Tag Archives: Assessment

Assessment

Behind the Book: Assessment in Counseling

Heather Rudow March 7, 2013

78074

Danica G. Hays, an associate professor of counseling and department chair at Old Dominion University, is the editor of the fifth edition of Assessment in Counseling, published by the American Counseling Association in November. Hays, a member of ACA, the Association for Assessment and Research in Counseling, the Association for Counselor Education and Supervision, and the National Career Development Association, has fostered an interest in this topic — and in earlier editions of the book — for many years, dating back to her time in grad school.

What inspired you to edit Assessment in Counseling?

I learned about assessment in graduate school from the second edition of the text, and as a counselor educator I taught assessment using the third and fourth editions. I was privileged to supplement the valuable content of previous editions with activities and content I have found useful both as a student and counselor educator. As a counselor working in a variety of settings, I found myself going back to this text for foundational material about assessment as well as titles of and information about specific tools to be used with clients dealing with mental health issues, career concerns, substance abuse, and so on.

So, when I was approached to author the fifth edition, it was an easy yes: I already knew how valuable the information was for me in academia and the clinical world, and I had ideas to expand information to hopefully engage others in the assessment process.

The new revision was needed to update students and practitioners on recent changes in specific assessments and diagnostic procedures (e.g., GRE, WAIS, DSM-5), expand on topics such as the history of assessment, test access issues, high stakes testing, cultural bias in assessment, qualitative assessment and specialty areas of assessment and related standards and assessment of violence such as intimate partner violence and child abuse.

What do you hope counselors take away from the book?

I think for many students and counselors who hear the word “assessment,” they think of images of standardized tests and become quickly disinterested, or think they counsel clients, not conduct assessments. I want to dismantle these stereotypes. My hope is that students and practitioners will take away from this book that counseling is assessment. Assessment is more than administering, scoring and interpreting tests; it is a process that counselors use to evaluate client or student issues and readiness for change, gather and integrate session information for treatment planning or decision-making, measure counseling outcomes, and advocate for individuals and their communities to foster psychosocial, physical, academic and occupational well-being. Thus, counselors can rely upon various qualitative or quantitative tools to work with individuals at every stage of counseling.

I have included several pedagogical strategies such as self-development activities, tip sheets, testimonials from counselors and students, case examples, sample reports, chapter pre-tests, review questions and chapter summaries.

Who do feel is the best audience for the book?

The primary audience for this text is professional counselors in agencies and private practice, school counselors, college counselors, counselor educators and other instructors of assessment courses in counseling and education. Other appropriate groups include psychology instructors, social work instructors, marriage and family therapy instructors, psychologists, social workers, and marriage and family therapists.

What are some main issues or topics in the counseling profession that relate to this book?

This text is most appropriate as a graduate-level text, and students gain knowledge about the following in the text:

  • Foundational information about assessment in counseling, including the history, purpose and use of assessment; phases of the assessment process; and ethical, legal and cultural considerations in every phase of the assessment process.
  • Key statistical and measurement concepts to ensure a basic understanding of psychometric properties, scale development, raw score conversion and culturally-sensitive assessment.
  • Common assessment practices typically occurring in the initial phases of counseling, including intake interviews, mental status examinations, screening of psychological symptoms, suicide risk assessment and clinical diagnosis.
  • Specialized evaluation of mental health concerns including substance abuse, depression, anxiety, anger, self-injury, eating disorders and attention-deficit hyperactivity disorder.
  • Information about types of assessment, including assessment of intelligence, ability, career development, personality, and interpersonal relationships.
  • Detailed information about reporting assessment data in cases presentations and reports.

How did you first get involved with the subject?

I have been involved for over 10 years with the Association for Assessment and Research in Counseling, so I have grown to really appreciate assessment and effective counselor training in assessment procedures. I also witnessed some really bad ways to assess that led to misdiagnosis and poor treatment options— I know advocacy was important because real people are affected by assessment. I hope this book is just one step toward that.

What surprised you as you were editing Assessment in Counseling?

I was surprised to see how little we know empirically about what assessments counselors use, how they see different components of what they do as assessment procedures, how they use assessments, how inaccessible assessment information is to individuals and what issues aren’t prominently addressed in assessment texts, such as interpersonal violence and other forms of trauma, concrete examples of diversity considerations and crisis assessment.

Why should counselors feel compelled to read this book?

As I mentioned, counselors and counselor trainees tend to be “turned off” by assessment, as they think assessment is only about testing, and that they don’t plan on doing testing. It is my hope that the revised content will illustrate how assessment practices expand beyond quantitative, standardized assessment and are infused in our daily professional lives. Thus, counselors need to be aware of the value of assessment in our profession, as well as the continual pressing issues that threaten culturally-responsive assessment and diagnostic practices.

Click here to order Assessment in Counseling.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Understanding bulimic dissociation to create new pathways for change

Rebecca Heselmeyer & Eric W. Cowan December 1, 2012

Given the extensive research on eating disorders, motivated clients and a gold standard treatment — cognitive behavior therapy — it is perplexing that recidivism rates remain so high for bulimia. It behooves us as counselors to investigate possible hindrances to effective treatment and adjust our approach accordingly for those clients with bulimia who have not achieved long-term resolution. It is notable that, despite the substantial evidence linking dissociation and bulimia, many counselors remain unaware of this connection. Further, the nature of the relationship has not been sufficiently explored. In this article, we apply principles from self-psychology to bulimic dissociation and use this new understanding to inform clinical practice.

When I (Rebecca) first met Sonya, she sat across from me tearfully expressing the shame she felt about her binging and purging and the feeling of defeat she experienced from failed efforts: to stop thinking about food, to stop scrutinizing her body, to stop mindlessly gorging on food and then rushing to vomit. Sonya presented as many clients with bulimia do — she expressed a desire to change and a willingness to try whatever therapeutic assignments I may assign to her. Rather than engage with her in familiar and expected territory by focusing on food (nutrition, food journals and so on), I turned my attention to a different part of Sonya’s experience, inviting into our conversation the part of her identity that up until then had likely been unacknowledged and invalidated repeatedly. We have labeled this the dissociated bulimia identity (DBI). To explain our reasoning for yet another coined term with a nifty initialism, let’s shift gears and look at the underlining theory.

Self-psychology and the vertical split

Heinz Kohut proposed that children need specific interactions and feedback from caregivers to formulate cohesive, integrated selves. An important part of this process involves mirroring, in which caregivers demonstrate accurate, empathic affective attunement with the child. For example, a child may cry out upon seeing shadows in a dark bedroom at night. An attuned care provider might respond by giving language to what the child is experiencing (“You are afraid”) and comforting the child. Through such interactions, the child not only learns language for his or her affective state, but also learns that he or she can be afraid and still be loved. Gradually, with additional interactions in which the caregiver reflects the child’s fear in a nurturing manner, this affective state becomes identified and integrated into the child’s sense of self.

