors need to be aware of indigenous healing systems (such as religious leaders and institutions, energy healers, and respected community leaders) and be willing to work collaboratively with them when it is to the benefit of the client. Ignoring these indigenous resources can have a negative effect on the client’s welfare, and therefore, has ethical implications. In summary, we see it as ethically incumbent on practitioners who work in the community to assume some or all of the alternative roles described above when needed to benefit their clients and provide optimal and at times alternative care. We are not discounting the efforts of practitioners primarily engaged in individual counseling as they also contribute significantly toward creating a more actualized community. 466 / chaPter 13 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 partyEducating the Community There are many reasons for the underuse of available mental health resources. Clients may be unaware of their existence; they may not be able to afford the services; they may have misconceptions about the nature and purpose of counseling; they may be reluctant to recognize their problems; they may harbor the attitude that they should be able to solve their own problems; they may feel a social stigma attached to seeking professional help; or they may perceive that these resources are not intended for them because the services are administered in a culturally insensitive way. Services are not always easily accessible, which discourages some from making use of resources in the com- munity. A major barrier for clients is that access to social and psychological services can be confusing, and those providing services may not be receptive or friendly. One goal of the community approach is to educate the public and attempt to change the attitudes of the community about mental health and the attitudes toward those who deliver mental health services. Many people still cling to a very narrow definition of mental illness. Widespread misconceptions include the notion that once people suffer from any kind of emotional disturbance they can never be cured, the idea that people with emotional and behavioral dis- orders are merely deficient in “willpower,” and the belief that the mentally ill are always dangerous and should be separated from the community lest they “contaminate” or harm others. Professionals face real challenges in combating these misconceptions, but unless this is done many people will not seek pro- fessional help. Practitioners are ethically bound to actively work at presenting mental health services in a way that is understandable to and respectful of the community at large. Counselors can assume an advocacy role for the counsel- ing profession by informing the public and potential clients about psychologi- cal services. Community education can open doors for people who previously would not have sought these services due to their misconceptions or pre- conceived notions about the mental health profession (MacLeod & McMullen, 2016). Influencing Policymakers The challenges facing community workers can be overwhelming, especially with current constraints on funding and the bureaucratic malaise. How can dedicated community workers continue to develop social programs if they are constantly faced with the possibility that their programs will be cut back or canceled? There is little room for staff members to initiate innovative social programs when the agencies themselves are concerned with mere survival. One way community workers can initiate change is by organizing within an agency or even several agencies and developing a collective voice. Practitioners can empower a community to organize political action to influence the state and national government to fulfill their responsibilities. This action may involve pro- viding funds, technical assistance, legal protection, or other support a smaller community requires to flourish (Homan, 2016). The Case of a Nonprofit Agency Designed to Educate the Community the coalition for children, adolescents and Parents (ccaP) is a community agency aimed at the prevention of adolescent pregnancy. this small grassroots agency in Orange county, california, applies outreach strategies to educate the community as a way to meet a critical need in the community (hogan-garcia & scheinberg, 2000). ccaP has served as a model for how to involve the community in a project to enhance the community. from its inception, a high priority has been given to hiring a multiethnic staff that could serve and mirror the com- munity. the staff is committed to understanding each other, rather than allowing their differ- ences to separate them, and staff members meet frequently for cultural sharing. those who work at the agency have opportunities to critically examine their ethnocentric assumptions about the world and the community. all the members of the agency staff are committed to clarifying and understanding personal values, beliefs, and behaviors. One of the early projects designed by ccaP involved outreach and education in the Latino community to prevent the spread of hiv. a Latina staff member conducted interviews with 30 mothers in the community regarding their understanding of hiv, human sexuality, and teen pregnancy. from this contact with these mothers, a group of leaders (comadres) was formed to educate the community. the women who served as leaders met for monthly meetings, which were held at a neighborhood center. eventually, the women invited their husbands into the classes. this project was funded by an external source, and the agency was required to report to the funders about the outcomes of the project. hogan-garcia and