Clients impart so much about themselves, verbally and nonverbally, in counseling sessions that it will overwhelm clinicians who don’t organize the information and use it to create a structured plan for their work together, contends Nathaniel N. Ivers, associate professor and chair of the Department of Counseling at Wake Forest University.
Fully understanding a client’s situation, symptoms and needs and then matching them with a diagnosis (when appropriate) and a treatment plan that will help them heal, grow and thrive are core aspects of professional counseling. Counselors learn these skills, at least conceptually, in graduate school but gain true understanding of them through their direct work with clients.
Practically applying that knowledge is “where the rubber hits the road,” says Ivers, a member of the American Counseling Association. Examining a client’s concerns in depth — moving beyond surface-level questions such as “How did this week go?” or “What do you want to talk about?” — is the most integrative and effective way to devise a rich treatment plan and pinpoint a destination that the client and practitioner will work toward together in therapy.
Ivers acknowledges that counselors who are busy with full caseloads may be resistant to the idea of dedicating time to create a comprehensive, integrative plan for each client. But as he tells his students: The more you do it, the easier it will get.
“Eventually, you won’t have to write out a full, multipoint case conceptualization plan for every client,” says Ivers, a licensed professional counselor in Texas and a licensed clinical mental health counselor in North Carolina. “But when you eventually have … trouble figuring out [a case], that’s when you need to fall back on it — put pen to paper and conceptualize a full plan.”
When teaching these concepts to students, Ivers often shares a quote from psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo in Canada and one of the founders of cognitive behavior therapy: “A clinician without a case conceptional model is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”
An important responsibility
The three components of assessment, diagnosis and treatment planning are intrinsically linked and provide a “map” for counselors to offer evidence-based treatment that best fits the client, says Shannon Karl, an ACA member who is a professor and field-based clinical coordinator in the Department of Counseling at Nova Southeastern University in Florida. Not only is the process vital to establishing a foundation for counseling work with a client, but it also creates a pathway for the individual to access appropriate treatment services from counselors and interdisciplinary professionals.
Assessment, diagnosis and treatment planning are important responsibilities, and mastery of these skills is often closely tied to clinician confidence, Karl says, so it’s understandable that new professionals may worry if they are getting things right. She urges counselors who feel this way to remember that their mentors are there to advise and support them. Similarly, counselor education and supervision programs are meant to help trainees through this learning curve, she says.
Even so, both novice and experienced counselors should seek continuing education, peer consultation and mentorship in these areas throughout their careers, stresses Karl, co-author of the ACA-published book DSM-5 Learning Companion for Counselors. It is imperative for counselors to keep these skills sharp and up to date, not only because they are integral parts of the counseling process but also because diagnoses and related criteria are constantly changing and evolving.
Karl was on an ACA task force formed to study the updates and changes introduced in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. She was dismayed, she says, to see how long it took many counseling practices to update their procedures to reflect the changes made between the fourth and fifth editions of the DSM.
Karl urges clinicians to stay informed and up to date by attending workshops, conferences and other continuing education events; consulting regularly with professional peers; seeking mentorship or supervision; joining professional Listservs; and reading counseling journals and other publications. Remaining active with state and local counseling organizations will also help practitioners stay abreast of criteria and processes that vary state to state, she notes. Leadership within the counseling profession must ensure that funding for continuing education on assessment, diagnosis and treatment planning is prioritized, especially for counselors in economically disadvantaged or rural areas and settings where practices or clinics are short-staffed, Karl adds.
“One thing we can do at all levels is make sure that clinicians have access to free or reduced-cost continuing education, workshops and seminars. Accessibility is important,” says Karl, a licensed mental health counselor whose area of focus is childhood trauma and DSM-5 disorders. “It’s important for professional counselors, regardless of work setting, to be able to best serve their clients, and one way to do that is to be active in learning regarding assessment, diagnosis and best treatment planning. We can’t help others heal in isolation.”