Assuming the care provider responds to the multitude of emotional experiences with validating, reflective attunement, the self then develops into a cohesive being where all affective states — love, joy, fear, grief, discouragement, excitement, loneliness and so on — have an identified and accepted place. The child has been welcomed into the world of shared meanings and connections and has formed a cohesive sense of self composed of, to use Harry Stack Sullivan’s language, “reflected appraisals.” Further, the process that enables identification and integration also teaches the child about self-care; the nurturing and soothing interactions with the caregiver over time become internalized so that the child develops the ability to self-soothe and manage emotional experiences without relying on the caregiver’s presence.

Now imagine the same child in the frightening, dark bedroom, crying out at the lurking shadows. In this house, the caregiver responds with taunts, calling the child a scaredy-cat and snapping at her to go back to sleep “or else.” Continued interactions of this nature also identify the affective state while invalidating the experience of it. The child is taught that fear is not allowed and is shamed for experiencing it. There is no comforting hug or lullaby to internalize; there is only the message of rejection. There is a disconnect between the child and others, which results in a parallel disconnect from internal thoughts and feelings. Dependence on the caregiver is crucial for survival, so anything that might threaten this relationship is sacrificed. Consequently, affective states met with invalidation become disavowed and denied integration into the “socially acceptable self.” But where do these affective states go?

Kohut proposed that lack of adequate and empathic mirroring results in a “vertical split” — a metaphor for the partition between self-experiences integrated into the “normal” self and disavowed affects and frustrated developmental needs. Repression can be understood as a horizontal split, with unconscious desires tucked away deep in the psyche and blocked from the rest of the aware mind and body. The vertical split, on the other hand, designates a chasm between selves: the integrated affects and being states that were met with empathic mirroring and those that were sacrificed in an attempt to maintain the essential relationship with primary caregivers.

Therefore, for clients with bulimia, validated affective states become integrated into the normal, socially acceptable self, while invalidated affective states are sequestered on the other side of the split, forming the unacknowledged, rogue DBI. Acknowledging this part of the self-experience has been deemed threatening and forbidden. Perhaps more important, the child never learns to effectively acknowledge, self-soothe and manage this part of self-experience. Needless to say, mere ignoring cannot relieve the emotional demands of loneliness, lust, anger, guilt, despair and other feelings. When the DBI demands attention, the now-adult client may address it in the one way she or he knows how — with food.

Media teach us time and again that food is a source of comfort, pleasure and love. The absurdity of media campaigns goes so far as to sexualize food. Jean Kilbourne, in her “Killing Us Softly” lectures, observes the potency of a variety of media messages, including ones that offer food as a substitute for relationships. Food is also culturally anchored in our experiences: family gatherings, celebrations and times of mourning. Our bodies respond physically and physiologically to eating. In the most basic sense, food literally fills a void within us. Binging provides momentary relief and escape, and the process at work is twofold.

Dissociative symptoms are present throughout the binge-purge cycle, with peaks occurring during the binge and immediately after the binge. Dissociation is commonly thought of as an escape from painful psychological experiences. Dissociative symptoms are on a continuum ranging from minor alterations in perceptual functioning to significant disruptions, such as a dissociative fugue. The dissociation associated with bulimia is primarily categorized as mild to moderate. Clients may feel out of control or have a detached experience of watching themselves binge.

Let’s explore the dual process at play, using Sonya as an example.

Dissociation, revisited

Sonya would often report the quick onset of the urge to binge. As she began, her feelings of disconnectedness and lack of control grew, enabling her to eat beyond capacity by blunting both the physical and emotional discomfort she would otherwise experience. Psychologically, the dissociative symptoms she experienced also provided temporary relief from the triggering affective state. At the same time, the dissociative experience allowed Sonya to “jump” the vertical split and access the very region housing the unmet need that was triggering the binge — in her case, a deep sense of helplessness. This dis-integrated part of her self-experience that was reproached during her development has shown up in her adult life, but she lacks the ability to effectively identify, manage and attend to it.

The binge-purge behavior brings with it dissociative processes that temporarily provide Sonya with both an escape from pain and access to the region where she can acknowledge and soothe that otherwise denied self-aspect. The function of dissociation is to “escape” to a very specific and important place: her DBI. In other words, while Sonya is desperately (and ineffectively) seeking physical comforts, her psychological self is likewise seeking to self-soothe the neglected and needy DBI. She is momentarily allowed access to this outlawed part of the self and can attend to the very real need for nurturing and validation.

With the conclusion of the binge also comes the conclusion of dissociative symptoms. Sonya becomes more aware of her physical self — and simultaneously is returning to her socially acceptable, normal psychological self — and is swept by feelings of shame and guilt. Physically she feels great discomfort and embarrassment at the quantity of food she has consumed, while psychologically she has trespassed to visit and comfort the forbidden DBI. She has broken the rules — physically by food consumption and psychologically by traversing the vertical split. Guilt reigns supreme, and she purges to expunge herself of the harm done.

Through this lens, the functionality of the binge-purge behavior and dissociation can be seen as the client’s best effort to attend to a disorganized self-experience. For many clients, including Sonya, bulimia is a clinical presentation that, at its core, is a disorder of self rather than being fundamentally rooted in body image concerns. The clients’ repeated attempts at self-care through the use of food fail because the core unmet developmental needs are never brought out of exile and given their rightful place in the integrated “normal” self. Symptom-focused counseling that serves largely as behavior management — food journals, nutritionists, love-my-body activities — prove ineffective for these clients because there is no room for the underlying disorder of self to emerge in the therapeutic dialogue. For this to happen, there needs to be a shift in the counseling mindset and conversation.

Clinical applications

If I had partnered solely with Sonya’s desire to extinguish her bulimic behaviors, I would also have partnered solely with her “socially acceptable” self  — that part of her that genuinely does want to stop binging and purging. Concurrently, I would have communicated to her that her DBI was not welcome.

The DBI relies on the function of her behaviors for much-needed psychological care, so there is likely a very substantial part of Sonya that wants to binge and purge and has no intention of giving this up. Focusing the counseling conversation on ways to extinguish and change behavior, without also addressing the purpose of the behavior and offering an alternate way of accomplishing the function, invalidates the part of the client’s experience that appreciates and needs the behavior. If approached in this manner, the client’s DBI is likely to “go into hiding” for fear that successful counseling will result in its extinction (rather than integration). In effect, this guarantees an unsuccessful long-term counseling outcome.