scheinberg (2000) sum- marize these outcomes as follows: by the end of the contract year, the agency had exceeded the expectations of funders with the project and the comadres Project had spread the word about hiv prevention to friends, neighbors, and fam- ily members. the empowerment of disenfranchised women and men continued beyond the contract term. ccaP staff continued to meet with and follow this special group of friends. three women went back to school, a group of the women formed a spanish-speaking Pta group, and one went on to become a school board member. (p. 28) in 2000 the agency served more than 12,000 clients, providing after-school recreational services, tutoring, academic enrichment programs, physical examinations, parenting education, conflict res- olution, cultural-diversity training, school-based group counseling, a homeless shelter, drug abuse prevention, and child care training. Commentary. this agency is an example of an effective collaboration committed to ensur- ing that the members of the community have a full voice in determining the nature of com- munity services. because the individuals on the staff believe in the value of understanding cultural diversity, they are able to serve as a bridge between the mainstream and minority communities. this is also a good example of developing leadership rather than simply provid- ing leadership. • LO9 Promoting Change in the Community Effective community workers encourage community members to discover their own strengths and to build on these resources. Homan (2016) poses a question that has significant implications for community work: “Are you willing to honestly examine who owns the project?” From Homan’s perspective, if we are just doing things we think are right for people, rather than the project really being theirs to take charge of, we may be unconsciously reasserting a form of social control. Although some client/constituent groups do not have the immediate skills, or even the time to take care of every aspect of a change project, they can learn skills and receive support for their work. Thus the matter of “who owns” the project is an important ethical concern. A Developmental Versus a Service Approach Homan (2016) compares the functions of community workers who operate within a developmental approach with those who rely on a service orientation. The developmental approach is grounded on strengths, focuses on assets and capacities, promotes capability and power, changes conditions, and is aimed at prevention. This approach builds on identifying resources within the individual, the group, or the community that can be more fully activated. In contrast, a service approach focuses on problems to be solved and holes to fill. It is concerned more with maintaining rather than changing conditions and is oriented toward fixing problems rather than prevent- ing them. A service orientation relies on experts and reinforces power imbalances, whereas a developmental approach relies on partnerships and equalizes power relationships. Ways to Involve Yourself in the Community If you want to bring about change within the community, you need to be willing to get involved. Here are some things you might do to link individuals to the environment in which they live. Rate each of these activities, using the following code: Working Within a System LO10 One of the major challenges for counselors who work in the community is to learn how to make the system work for the clients they serve and, secondarily, work for themselves so that in the process they do not lose their ability to be effective. Work- ing in a system can put an added strain on the counselor due to the monumen- tal amount of paperwork required to justify continued funding, high caseloads, and a multitude of policy directives. Another source of strain is the counselor’s relationships with those who administer the agency or institution. Practitioners who deal with clients directly may have little appreciation for the intricacies with which administrators must contend in managing and funding their programs. If communication is poor and problem solving is inadequate, tension and problems are inevitable. The ultimate challenge is to empower the community to address its own problems. The Challenge of Maintaining Integrity in an Agency Environment Many professionals struggle with the issue of how to work within a system while retaining their integrity and vitality. Although working in an organization is often- times frustrating, counselors need to examine their attitude, which might be part of the problem. Blaming others does not effect change. Focusing on the things that can be changed fosters a sense of personal power that may allow for progress. Homan (2016) suggests that simply putting up with problems within a system is rarely gratifying and that workers gain professional satisfaction by actively tak- ing steps to promote positive changes. Recognizing the need for action is the first step toward responding to unacceptable circumstances. Once a problem has been identified, you have four options: • You can change your perception by identifying the situation as acceptable. • You can leave the situation, either by emotionally withdrawing or by physi- cally leaving. • You can recognize the situation as unacceptable and then decide to adjust to the situation. • You can identify the situation as unacceptable and do what you can to change it. (pp. 108–109) Each of these actions has consequences for both you and your clients. If you recog- nize that you do have choices in how you respond to unacceptable situations, you may be challenged to take action to change these circumstances. From an ethical perspective, you are