Danica Hays, author of the ACA-published book Assessment in Counseling: Procedures and Practices, notes that counseling graduate students often take only one class each on assessment and diagnosis. Continuing education, in addition to competency gained through experience, is needed to round out counselors’ knowledge, she says.
“With the amount of material to cover, [counselor graduate education] lessons are often distilled to case conceptualization and treatment planning as simply following a recipe,” says Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas. Gaining comprehensive knowledge that includes “other ways of knowing — often from scholars and practitioners of color — can be incredibly helpful to ensure clients are not harmed by an incomplete and/or distorted story told on their behalf,” she adds.
Tracie Keller, a licensed professional clinical counselor and supervisor in Ohio, has found that teaming directly with the client to identify goals and build a treatment plan strengthens the level of trust and rapport between clinician and client, which in turn improves treatment outcomes. She chooses to highlight this collaborative approach on the website for her group practice in Columbus, Ohio, by including the following statement: “We believe that treatment planning is a process that both the therapist and the client determine together.”
Keller tries to think about the process from the client’s perspective. She notes that if she went to a medical doctor and the doctor prescribed a treatment plan and medication without bothering to tell her that she had the flu, she’d question what was going on and whether the doctor valued her input.
Keller, who specializes in treating clients with eating disorders and trauma-related concerns, says a prescriptive approach has never really worked for her. “[Clients know] themselves the best,” she says. “For me, it [collaborative treatment planning] is something that helps build a lot of trust. It’s not just prescribing ‘this is what I want you to do,’ but instead walking alongside [clients] to execute the goals they want. … If the client doesn’t buy in, [counseling] won’t be successful.”
Hays notes that involving clients in case conceptualization and treatment planning also allows for better cultural understanding and responsiveness. Counselors have a significant responsibility to get a client’s story right, she says, and “getting the story right involves co-constructing it with the client in a way that honors their cultural experiences as well as points of trauma and resilience.”
“Really good assessment is committing to gather a client’s story with that client, engaging in basic helping skills to affirm what the client is sharing as they share it, incorporating multiple qualitative and quantitative tools in the process, and proposing and evaluating treatment approaches with the client,” Hays asserts. “Thus, assessment may not involve many questions but [rather] more space within sessions for the client to share their stories, with the power and voice to confirm or disconfirm an evolving conceptualization of those stories.”
When Keller begins working with a new client, she listens carefully as they talk through their history and symptoms. Possible diagnoses and issues to work on in counseling often become apparent to Keller as she listens, but she stores those ideas away for the time being. Instead, she prompts the client to think of treatment goals, asking questions such as “If you could change anything in your life through our work together, what would that be?” or “What would you want to be different in your life after our relationship concludes?”
Clients presenting with symptoms of an eating disorder might respond with statements such as “I don’t want to fight my body anymore” or “I’m sick of hating my body,” Keller says. In this example, Keller and the client might work together to create a goal of improving the client’s body image in counseling. Later, once the client has made some progress on that goal and established a stronger therapeutic relationship with Keller, she will circle back to some of the issues that revealed themselves in the initial assessment session and try to tie those issues into the client’s treatment goals. If the client mentioned purging behavior or restrictive eating in the initial session, for example, Keller might gently raise the idea that this behavior could be something to work on as part of reaching the client’s goal of obtaining a healthy body image.
Because Keller accepts insurance at her practice, she diagnoses all of her clients to submit for reimbursement. Keller lets each client know that she will share their diagnosis with their insurance company, and she dedicates time to explaining the diagnosis to the client and how she arrived at that decision. Depending on the client, she sometimes takes out her copy of the DSM-5 in session and looks through the diagnosis criteria with them.
“I talk about it from the start because they’re in a very vulnerable space [at intake], and it’s important to be really transparent about what their diagnosis is and what it means,” Keller says. She never moves forward with a treatment plan or diagnosis unless a client agrees to it.