Instead, I invited Sonya to tell me about the part of her that wants to binge and purge. This is a potentially shame-laden and socially ostracized part of Sonya’s being, so it is important for me to seek it out and welcome it rather than assume it will enter the therapeutic dialogue without active and sometimes repeated invitation. Counselors need to provide an experience in which all parts of the client’s experience — both the desire to cease behavior and the desire to maintain it — are welcomed and validated. We encourage counselors to address the DBI directly (“Tell me about the part of you that needs to keep doing this”) or by using third-person language (“Tell me about her — the part of you that defies your attempts to control her”). In addition, use language that demonstrates an appreciation for the adaptive function of bulimia that is, in a sense, trying to help.

Occasionally, it may serve as a powerful paradoxical intervention for the counselor to urge the client not to give up the binge-purge behavior too quickly. Clearly, this intervention is not appropriate when working with clients who have significant health risks. But for clients in relative physical good health, and especially for those who have had extensive counseling, an intervention of this sort likely will be unexpected and get beyond psychological resistance by “siding” with the DBI against the socially conforming self. You can observe to clients how cruel they are to their bulimic selves when they use disparaging language (“I’m such a fatso loser when I binge”).

Once it is established in the therapeutic dialogue that all parts of the client’s experience are welcomed and validated, new pathways for healing can emerge because the client, with the counselor’s support, can begin to acknowledge and express the frustrated developmental needs that are the driving force behind the bulimic behavior. An important part of this approach is keeping the therapeutic conversation focused on the client’s inner world of needs, feelings and thoughts, particularly those that are outside the client’s normal experience, so the client can expand self-reflective awareness.

Once clients gain insight into the role their bulimia has served in managing emotions and needs, a powerful experiential process unfolds as the counselor provides the empathic mirroring response that was previously withheld during the client’s childhood development. Counseling provides the repeated, accurate, empathic attunement that the client’s caregivers failed to supply. Just as over time the child internalizes the caregiver’s ability to soothe and comfort, the client’s new awareness of emotional triggers, coupled with the empathic, attuned response from the counselor, allows the client an opportunity to begin addressing and meeting her or his needs in a new, direct way. The ongoing process of welcoming the formerly forbidden self-experiences into the counseling relationship gradually breaks through the wall of the vertical split, allowing a merging of selves into a now fully integrated self. As this happens, the need for bulimic behaviors diminishes and, without a purpose, the behaviors eventually cease.

Similar to the experiences of other clients, the turning point for Sonya came when she felt at liberty to speak about the part of her that could not imagine life without binging and purging. Gradually, Sonya’s sense of inner connectedness and connection with others grew, and she became skillful at recognizing her emotional needs and attending to them in healthy ways. Her binging and purging has subsequently tapered.

We hope you will find this conceptualization and the suggested techniques enriching to your counseling practice.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Rebecca Heselmeyer is a staff counselor in residence at the James Madison University (JMU) Counseling and Student Development Center, adjunct instructor for the JMU Counseling Programs and a member of the Rockingham Memorial Hospital Psychiatric Emergency Team. Contact her at heselmrj@jmu.edu.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at JMU and the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

Proof positive?

Lynne Shallcross September 1, 2012

Offering counseling treatments that are backed by research is a personal passion for R. Trent Codd. When he founded the Cognitive-Behavioral Therapy Center of Western North Carolina 11 years ago, it was with the mission of delivering and disseminating evidence-based treatments. His practice hires only clinicians who are trained in and dedicated to delivering evidence-based treatments. It also offers training to other clinicians and agencies and produces a free podcast dedicated to evidence-based treatment and cognitive behavior therapy (CBT).

Codd believes a similar focus on evidence-based treatments should be more widely adopted throughout the counseling profession. Although the ACA Code of Ethics states that counselors will use empirically supported treatments, Codd asserts other aspects of the profession’s culture allow for training in and practice of non-validated and potentially harmful treatments.

As an example, Codd shares his viewpoint on critical incident stress debriefing (CISD). “The data here are clear that people recover following a trauma if this intervention is delivered. However, they do so more slowly than with no intervention. That is, this treatment has been shown to impede the natural recovery process,” says Codd, who is a diplomate in the Academy of Cognitive Therapy. “To be more explicit, this intervention is harmful. Delivering harmful interventions is certainly not congruent with the ACA Code of Ethics.”

The American Red Cross and other organizations promote CISD, which can contribute to confusion among counselors, Codd says. Counselors who don’t read the research literature might assume that a technique is safe and effective — even if research seems to indicate otherwise — simply because multiple organizations endorse that technique, he says. (There is ongoing debate about CISD within the mental health professions, and its proponents take issue with claims that there is no evidence of its effectiveness or that it has been proved to be harmful.)

To Codd, the ongoing use of CISD is just one illustration that research and evidence-based practice have yet to find the following they deserve within the counseling profession. “I wish I knew what to recommend to remedy this problem,” he says. “This is something that I’ve spent quite a bit of time thinking about over the years. I think the only thing that will make a difference is a change in the professional counseling culture. The bottom line is that we, as a profession, are going to have to agree that this is important. Unless that happens, I don’t think much change is going to occur.”

From his position as president of the American Counseling Association, Bradley T. Erford says he senses the push for evidence-based practice coming from multiple sides — and he hopes that push will continue to grow stronger. Externally, he says, health care providers and government organizations are increasingly demanding to see counseling practices with demonstrated effectiveness. Internally, Erford says, the counseling profession is constantly striving to identify what works, how well, with whom and under what conditions, as any scientific discipline should.

“Knowing and applying what works in counseling not only raises the integrity of professional counselors, it also serves to protect the public from ineffective or even dangerous interventions and treatments,” says Erford, a professor in the school counseling program at Loyola University Maryland.

In Erford’s view, conducting research and using evidence-based practices are important to the profession for two main reasons: adherence to professional ethics and economic survival. “The ACA Code of Ethics states [in Section C, Professional Responsibility] that ‘Counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies,’” Erford says. “That statement pretty much says it all. Regarding economic survival, if professional counselors use the best available research-based approaches to help clients and students, counselor effectiveness, client satisfaction and third-party insurer satisfaction improve. When professional counselors provide effective services, our services become even more valued, and we create a market for more counseling jobs at higher pay.”

Kelly Wester, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro (UNCG), cites credibility and accountability as two additional reasons that counselors should conduct research and then adhere to evidence-based practices. This would assure clients that whatever treatment a counselor is offering has been shown to be effective, says Wester, a member of ACA who co-chaired the development of research competencies for the Association for Counselor Education and Supervision in 2011.