expected to alert your employer to circumstances that may impair your ability to reach clients. By creating and participating in support groups, those who work in an agency might find ways to collectively address problems in the system of which they are a part. A case can be made for the value of support groups in agency settings. These groups create an internal subculture that provides some support in dealing with bureaucratic pressure. Workers alone will likely have difficulty in changing large organizations, but when they unite, they have a greater opportunity for effecting change. The Case of Toni for over 20 years toni has worked with women in recovery in a community agency that is funded by a grant. to prevent burnout, she and her coworkers organized a sup- port group among the community workers in the agency. her group consists of about 15 people, some of whom are case managers, treatment counselors, nurses, social work- ers, and supervisors. they meet at the agency during work hours twice a month for up to 2 hours. During these sessions the workers have opportunities to talk about difficult clients or stressful situations they are facing on the job, such as cutbacks and increased workloads. Personal concerns sometimes have an impact on workers’ abilities to function professionally, and members are able to use the support within the group as a way to deal with personal issues. • • • if you worked in an agency, would you want this kind of support group that toni describes? to what extent do you think members of this group could effect change in the agency? how might you deal with the demands of an increased workload due to cutbacks? Commentary. toni’s case represents a familiar scenario that mental health workers will increas- ingly face in effectively working in an agency. Workers in community agencies will increasingly be expected to meet the demands placed upon them with fewer staff and resources to accom- plish the tasks expected of them. those who work with client populations with high needs can experience compassion fatigue and can quickly burn out. self-care is extremely important in this situation. One way toni found to take care of herself was by finding ways to meet with colleagues in the agency to discuss how others were dealing with the demands of their work situation. • Being an Advocate and Working in a System LO11 Counselors walk a fine line when trying to support causes of equity, justice, and fairness while keeping their jobs. Bemak and Chung (2008) and Chung and Bemak (2012) identify some strategies and skills counselors can use to be effective advo- cates within a system, especially in an educational setting: • Define your role. • Emphasize equal opportunity. • Reach out to the larger community with intervention strategies. • Provide clients with tools that will promote constructive change. • Formulate partnerships with clients who may lack the skills to self-advocate. • Learn about organizational systems. • Work with individuals within a system who will work toward social change. • Form collaborative relationships with other mental health professionals. • Promote social action within a sociopolitical context. • Generate team support by collaborating with community agencies. As social justice counselors, we cannot preach social justice values in our work setting unless we are willing to practice what we teach (Chung & Bemak, 2012). “It demands that we question ourselves about, if, how, and when we are will- ing to take risks which are fundamental to multicultural social justice counseling” (p. 266). For thoughtful discussions of community action, many case examples of social justice programs, and re-visioning clinical practice, we highly recommend Helping Beyond the 50-Minute Hour: Therapists Involved in Meaningful Social Action (Kottler, Englar-Carlson, & Carlson, 2013). Relationships Between Community Worker and Agency LO12 The ethical violations in a community agency are more complex and difficult to resolve than violations pertaining to individual counseling. If a worker is not moti- vated, the system may tolerate this lack of motivation. If the system violates the rights of the client (community), then this is a real challenge to address. There is no easy solution to systemic problems, but clearly the people seeking help are vulner- able and need to be protected. Correcting systemic abuse demands the willingness of those involved in the system to practice aspirational ethics and take action. Moving Toward Empowerment Think about how you can empower yourself to help create systemic change in your community. Imagine yourself in each of these situations, and ask yourself how you could increase your effectiveness within the system: • What would you do if the organization for which you worked instituted a policy to which you were opposed? • What would you do if you believed strongly that certain changes needed to be made in your institution but your colleagues disagreed with you? • What do you think you would do if members of the staff seemed to work largely in isolation from one another? • What are some steps you can think of to promote change within an agency? • What do you consider to be the ethics involved in staying with a job after you have done everything you can to bring about change, but to no avail? The Case of Adriana adriana works in a community mental health clinic, and most of her time is devoted to deal- ing with crisis situations. the more she works with people in crisis, the more she is convinced that the focus of her work should be on preventive programs designed to educate the public. adriana comes to believe strongly that there would be far fewer clients in distress if