After talking through the diagnosis with the client, she explains the methods and tools she uses (such as cognitive behavior therapy or eye movement desensitization and reprocessing) to treat that particular diagnosis and how she will tailor her approach to help the client meet the treatment goals they have identified.
A large portion of the initial goal-setting and therapeutic work with clients is frequently focused on reducing symptoms, Keller notes. As treatment progresses, she works with clients to shift or change treatment goals to move beyond symptom management and to focus on the issues that lie beneath their original presenting concern.
For example, a client with chronic depression might first identify goals that involve improving their mood and alleviating their symptoms. Later, as their symptoms lessen and the client is feeling better, they could be ready to focus on past trauma or relationship issues that they didn’t have the bandwidth to tackle earlier, Keller says.
She finds this process often happens organically; the “win” of seeing symptoms lessen often motivates clients to identify additional goals. “It’s cool because you have a lot of trust and past success in therapy [at that point] to go off of, and the client often wants to dig deeper and make greater changes,” Keller says.
Client treatment plans need to evolve and stay flexible because clients’ needs will change throughout therapy. Keller notes that it is common for individuals with eating disorders to experience periods when their symptoms worsen, sometimes to the point of needing hospitalization or inpatient care. Whenever this happens, Keller works with the client to shift their treatment plan and identify different goals for the near future, and then they repeat the process after the client has been discharged or their situation has otherwise improved.
Assessment shouldn’t be limited to the initial and concluding sessions with a client. As Keller points out, an important part of this process is being attuned to a client’s needs and blending assessment work into each session. She says that she continually listens for short- and long-term treatment goals.
“As you go on through treatment, you’re getting information [from the client] with each session,” Keller says. “As you walk with them, you’re learning more and more: how they relate to you, how they relate to other people. You can’t ignore that information. It will guide you. I’m constantly assessing and holding that information.”
Keller acknowledges that her understanding of the treatment planning process has expanded over time. “Now it’s a process that is pulled up in my mind during every single session — not just at intake and conclusion,” she says. “Even if I don’t verbalize it with the client, I’m thinking of every conversation through the lens of their goals. It becomes an unspoken but ever-so-present aspect of the work, and it moves it along.”
Diagnosis: A love-hate relationship
Many professional counselors have mixed feelings about diagnosis. On one hand, it can be a tool that connects clients with the mental health care they need. On the other hand, it can be viewed (both by clinicians and clients) as a “label” that follows clients throughout treatment and, in some cases, life.
Keller says she understands both sides; however, she values diagnosis and finds it useful. Diagnosis is a tool that allows her to understand how she can initially help her clients, and it guides her interventions and therapeutic approach as treatment progresses. It can also remove financial barriers to mental health care. Counseling can be expensive, and insurance companies typically require a diagnosis for reimbursement. So, Keller views diagnosis as a way of providing treatment access for clients who wouldn’t be able to afford counseling without insurance coverage.
The key, Keller says, is to be fully transparent with clients and include them in the diagnostic process, especially for diagnoses that can carry a stigma, such as personality disorders, substance use disorders and eating disorders. In some cases, counselors may need to offer psychoeducation to dispel inaccuracies or stereotypes about a diagnosis.
“I can have a love-hate relationship with it [diagnosis] at times,” Keller admits. “It can have a stigma and the burden of sharing it with insurance. … Oftentimes in therapy, we end up having to process and unpack a lot, [including] what they [clients] have heard and experienced in carrying that diagnosis. If I can be involved in that process with them and acknowledge the stigma, I can help them.”
Ivers says there can be limits to diagnosis, including when clients develop a sense of dependency on their diagnosis or use it as a “crutch.” But as a whole, he finds that the process of diagnosis generally encourages counselors to seek out best practices, research and resources to help and support their clients.
“We have to be cautious that we don’t reduce people to their diagnosis,” Ivers warns. “But for others, finally receiving a name for the cluster of symptoms they’re experiencing can be a relief. It also can open them up to treatment and connect them with you [their counselor] or other practitioners who can help for their specific concern, [including] prescribing medication.”