“Using the medical profession as an example, if an oncologist told you that you required an invasive medical procedure to remove or minimize the cancer that was in your abdomen, you would want to know of the effectiveness of this procedure, the risks and the benefits,” Wester says. “You may even want to know who else has been through this procedure and their outcome so you [can] compare yourself, your demographics and your situation with those individuals to see how you may fare in the treatment. While counseling is typically not as invasive as some cancer treatments, our clients may have the same interests and concerns regarding their treatment. Thus, counseling research should be done so that our clients, as well as supervisees and students, know the benefits, risks and outcomes of engaging in the service we are offering them and can truly make an informed choice.”

ACA Chief Professional Officer David Kaplan says health care companies are beginning to suggest that they may stop reimbursing mental health practitioners who don’t use evidence-based practices. The danger if that scenario plays out, Kaplan notes — particularly if counselors don’t begin producing more evidence of effective counseling interventions — is that counselors might find themselves locked out of using helpful approaches because of a lack of research on those approaches.

CBT is often recognized as the most effective treatment in many situations, Kaplan says. This is not necessarily because CBT is the only approach that works, he says, but because it is the treatment that fits best into the prevailing research paradigm. Therefore, the evidence needed to support its effectiveness has been ample. “If we don’t generate outcome research across the entire gamut of counseling interventions,” he says, “the only approach the insurance companies are going to let us use and the only one the government will fund [in the future] will be CBT.”

‘A theoretical basis is not enough’

When it comes to conducting research and applying it to counseling techniques, a variety of terms are used. According to Codd, the term evidence-based has been applied more liberally in recent years. He understands the meaning to be “following approaches and techniques that are based on the best available research evidence.”

Kaplan says the technical definition of evidence-based research promoted by the National Institute of Mental Health and other federal agencies requires the inclusion of a manual with specific step-by-step protocols so the procedure can be replicated. The term best practices, on the other hand, implies that a counselor is looking for the one “right” approach that works better than all other approaches, he says. “That term is losing favor because we know that there’s not one absolute best approach to a problem. There are different interventions that can work,” Kaplan says.

Outcome research is another relevant term. According to Kaplan, it encompasses conducting research that speaks to Gordon Paul’s question posed in the 1960s: What works best with this particular client in this particular situation with this particular problem in this particular setting?

Wester views evidence-based practice as consisting of quality research findings, counselor skill and ability, and client desires. “I think the myth is that evidence-based counseling equates to using a manual that gives you Week One, Week Two and Week Three and that it does not allow you to account for individual clients who come into our office,” she says. “This is not my understanding of evidence-based practice. Evidence-based practice, to me, is what has been proven to work, and it typically provides more of an outline of interventions or steps that allow us to work with our clients from a method that has been proven to be accountable. Simply because the evidence-based practice indicates that we need to set goals in week one does not mean that we ignore the client who walks into our office during intake crying and in crisis. That wouldn’t be ethical on our part as counselors. It would mean that the ‘week one’ part of the evidence-based practice might take another week or two to finalize … while we stay with their emotion and work with the client to alleviate the crisis.”

Regardless of the terminology used, more research needs to be done to support the techniques counselors are using, Kaplan asserts. Historically, the counseling profession has been grounded in theory, he says, and as a result, many practitioners have thought that if they followed a particular theory, they were being successful, regardless of client outcomes. “With the push in recent years for accountability and to show that what you do works, having a theoretical basis is not enough,” Kaplan says.

As a whole, the counseling profession has been more resistant than other helping professions to the push from health care and government to back treatments up with research, Kaplan says, in part because counselors don’t generally like to do research. “Counseling tends to attract professionals who are interested in interacting with people and helping people directly,” he says. Those who are more interested in conducting research tend to gravitate toward other fields such as psychology, Kaplan says.

Counseling also attracts greater numbers of people who are creative and like to use creative interventions, Kaplan says. The downside to that is that creative interventions are often more difficult to research, he says. For example, behavior therapy approaches are more concrete — “do this, then this” — so they better lend themselves to the prevailing quantitative research model, he says.

Another factor in play is that it can be more complicated to determine what works in counseling than in other professions, Erford says. “Take medicine, for example. It is relatively simple to determine if one pill works better than another for treating a certain medical problem,” he says. “The personalities of the doctors and clients, while diverse, generally have little effect on the client’s physical system. Likewise, what the client does before and after taking the pill usually has little effect. The administration of the treatment and consequences are usually easily controlled. This is not the case in counseling. The treatment must be personalized to client needs, which means that even if a professional counselor is using a manualized treatment protocol, variations occur in how the treatment is administered. And the treatment is only a small piece of the puzzle when trying to understand clients’ complex change processes.”

Erford points to research from Michael Lambert 20-plus years ago showing that only 15 percent of the treatment outcome was due to specific techniques used. In comparison, 30 percent was due to the therapeutic alliance, 15 percent to the client’s expectations for change and 40 percent to factors outside of counseling. “So, in order to maximize client outcomes, all four facets should be the focus of the professional counselor, not just what evidence-based practice you are using,” Erford says. “On the other hand, while 15 percent may sound like a small amount, it makes a huge difference to overall client well-being and counselor effectiveness. That said, when clients perceive that counseling is working, their expectations improve, they are more likely to follow through on out-of-session activities and the therapeutic relationship improves. So, these change factors are not four discrete facets; they are synergistic and interconnected.”

No matter the reason for it, the profession’s dearth of research leaves counseling at a disadvantage in Codd’s opinion. “It pains me to say this about my profession, but I really believe we lag significantly behind these other disciplines in this area. I think it’s important for our field to catch up to these other disciplines if we are to truly mature as a field.”

Widening the scope

Finding middle ground on the topic of evidence-based practice will require a little give on both sides, Kaplan says. On one hand, counselors need to acknowledge that to advance the profession and to do the right thing for their clients, they must produce evidence that what counselors do is working, he says. On the other hand, organizations and agencies that fund research need to be more flexible concerning what constitutes acceptable research, he says. This could mean embracing qualitative research rather than focusing only on quantitative research and understanding that not all approaches will use “cut-and-dried protocols,” Kaplan says.

Wester agrees, adding that qualitative and quantitative research should be viewed on a continuum, where both have their own strengths. “Qualitative provides us more of an in-depth understanding and allows us to explore areas and opinions that we are unsure of, while quantitative provides us numerical support and evidence that something works or doesn’t,” she says. “No one methodology is better than another; they serve completely different purposes. Thus, what research should look like is less about the methodology and more about what research questions will benefit and impact our counseling field. What questions would help us to be better counselors, be more effective with our clients and train our students better? Once we have those questions, then the methodology that best answers those questions should follow.”

The counseling profession also needs to change the current focus of the research it conducts, Kaplan says. “We need to focus more on clients in research than ourselves,” he says. “The [current] research is often focusing on asking ourselves opinions about ourselves and has nothing to do with client outcomes. We need to find real clients who have real problems, and we need to find out if what practicing counselors are doing with their clients is working. And, yes, that’s hard to do.”