people were effectively contacted and motivated to participate in growth-oriented educational pro- grams. she develops detailed, logical, and convincing proposals for programs she would like to implement in the community, but these proposals are consistently rejected by the director of her center. because the clinic is partially funded by the government for the express purpose of crisis intervention, the director feels uneasy about approving any program that does not relate directly to this objective. if you were in adriana’s place, which of the following courses of action would you choose? _____ 1. _____ 2. _____ 3. _____ 4. _____ 5. _____ 6. i would do what the director expected. i would continue to work toward a compromise and try to find some way to make room for my special project. if i could not do what i deemed important, i would have to consider looking for another job. i would involve clients in setting the direction for the proposal and providing the necessary support to secure approval. i would get several other staff members together, pool our resources, and look for ways to implement the program as a group. With my director’s approval, i would try to obtain a grant for a pilot program in the community. Commentary. adriana has tried repeatedly to convince the director of the center that pre- ventive programs would help to avert crises and improve community health. One alternative role open to her is to advocate for policy changes in government regulations. at the local level, adriana could join forces with others in her agency to work toward an expanded definition of crisis intervention that includes preventive measures. at the state level, adriana could reach out to colleagues in her state’s counseling association to identify peers who may be interested in helping to advocate for policy changes in government regulations specifically in relation to preventive programs for crisis interventions. • As a mental health practitioner, you may need to decide how you will work within a system and how you can be most effective. Study the agency’s philos- ophy before you accept a position, and determine whether the agency’s norms, values, and expectations coincide with what you expect from the position. If you are not able to support the philosophy and policies of that agency, you are almost certain to experience conflicts, if not failure. It will be up to you to find your own answers to questions such as these: • To what degree is my philosophy of helping compatible with the agency where I work? • • How can I meet the requirements of an institution and at the same time do what I most believe in? What can I do to bring about change in a particular system? What special ethical obligations am I likely to face in working in a system? The Case of Ronnie ronnie, an african american student, moved with his family into a mostly White community and attends high school there. almost immediately he was on the receiving end of racial jokes and experienced social isolation. a teacher noticed his isolation and sent him to the school counselor. it is evident to the counselor that ronnie is being discriminated against, not only by many of the students but also by some of the faculty. the counselor has no reason to doubt the information provided by ronnie because she is aware of racism in the school and in the community. she determines that it would be much more practical to help ronnie learn to ignore the prejudice than to try to change the racist attitudes of the school and the community. • how do you evaluate this counselor’s decision? What are its ethical ramifications? Does she have an obligation to work to change community attitudes? • if you were consulted by this counselor, what suggestions would you make? • Does a school system have an ethical obligation to attempt to change attitudes of a com- munity that discriminates against some of its citizens? • What are the risks of not addressing the problem of racism? Commentary. this counselor is struggling with the nature of the challenge and seems ill equipped to take it on. she may fear reprisals if she acts on values that are not shared by many in the community. she may want to do what is needed to promote the well- being of her client, yet she may be struggling with self-doubts and with anxiety about not being accepted by some faculty members. although this counselor seems unwilling or perhaps is unable to confront racism within the school setting, she has an ethical duty to advocate for change in the school community. by talking with the teacher who sent ronnie to her, she may be able to begin to gather a coalition for change in the school community. she might consider presenting workshops and classroom guidance activities on racism in the school. the counselor also may be able to gain the support of the school administration if she approaches the problem in a noncombative manner. in this case, the client is the school community, and ronnie’s troubles will not be resolved without community change. • As mental health professionals, we are expected to translate our awareness of inequities and societal conditions into various forms of social action. Part of our ethical and moral obligation is to advocate with the aim of creating a just society in which all people have equal opportunities and resources to strive toward their personal goals. Chung and Bemak (2012) capture the essence of this message in this way: “We must move forward and beyond the traditional approach of focus- ing solely on the intrapsychic, accept and recognize the impact of sociopolitical factors on our clients and their families, and determine how our advocacy can effectively address those issues” (p. 182).