Karl agrees that one benefit of diagnosis is that it often helps connect clients to interdisciplinary treatment. Even if a counselor is not required to assign diagnoses to clients, they need to have a “comfortable awareness” and foundational knowledge of the diagnosis process and be able to triage clients to connect them to further treatment if needed, Karl says. Screening skills and competency regarding diagnosis are also a requirement for counselor licensure in many states and therefore something to keep oneself updated on through continuing education, she adds.
Diagnosis also requires counselors to know how to use the DSM. Karl advises clinicians to become comfortable with looking things up in the manual and knowing where to turn when they have questions or need more information, rather than trying to memorize its contents.
Additionally, there are certain conditions mentioned in the DSM that counselors would not be involved in diagnosing, such as neurodevelopmental disorders. Because counselors will often be included in treatment plans for clients with those types of diagnoses, however, they still need to be proficient enough to have an understanding of any DSM diagnosis and its best treatment practices, even if they do not diagnose the client themselves, Karl notes.
Trying to remember all the nuances of the diagnoses in the DSM is “setting yourself up for failure,” Karl says. The DSM-5 contains more than 1,000 pages and hundreds of diagnoses. Even if clinicians were able to remember everything the manual contains, revisions and updates are made to the information regularly. For that reason, Karl urges counselors to focus on having a core knowledge of the manual, being comfortable enough to use it as a resource and adapting with it as it changes.
Counselors are human beings with individual personalities and worldviews, so there is always a chance of potential bias creeping into assessment, diagnosis and treatment planning. To avoid this, clinicians must diligently reflect on their biases and really think about their assessment questions and diagnosis processes, says Ivers, who presented the session “Using Case Conceptualization to Navigate the Turbulent Waters of the Human Condition” at ACA’s 2018 Conference & Expo.
Ivers stresses that counselors need to critically examine why they are asking what they are asking — and what they are not asking. “If a client is acknowledging some of the cultural struggles they’re facing and we skirt those issues and do not focus on them,” he says, “what we’re telling them is that it’s not therapeutically important.”
“Case conceptualization is a tool, and when used effectively, it can be extremely helpful,” Ivers notes. “But when used ineffectively, it can be hurtful and damaging. In the case of culture, it can actively discriminate and misalign. It can [cause a clinician to] try and fit a client into a mold.”
Clinicians must also keep in mind that assessment and diagnostic tools can have an innate bias. Models often have a “cultural flavor” and are based on what is traditional (or Westernized) rather than on what is deviant or nondominant, Ivers says. He teaches Jon and Len Sperry’s case conceptualization method to his students at Wake Forest. One of the benefits of the model, Ivers says, is that it allows for flexibility and modification based on a client’s cultural factors. (For more information, read Jon and Len Sperry’s Counseling Today article “Case conceptualization: Key to highly effective counseling.”)
“There are evidenced differences in how symptoms are expressed culture to culture and, thus, individuals do not neatly fit in diagnostic or treatment ‘boxes.’ Fostering one’s competency is embracing these tensions,” says Hays, who is an ACA fellow.
She points out that research shows there are disproportionate rates of mental health issues among people of marginalized statuses. “The question has been whether differences in diagnostic rates — based in case conceptualization — are actual differences among cultural groups or whether they are a result of faulty assessment and diagnostic processes on the part of the counselor,” Hays says. “The answer is likely a little of both. Counselor cultural bias does substantially shape assessment and treatment, and experiences of privilege, oppression, trauma and resilience shape what symptoms are presented.”
Keller acknowledges that the potential for practitioner bias in assessment, diagnosis and treatment planning is one of the messiest aspects of professional counseling. What she finds invaluable in this realm is seeking feedback through regular consultation with professional peers as well as attending counseling herself.
Personal counseling and professional consultation allow Keller to process things, identify her “blind spots” and work through her own biases, “so they don’t come out in the counseling room,” she says. “The last thing I want is for my stuff to affect [my client’s] stuff.”