But before producing and applying the research these leaders say the profession needs, counselors must acquire the requisite skills, which Wester says they should be learning both in graduate school and through continuing education after graduation. “Graduate school training provides the basis and grounding for what we need to know as professionals, but the world keeps changing, our clients keep changing, and the interventions and treatments continually change — and so does research,” she says. “Thus, continuing education is important to stay abreast of knowledge and gain new skills.”

In Codd’s view, graduate programs need to up their games and better train future counseling researchers. “I think our curriculums should add course work and, even more importantly, require active participation in research projects — doing the behavior as opposed to just reading and hearing about how the behavior is acquired,” he says.

Making research relatable

Codd senses a divide in counseling between those in favor of increased research and evidence-based practice and those who do not want to see the profession rely so heavily on research. Among the objections he has heard is that certain theories cannot be researched and that scientific methodology is not valuable.

He suspects, however, that much of the resistance to research has to do with how hard it can be for human beings — including counselors — to let go of deeply held beliefs. “We cling to our pet theories [and have] perhaps even built our careers around writing, lecturing [and] delivering certain interventions,” he says. “Learning whether or not we’ve been correct can be hard to take.”

Throughout the history of the counseling profession, people have argued about whether counseling is a science or an art, Erford says. He believes it is both. “We are a scientific discipline that allows practitioners to creatively adapt to the individual needs of a client,” he says.

One obstacle that may keep more counselors from adopting a pro-research attitude is that many practitioners do not view the literature base as being particularly user-friendly or helpful, Erford says. “Some counseling journals, like the Journal of Counseling & Development, have tried to address that by requiring that authors provide a section called ‘implications for counseling practice.’ But what we know about what works in counseling today is so much broader and deeper than it was 20 or 30 years ago. Most practicing counselors don’t have time to keep up with all of the published literature. They want meaningful, easy-to-read summaries that will help them to hit the ground running and create effective client or student outcomes. Some counselor researchers have begun conducting meta-analyses and systematic research syntheses to try to pull together related literature, sort of like one-stop shopping. Many of the textbooks I write have a synthesis chapter, which addresses the question, ‘What works in counseling?’”

ACA is developing two initiatives intended to address this need, Erford points out. “First, we are exploring how best to provide summaries of research-based approaches to issues encountered by counselors. Once produced, these informational summaries will be available to ACA members and will be designed to help practitioners, students and counselor educators stay abreast of effective counseling practices. Also, the new ACA National Institute for Counseling Research Task Force will identify and recognize the best counseling research produced during each year as exemplars for the counseling profession.”

Wester points to a “practitioner-researcher gap” within the counseling profession that she says has yet to be successfully bridged. “Practitioners frequently will question the applicability of our findings and our research, indicating it does not allow them to use their creativity or speak to the uniqueness of each client,” Wester says. “Interestingly, we think about evidence-based practice as research [telling] us what to do. However, if one would really explore the literature on evidence-based practices, it is the combination of a) quality research findings, b) counselor skill and ability and c) client wants and desires.”

Erford agrees, saying the push for additional research and evidence-based practices in no way diminishes the importance of creative and innovative theories, interventions and treatments. “Instead, the emphasis is on subjecting innovative and creative treatments and new theories to rigorous study in order to determine treatment efficacy, just as currently accepted evidence-based practices have been rigorously tested,” he says. “In the classic sense, after the treatment has been proposed, the new treatments are studied using randomized controlled trials on real clients with a real target condition. If the results are positive, evidence emerges that the treatment is supported. Usually, multiple clinical trials are needed to support an evidence-based practice.” Having more than one evidence-supported approach expands options for clinicians and clients, Erford says.

‘Voices from the field’

Counselor practitioners should not only be using research to inform their practices with clients, they should also consider taking part in research themselves, Erford says. “Practitioner voices from the field are incredibly powerful,” he says. “Much of the progress we have made over the past century is because practitioners noticed important things about clients, the counseling process, and the strategies and techniques used, and then shared these insights with other practitioners and researchers.”

In general, however, counselor practitioners seem less likely to participate in research and collaboration with counselor researchers than do practitioners in related professions such as psychology and psychiatry, Erford says. “Part of this is a professional orientation issue, which we are addressing in counselor education,” he says. “We need to recruit and produce graduate students who are excited and knowledgeable about research and its application to practice, and then keep them excited and engaged as they enter practice. If practitioners understand how research can be applied to clients in the field, they will notice things and question their practices more actively, thus opening their curiosities to research opportunities.”

Erford says he and a few colleagues completed meta-studies between 2010 and 2012 of 10 ACA and division journals, learning that in nearly every case, practitioner contributions to the counseling literature have declined significantly during the past 20 years. “Professional counselors, regardless of setting, are supposed to be collecting data to substantiate effectiveness and outcomes with every client or student served,” he says. “This constitutes a huge pool of existing data. If we could develop a system for collecting and using this outcome data for research, we would leap ahead in our understanding of what works in counseling. Partnerships between counseling researchers and practitioners could be mutually beneficial, meeting the needs of the researcher for access to clients and data, and the practitioner for access to research or evidence-based practices and assessments that help with screening, diagnosis and accountability. If you are a practitioner with ready access to clients or the data they generate, please reach out to counseling researchers in universities and institutes. Through networking, we can build a powerful system for research and development.”

Before counselor practitioners can team up with researchers, the lines of communication need to be opened, Wester says. “One of the things our department did [at UNCG] was to send our internship site supervisors a survey on what was needed in terms of research and [asking if they would] be interested in collaborating with our department faculty on answering any questions they were interested in or needed answered through research,” she says. “They were able to indicate what they needed in terms of current literature, what they would like in terms of research relationships, topics they needed help researching and how we could help them and their agency. The first step is setting up the lines of communication between practitioners and researchers. But practitioners should feel able to contact the local universities, or even their
alma maters, to inquire how to bridge the gap.”

Research in a humanities profession

James Hansen, professor and coordinator of the mental health specialization in the Department of Counseling at Oakland University in Rochester, Mich., agrees that research is a vital part of professional counseling. But he believes counseling should be “informed” by research — rather than “guided” or “determined” by it — for two fundamental reasons.

First, Hansen says, the essence of counseling is the relationship between the counselor and the client. “Indeed, one of the most consistent research findings over the past four decades is that the quality of the counseling relationship is the within-treatment variable that accounts for the majority of the variance in counseling outcomes,” says Hansen, a member of ACA and the Association for Humanistic Counseling, an ACA division. “Therefore, the research unequivocally informs us that the quality of the counseling relationship is the factor to which practicing counselors should be most attentive. However, every counseling relationship is unique, just like every marriage, friendship, etc., is unique. Therefore, although research informs us that the counseling relationship is vitally important, research cannot tell us how to deepen a particular counseling relationship because every counseling relationship is unique.”

