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Issues in Theory and Practice

Chapter 10

Developing a Counseling Style

Ideally, the theoretical approach you use to guide your practice is an expression of you as a person and is the result of intensive study, reflection, and clinical experience.

Ultimately, your counseling orientation and style must be appropriate for the type of counseling you do and the unique needs of your clients.

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.

Developing a Counseling Style

Many of the assumptions of contemporary theories are inappropriate for evaluating clients from cultures that focus on interdependence, downplay individuality, and emphasize being in harmony with the universe.

Practicing counseling without an explicit theoretical rationale is somewhat like trying to sail a boat without a rudder.

Developing a Counseling Style

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 counselors can use to make sense of what they are hearing and what needs to change.

Developing a Counseling Style

Is it OK to use the term “ECLECTIC”?

What does the term “INTEGRATIVE” mean?

Ch 10 Activities Sheet

Discuss activity #1 with a peer

The Division of Responsibility in 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.

The Division of Responsibility in Therapy

A contract encourages client and therapist to specify the goals of therapy and the methods likely to be employed in obtaining these goals.

Therapists who work within a managed care context need to discuss with clients how being involved with managed care will influence division of responsibility between the HMO, the client, and the therapist.

Deciding on the Goals of Counseling

Both therapist and client should clearly understand the goals of their work together and the desired outcomes.

The aims of therapy are specific to a particular culture’s definition of psychological health; no single approach is equally effective in working with all client populations.

Deciding on the Goals of Counseling

In a managed care system, the goals will need to be highly specific, limited to reduction of problematic symptoms, and often aimed at teaching coping skills.

In crisis intervention, goals are likely to be short term and functional, and you may be much more directive.

Deciding on the Goals of Counseling

In schools, you may combine educational and therapeutic goals.

In serving older adults residing in an assisted living community, you may stress coping skills and ways of relating to other residents.

Techniques in Counseling

Practitioners need to function with intentionality.

They must have a clear understanding of the techniques they employ and have a sense of the expected outcomes of their interventions.

Some specific techniques appear to be more effective with particular symptoms and disorders, especially for certain behavioral disorders.

Techniques in Counseling

The techniques counselors employ, although important, are less crucial to therapy outcomes than are the interpersonal factors operating in the client–counselor relationship.

Diagnosis as a Professional Issue

Key terms:

Medical diagnosis

Psychodiagnosis

Differential diagnosis

DSM-5

Theoretical Perspectives on Assessment and Diagnosis

Psychoanalytic Therapy

Adlerian Therapy

Existential Therapy

Person-Centered Therapy

Gestalt Therapy

Behavior Therapy

Theoretical Perspectives on Assessment and Diagnosis

Cognitive-Behavioral Therapy

Reality Therapy

Feminist Therapy

Postmodern Approaches

Systemic Approaches

DSM-5

In the DSM-5 revision process, the American Psychiatric Association paid considerable attention to:

Developmental issues

Gaps in the current system

Disability and impairment

Neuroscience

Cross-cultural issues

Arguments for Psychodiagnosis

No third-party reimbursement without acceptable diagnosis

Difficult to formulate treatment plan without defining problem

Provides team members with a common frame of reference

Allows therapists to rule out medical conditions

Arguments for Psychodiagnosis

Used to assess whether clients pose danger to self or others

Provides framework for research

May be a minimum standard of care for some licensed professionals

Arguments for Psychodiagnosis

May seldom have a choice about diagnosis

May be critical to determine therapeutic success

Helps to normalize a client’s situation

Arguments Against Psychodiagnosis

Emphasis of DSM is on pathology

Can minimize uniqueness of client

Ignores natural capacities for self-healing

Can lead people to accept self-fulfilling prophecies

Arguments Against Psychodiagnosis

Assumes that distress in family is result of individual pathology

Many therapists are not competent to use DSM diagnosis properly.

DSM has been criticized (e.g., reliability and validity questioned, failure to predict treatment outcomes)

No third-party reimbursement without acceptable diagnosis

Difficult to formulate treatment plan without defining problem

Provides team members with a common frame of reference

Allows therapists to rule out medical conditions

Used to assess whether clients pose danger to self or others

Provides framework for research

May be a minimum standard of care for some licensed professionals

May seldom have a choice about diagnosis

May be critical to determine therapeutic success

Helps to normalize a client’s situation

Pros of Diagnosis

Cons of Diagnosis

Emphasis of DSM is on pathology

Can minimize uniqueness of client

Ignores natural capacities for self-healing

Can lead people to accept self-fulfilling prophecies

Assumes that distress in family is result of individual pathology

Many therapists are not competent to use DSM diagnosis properly.

DSM has been criticized (e.g., reliability and validity questioned, failure to predict treatment outcomes)

Ethical and Legal Issues in Diagnosis

Some practitioners who are opposed to a diagnostic framework take the path of least resistance, giving every client the same diagnosis.

Presenting an “acceptable” but inaccurate diagnosis is both unethical and fraudulent.

E.g., adjustment disorder

Relational problems

Ethical and Legal Issues in Diagnosis

It is an ethical (and sometimes legal) obligation of therapists to be mindful that a medical evaluation is many times indicated.

Competence in using the DSM appropriately is an ethical issue.

Cultural Issues in Diagnosis

Cultural sensitivity is essential in making a proper diagnosis, and a range of factors need to be considered in interpreting assessments.

What is considered healthy can vary greatly from one culture to the next.

Cultural Issues in Diagnosis

There is a tendency for some practitioners to overdiagnose, underdiagnose, or misdiagnose clients from marginalized groups.

Accurate assessment and diagnosis involves taking into consideration realities of discrimination, oppression, and racism in society and mental health disciplines.

Cultural Issues in Diagnosis

Consider the ways in which clients’ socioeconomic and cultural experiences can influence behavior, including the presentation of symptoms.

Ch 10 Activities Sheet

Discuss activity #2 with a peer

Ch 10 Activities Sheet

Discuss activity #3 with the class

Using Tests in Counseling

It is important for counselors to:

Be familiar with tests being used and take tests themselves

Recognize limits of competence to use and interpret tests

Know reasons why a particular test is being used

Make clients aware that tests are merely tools that can provide useful information

Using Tests in Counseling

It is important for counselors to:

Select tests appropriate for client given their unique cultural, social, and cognitive factors

Give test results, not simply test scores

Be sensitive to ways clients respond to results

Assure clients that test results will not be used against them

Assure confidentiality unless consent is given

Know the limitations of tests being used

Evidence-Based Therapy Practice

APA Presidential Task Force’s Definition, 2006:

“The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences”

Evidence-Based Therapy Practice

The three pillars of EBP:

Best available evidence, clinician expertise, and client characteristics

EBP should enhance public health, but keep in mind it remains unclear and controversial whether EBPs perform reliably better than practices not designated as evidence-based

Use resources to find EBP:

SAMHSA: Substance Abuse & MH Services Adminstration

NREPP: Nat’l Registry of EPB & Practices: LINK

Findings From Psychotherapeutic Research

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” associated with therapies.

In general, therapies achieve similar outcomes.

Findings From Psychotherapeutic Research

Most therapists learn more about effective therapy techniques from their experience than from the research.

Approximately 10 percent of clients get worse as a result of therapy.

The relationship between therapist and client is the best predictor of treatment outcome.

Findings From Psychotherapeutic Research

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.

Ch 10 Activities Sheet

EPB Debate! Activity #4

Ch 10 Activities Sheet

Interview Question Prep: Activity #5