Ivers admits it is “inherently reductionistic” to take all the information that a counselor gleans from a client through the therapeutic relationship and organize it into a treatment model and plan. There is no way to keep from losing data as the counselor processes all the information, he says.
“Therefore, it’s important to remain flexible and be aware that there can be blind spots,” Ivers advises. “You’re never going to get it 100 percent right, and that’s why we [counselors] are always reassessing and modifying a treatment plan. But you’re hopefully on the right path.”
A career-long learning curve
It’s not easy to competently assess what a client needs and then match those needs with an accurate and responsive treatment plan that will help the person to heal. Therefore, counselors find themselves continually developing and strengthening these skills over the entire course of their careers.
Keller says it remains her goal to grow her skills in assessment, diagnosis and treatment planning over the decades to come with the mission of better serving her clients. “To be an effective counselor is to trust and to be OK with always learning and pushing ourselves to grow,” Keller says. “If I stop doing that, I probably shouldn’t be practicing anymore. Counseling is a process that I have to be willing to grow and change and evolve with — just as clients do. [Counselors should] trust that wherever you’re at in your professional journey, it’s OK — and it’s good even — to be learning.”
Wrestling with a client’s previous diagnosis
It’s not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes via referral, the counselor may have case notes that include the diagnosis in writing. In other situations, a client might report to the counselor that they were told they have a certain diagnosis. This introduces the possibility that the client might have misunderstood or misremembered clinical terms that they heard from the other practitioner or found on the internet.
So, what happens if the counselor, after getting to know the client, disagrees with the previous diagnosis? It’s a common scenario, says Shannon Karl, a licensed mental health counselor and professor at Nova Southeastern University. She urges counselors to remember that individuals grow and change, so a diagnosis shouldn’t stay static. A previous diagnosis may no longer be relevant or applicable for a client, especially if it’s more than a few years old.
Counselors need to come to their own conclusions about a client without allowing a previous diagnosis to color their assessment, Karl says.
Danica Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas, suggests that practitioners ask the client questions to get additional information about a past diagnosis, including how (and by whom) it was made, how the client feels about the diagnosis, the extent to which the client still identifies with the diagnosis, and how or if they feel that the diagnosis led to finding support to address their symptoms.
“Given the inevitable role of bias in clinical decision-making, counselors should always be cautious when a client presents a treatment history in which they were diagnosed a particular way,” Hays says. “It is important that counselors not quickly jump to a diagnosis based on what has been diagnosed before. This is a clear example of the improper ways that cognitive tools are used to yield misdiagnosis and client maltreatment.”
A counselor’s role also includes ensuring that a client feels heard and trusted when they talk about previous diagnoses or conditions that they think they have but that have yet to be diagnosed, adds Tracie Keller, a licensed professional clinical counselor.
“I try and hold that [information] with respect and honor, but at the same time, I do my own assessment and treatment plan based on what I’m hearing,” says Keller, who owns a counseling practice in Columbus, Ohio. “I use that as a jumping-off point to garner further questions, [as] a starting point to dig deeper.”
Karl once worked as a mental health counselor in a pain clinic where she had the freedom to have an initial session with clients before she opened and reviewed the individual’s records. “Clients really valued that I wanted to take a few minutes to hear it [their mental health history] from them,” Karl says. “They knew they had the chance to share their story with me without any filters.”
Karl acknowledges that this will not be possible for most counselors. However, she urges clinicians to find ways to hear a client’s backstory in their own words, even if they know the client’s diagnosis and case history before the person walks in the door.
“We need to preserve the ability to hear clients’ stories from them,” Karl says. “Keep in mind that we are not defined by our diagnoses; we grow and evolve in positive directions. What was happening previously doesn’t mean it’s happening now. Be aware that assessment is a continual, ongoing process, and a diagnosis is never set in stone. If we come from that lens, it helps us see clients for who they are as opposed to what they’re tagged with.”
Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at firstname.lastname@example.org.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.