Second, Hansen says, all research is conducted within a set of assumptions. “The set of assumptions in ‘evidence-based,’ ‘best practices’ or ‘empirically supported treatment’ outcome research is that researchers should attempt to find the best techniques to use with particular disorders. The findings can then be disseminated to practitioners, who will diagnose their clients and use the techniques that have been found to be most effective with their client’s disorder,” says Hansen, who wrote a “Reader Viewpoint” in the October 2010 issue of Counseling Today on this topic, as well as another article for a special issue of the Journal of Humanistic Counseling due out next month.

But the set of assumptions is essentially medical, Hansen argues, and although that makes sense for medicine, it doesn’t make sense for counseling. According to Hansen, meta-analytic research studies have consistently found that specific techniques account for less than 1 percent of the variance in counseling outcomes. “Specific techniques, generally speaking, appear to be relatively unimportant to outcomes,” he says. “Therefore, a counseling research agenda that is based on finding specific techniques for particular diagnostic conditions is focused on a factor that only accounts for a minuscule portion of the outcome pie. A general research agenda for the counseling profession should be focused on factors that we know to be highly important to outcomes, not factors that are relatively trivial.”

The bigger factors in the pie, Hansen says, are the quality of the therapeutic relationship, extratherapeutic factors such as social support, and positive expectations from the client about counseling.

The truth about techniques is complex and nuanced, Hansen says. “Specifically, the evidence strongly suggests that the ‘contextual model’ of counseling is the general way of thinking about treatment that counselors should adopt. There is an important role for techniques in the contextual model, but that role is related to the overall context of counseling, not as isolated, technical interventions.”

Hansen adds a second point to support his contention that the set of assumptions often relied upon in evidence-based counseling research is faulty. He asserts that the manual many mental health professionals use to identify client disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is “fundamentally unsound” yet is used in evidence-based research. Hansen calls the DSM highly unreliable and believes it has virtually no validity. “Because evidence-based research operates from these deeply flawed assumptions, it is generally a harmful trend in counseling,” he says.

In Hansen’s view, counseling is a humanities profession, akin to history, literary analysis or philosophy. The raw data of all of those professions is in human meaning systems, he says. On the other hand, the sciences, such as biology, chemistry and physics, deliberately attempt to remove subjective human meaning from their investigative efforts, aiming to be objective and impartial, he says.

“Even if counseling is considered a humanities profession, science still has a valuable role in counseling, just as it does in other humanities professions,” Hansen says. “For instance, although historians study human meaning systems, they rely on scientific methods to date historical documents. However, science does not dictate or determine the activities of historians. It is simply used as a tool to help the profession along. I envision the role of science in counseling in much the same way. Science is a vital tool to help counselors determine if their interventions are working, for example. However, science should not dominate and determine the professional life of counselors or historians, because both of those humanities professions are aimed at uncovering human meaning systems — a goal which science, as an enemy of subjectivity, is grossly unsuited to accomplish.”

Although Hansen reiterates that research is vital to the counseling profession, he believes it’s important for its focus to be on enhancing understanding of the factors most known to help clients. “For instance,” he says, “we know that the quality of the counseling relationship is an important factor in counseling outcomes. However, we have a lot to learn about the nuances of the counseling relationship, how it unfolds, the points at which it is most important, etc. The primary agenda then should be to focus research attention on factors that are known to be vital to counseling outcomes.”

 To contact the individuals interviewed for this article, email:

Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org

Click here to read two additional perspectives on evidence-based counseling.

A home for research

In September, the American Counseling Association will launch its Center for Counseling Practice, Policy and Research. ACA Executive Director Richard Yep, one of the driving forces behind the center’s creation, discussed what counselors can expect from this new endeavor.

Where did the idea for the Center for Counseling Practice, Policy and Research originate?

The center concept was the result of input and commentary that I heard from leadership and members for many years. To have a dedicated unit within ACA that focused on areas of the counseling profession that could have both short- and long-term impact is something that we have wanted to do. With the support of the ACA Governing Council and the excellent input of those with whom I work on staff, we are now able to realize the launch of this new entity.

What will its goals be?

In the beginning, our hope is that the center will begin building a framework that will allow ACA to more deeply explore a number of issues that include how best to position counselors for job opportunities for which they are uniquely qualified through their education and experience. However, it will also be looking at the professional counselor who will be working in the middle of the 21st century to position them for whatever they may face. And an additional aspect of the center will encompass how we can host interns and scholars-in-residence here at ACA headquarters to work on projects of critical importance to the profession.

What do you hope to see the center accomplish?

In an ideal world, within three years, I hope that the center will have produced products, research and resources that result in more professional counselors being able to practice. An additional deliverable will encompass increased awareness by the public in terms of its understanding of the impactful and important work that these tireless mental health professionals do each and every day.

Why is this an important move at this time in the profession?

Professional counseling is at a crossroads. The services and support of the center are something that we hope will move the profession in a direction that will support more job opportunities, allow the public to better understand what counselors do and inform public policy decision-makers so that they help to create an environment that allows professional counselors to deliver the best possible services to clients and students. I am extremely excited about the work that I know the center can accomplish, and I look forward to the input, suggestions and feedback from our members in regard to the efforts we will make.

— Lynne Shallcross

 

Leaving room for creativity

Exploring creativity in counseling might sound at odds with following evidence-based counseling practices, but Thelma Duffey says that doesn’t have to be the case. Duffey, the founding president of the Association for Creativity in Counseling, a division of ACA, says evidence-based counseling and creative counseling interventions are largely complementary and developmentally aligned.

“Many creative interventions and techniques are founded in an established theory or theories and are implemented with these in mind,” says Duffey, a professor and chair of the Department of Counseling at the University of Texas at San Antonio. “For example, all best practices begin with a creative thought or idea. Many times, these may develop into models, techniques or interventions that emerge from our practices. We often talk through them and collaborate or share them with others. Finally, we assess and research their efficacy.”

“Now, one way that evidence-based counseling could interfere with creative approaches would be if we were to adopt a rigid, one-dimensional perspective on our work or endorse cookie-cutter recipes of treatment that don’t allow for context or counselor and client individuality,” Duffey says. “Evidence-based counseling practices could also interfere with creative approaches if we were to discredit spontaneity, creativity or innovation in our work. I see none of these as likely. Rather, I see counselors as embracing the idea that creativity involves using available resources, while ethically attending to best practices. Using music, the cinema and books are some excellent and ready resources that are compatible with evidence-based research paradigms.”

Duffey says she supports researching creative approaches, just as she would any other counseling approach. “The same quantitative research principles apply, such as adequate counselor training, valid and reliable measurement instruments, and clear methodology,” she says.

Although some counselors are more passionate about research, while others are more passionate about practice, Duffey says there’s room for a global view that incorporates both sides. “I believe that when counselors and counselor educators are flexible in their thinking, able to look at a big picture, allow for developmental progress and acknowledge the role of creativity and innovation while respecting rigor in research, the dichotomy ceases to exist.”

To contact Thelma Duffey, email thelma.duffey@utsa.edu.

— LS



Screening for possible domestic abuse

Susan H. Robinson October 24, 2011

A Columbus, Ohio, mother and her two children are stabbed to death. A mother and grandmother is beaten and shot to death in Newark, Ohio. A Logan, Ohio, mother with three children under the age of 6 is kidnapped and strangled; her body is dumped in a sewer. The commonalities? Each of the women was from central Ohio, and all were attacked at their home or work. Estranged boyfriends or husbands are facing charges in each case.

These cases happen to have taken place in my county or counties adjoining mine, but many people reading this article will likely be able to recount numerous cases with similar tragic endings that happened in their own localities. The details may vary, but almost all of the cases involve women and children with lives, hopes and dreams that are dashed because someone decided to go overboard in an obsession with power and control.

Many victims and potential victims of domestic abuse have sought help from various sources, including professional counselors. In numerous other cases, friends and family members have expressed concern. It is important for members of our profession to understand the dynamics of domestic abuse and to utilize that knowledge whenever possible to reduce the incidence of violent outcomes. We also need to be aware that this violence occurs in traditional and nontraditional family settings, among gay couples and among straight couples. The violence can be parent-to-child, child-to-parent and all other possible variations.

I grew up in an era in which most considered abuse a private matter. My nosy parents taught me otherwise. As an attorney, my father heard stories from his clients and made it clear to me that this behavior was not to be tolerated. Because this was the 1960s, knowledge of the signs of a potential abuser was essentially nonexistent.

Lenore Walker conducted groundbreaking research on the dynamics of abuse, and her first major publication was released in 1978. What followed was mountains of research and the shelter movement taking hold, so this issue became general public knowledge. Or so we thought.

As an adjunct psychology professor at a community college, I routinely include a section on the dynamics of domestic and intimate partner abuse in my courses. This is not a part of the standard curriculum, although some texts do incorporate information on the subject. The Ohio State University has its own policy on domestic and intimate partner violence; my school has drafted a policy that is scheduled to be reviewed for approval Nov. 1.

I started teaching a few months after my distant cousin was murdered. Realizing that it is not in my character to get a huge program started, I looked at that first class and decided, “I can reach these 35 people.” The response has been both heartwarming and scary. I have been told and learned through class papers that various students realized the danger of a situation for the first time after I taught on the subject. One of my students reached out to help a best friend who was in serious danger. I have heard horrific stories of people who lost their lives because of inaction. And people have shared with me how they found the courage to reclaim their own lives.

As a counselor, I am adamant about screening for possible abuse. Clients have come to me indicating they were victims. I have even had some clients who admitted abusing others, took responsibility and indicated a desire to stop. (In those cases, post-traumatic stress disorder was involved, and the problem was very quickly resolved.) It is equally common, however, for clients to recite details that indicate clear abuse patterns, while simultaneously denying the existence of abuse in their relationships. This is when I bring out the Power and Control Wheel, the Wheel of Equality and Respect, the cycle of violence and a list of signs of a potential abuser — the type of information I obtained during my initial attendance at a support group. It is not new information.

Two events were seminal in my becoming so active in this field. The first was my own misguided romance, the second my distant cousin’s death. I met my cousin only once. She had recently married and mentioned having “fallen and broken her nose” two days before the wedding ceremony. Three weeks after our meeting, she was dead.

In my case, I became involved with an extremely (more like insanely) jealous and verbally abusive partner. When I expressed concern to a counselor about the level of jealousy, I was told, “We’ll process that.”

Unfortunately, I didn’t recognize the jealousy as a sign of a potential abuser or his verbal attacks as actual abuse. Yes, I knew it was unacceptable behavior, but I had no idea it could be the precursor to or a sign of serious danger. When we (predictably) broke up, I was blindsided. Safety planning had never occurred to me, yet I wound up leaving my own home, first for several individual nights, then staying with various friends over a two-week period until he vacated. To do otherwise would have meant putting my life at risk.

After the dust ultimately settled, I contacted Ohio’s Counselor, Social Worker and Marriage and Family Therapist Board. The staff member who took my call indicated there definitely would be a meeting about establishing mandatory course work on domestic and intimate partner violence. That was in 1995.

I didn’t begin my own graduate studies until September 2001, eight days prior to the infamous terrorist attacks. Never was there any required course work pertaining to the subject of domestic and intimate partner violence. (I took the only elective I saw offered at the time on treating abusers.) At one point, I was even chastised for bringing the matter up. I garnered infinitely more domestic violence/intimate partner violence information from one hour at a support group sponsored by CHOICES for Victims of Domestic Violence than I did from my three years in graduate school. This is shameful.

Victims seek counseling every day in huge numbers, although they often start out unaware that abuse is an underlying issue for them. Many counselors are veterans of continuing education courses on the subject and read prolifically, providing the expertise these clients deserve. On the other hand, a shocking number of counselors take these victims on as clients when they truly have no idea what they are doing. Many even conduct couples counseling with these clients, further endangering the victims. Clearly, no counselor can be expected to become an expert in everything she or he might encounter. We do, however, have a responsibility to know when to make educated referrals.

There is no need to reinvent the wheel as counselors. In Ohio, nurses have a protocol they are required to follow whenever someone presents in the emergency room — a series of questions they have no choice but to ask. Counselors who do not work in a shelter setting have no such legal guidelines, however.

Nursing is surely not the only profession with such a protocol. Mental health professionals who work in shelter situations are no doubt well-informed and could be a good resource for the rest of us. Screening for domestic and/or intimate partner abuse needs to become a national counselor mandate.

It will save lives. Absolutely.

Susan H. Robinson is a professional counselor who practices in Ohio. Contact her  at sueslistening.com

Letters to the editor: ct@counseling.org

The challenge of diagnosing ADHD

By Mike Hovancsek August 2, 2011

I remember sitting in Ms. Smith’s sixth-grade class, in full daydream mode, as she droned on and on in the background. Suddenly, Ms. Smith declared, “Now that I have explained this assignment, I want you all to get right to work on it.” My classmates immediately started working diligently at their desks with paper and pencils.

I had no idea what the assignment was because I had been daydreaming through the entire explanation. Trying to remedy the situation, I walked up to the teacher and whispered, “I don’t understand what we are supposed to be doing.” Ms. Smith immediately became irritated. This was not the first time I had asked her to repeat instructions.

“I just spent several minutes explaining the assignment. Weren’t you listening?” she demanded in an angry whisper.

“Oh, I was listening, but I don’t think you explained it very well,” I whispered back in a sad attempt to deflect the blame.

“OK, I’ll explain it one more time, but that’s it!” Ms. Smith hissed in an impatient tone.

Standing up close to Ms. Smith, I took in details about her that I had never noticed from my desk. I could see her scalp through her curly blond hair, and she had an alarmingly large nose. Even worse, she had huge pores. “Man,” I thought, “you could actually store things in there!”

Just as this thought occurred to me, Ms. Smith said, “There, now I have explained the assignment to you twice. You should be able to do it perfectly at this point.”

As I walked back to my desk, I realized I had not heard a single word of Ms. Smith’s explanation. I had been too busy admiring her pores. I returned to my desk and drew pictures until it was time for recess. It was many years before anyone suggested that I may have a form of attention-deficit disorder.

In Essential Psychopathology and Its Treatment (2009), Jerrold S. Maxmen, Nicholas G. Ward and Mark Kilgus estimate that 5 percent of Americans have some form of attention-deficit/hyperactivity disorder (ADHD), which is more than 15 million men, women and children. These numbers are slippery, however, because ADHD often goes undiagnosed or misdiagnosed.

Many challenges exist when it comes to getting a proper diagnosis for ADHD. I will examine several of them in this article and provide some suggestions that can help improve diagnostic accuracy.

Attention-deficit/hyperactivity disorder is a misleading term. People who have this disorder might actually have very intense focus when they are interested in a particular topic, sometimes spending countless hours engaged in a favorite activity. This presentation is at odds with the attention-deficit part of the term and can cause diagnosticians to erroneously rule out ADHD as a diagnosis. Also, many people have “ADHD, Predominantly Inattentive Type,” which often does not include hyperactivity among its features. In fact, a person with that diagnosis often has hypoactivity.

In other words, a person with ADHD may have moments of excellent attention and absolutely no symptoms of hyperactivity — behaviors that completely contradict the very title of the disorder. In an attempt to remedy this, Edward M. Hallowell and John J. Ratey, in their 1995 book Driven to Distraction, suggest it would be a good idea to change the term to Attention Inconsistency Disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) can be misleading when it comes to ADHD. The writers of the diagnostic manual seem to imply that only children have this disorder. They list ADHD in the “Disorders Usually Diagnosed in Childhood” section, and the descriptive criteria include statements such as “Often leaves seat in classroom or in other situations in which remaining seated is expected.”

Only about one-third of children with ADHD grow out of the disorder. The rest take it into adulthood. In addition, a lot of people are not properly diagnosed until adulthood, when they may have symptoms that look different from the ones described in the DSM. Adults with this disorder might be quick to get angry or frustrated, often start projects and then abandon them to start other projects, self-medicate in an attempt to manage their symptoms or have a history of underachievement despite possessing a significant amount of talent and enthusiasm.

There is no valid test for ADHD. This is a really interesting issue. As mentioned earlier, many people with ADHD have very good focus when something interests them. As a result, they may get curious when you present them with a test. In those moments, their attention increases and they perform like people who do not have ADHD.

To complicate matters further, pharmaceutical companies created some of the ADHD scales. One test in particular has been the subject of lawsuits because it is suspected of being designed to provide marketing information to drug companies. Counselors might want to question any scale developed by people who profit from an affirmative result. If tests are used at all for diagnosing ADHD, it is important that counselors take the results with a grain of salt and consider them as only one of many available pieces of diagnostic information.

People with ADHD are not always the best historians. They may report that they don’t have a problem in one area or another, when the people around them might tell you something very different. Diagnosis is best when it combines feedback from family members, school records, records from past therapists and the client’s own self-reporting. It is also helpful to get to know a client over

the course of a couple of sessions before making a diagnosis because the client may behave differently or recall different information from one session to the next.

Several disorders (for example, bipolar disorder) look quite a bit like ADHD but require a very different course of treatment. Those other diagnoses must be ruled out before assuming that a hyperactive and/or unfocused person has ADHD.

Environmental and circumstantial factors can mimic ADHD symptoms. We live in a society that bombards us with far too much stimulation, much of it competing for our attention at any given moment. We might also have past traumas that distract or upset us. Relationships can have a similar effect. The chaos of office politics or a dysfunctional family, for example, can reduce focus and create mood instability. Rule out these factors by seeing whether the ADHD symptoms are present in different environments and whether they have been present since childhood.

Certain people could receive secondary gain from this diagnosis. For example, a teacher having trouble managing the behavior of a particular student might feel more comfortable attributing the problem to ADHD rather than to his or her own classroom management skills. In addition, clients might falsely present with symptoms of ADHD in hopes that it will increase their odds of receiving disability benefits or other entitlements. Be sure to consider possible secondary gains that clients might experience before making your determination.

ADHD has a high rate of comorbidity, which can confuse matters. People with ADHD might also have substance dependence, depression, anxiety and/or learning disorders. It is easy to diagnose clients with these more obvious disorders while missing the underlying ADHD. A mindful, informed diagnostician will keep an eye out for contributing/coexisting factors, including ADHD.

Substance addiction/dependence can disguise or mimic ADHD. As just mentioned, it is easy to be distracted by the issues associated with addiction and to miss the underlying ADHD, which can be a significant contributing factor to the addiction. Conversely, people who are using or in withdrawal from substances often exhibit anxiety, hyperactivity or distractibility that mimic ADHD. In the case of substance abuse/addiction, it can help to delay the diagnosis of ADHD until the client has experienced several months of sobriety.

Diagnosis is complicated by the fact that some medications used to treat ADHD have a high abuse potential. This could possibly motivate some clients to feign ADHD in order to get drugs. At the same time, people who legitimately have this diagnosis might be denied treatment by mental health professionals who suspect these clients are drug seeking. It is important to consider both scenarios when making diagnostic decisions.

Diagnosis potentially can lead therapists to overpathologize their clients. The goal of diagnosis is not to condemn a person or to give him or her an excuse to fail in life. The goal is to identify the most effective treatments available to help a client address identified problems.

Hallowell and Ratey argue that it may not be accurate to refer to ADHD as a “disorder.” For example, the very elements of ADHD that disrupt life can also cause a person to be spontaneous, creative, intuitive and intelligent. When clients learn to manage the dysfunctional elements of ADHD, they can then also benefit from its positive elements. It is important to identify, celebrate and access these strengths as part of treatment.

 

****

Mike Hovancsek is a supervising professional clinical counselor in Ohio. Contact him at therapy@ohio.net.

Letters to the editor:
ct@counseling.org