The Importance of Diagnosis and Treatment Planning in Counseling - Research Paper Example

Introduction Counseling is defined as “professional guidance of the individual by utilizing psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes” (Merriam-Webster Dictionary, www.merriam-webster.com). Thus this definition makes it amply clear that the counselor is not only a professional but also able to guide the individual by using a mixture of techniques and advice. By extension the counselor’s capabilities in diagnosing symptoms and planning the treatment process accordingly have to be in perfect alignment with the individual patient’s requirements. Counseling as a profession is comparatively newer and its current status is primarily the result of a breakaway from the traditional profession of psychotherapy. It’s all about professional guidance and this conceptualization helps in designing, planning and implementation of counseling strategies in an authentic professional setting. Here a clear distinction between guidance and counseling is of importance to the analysis. Guidance refers to a systematic process of helping individuals to decide on the relative merits of available choices. On the other hand counseling is primarily focused on helping the individual to make changes in the process of treatment. While guidance is more or less akin to helping individuals to make choices, counseling helps them to identify what strategic options are available to them and at what opportunity costs etc. This in turn helps them to change their own decisions. There are both a priori and a posteriori elements in this approach. Tough advantages outweigh disadvantages in counseling priorities might be overlooked by individuals if they happen to change decisions without the help of a counselor. Professional guidance is part of the help process provided by counselors. The relative importance of the whole process lies in its empowering capacity to enable the individual patient to make decisions by using strategic options available to them. This paper in analyzing the importance of diagnosis and treatment planning in counseling would also focus on the strategic importance of diagnosis and its implications for the subsequent decision making process. Analysis According to the American Association of Counseling (AAC) the whole gamut of counseling involves such things as the total facilitation of personal and interpersonal links across a diverse functionality-centric domain. There has been a body of literature on counseling psychology just the resultant outcome of a constant and sustained effort on the part of a handful of pioneers whose relentless efforts have brought about a qualitative change in the whole process of counseling as a professional dynamic and subject-oriented profession. The psychological dimension apart there has been a growing body of literature on the social, economic, cultural and moral aspects of counseling in the modern context of globalization. Thus both the literature and its orientation have acquired a greater degree of classical probity in the larger context of its impacting influence. The ever increasing complexity and diversity of societal and institutional frameworks in the globalization context are reflected in the equally complex and diverse nature and scope of counseling profession itself. It’s against this backdrop that the counseling profession’s obligations and duties have to be examined. In the still larger context such duties and obligations acquire a relative significance of being the only apolitically determined set of principles on which the foundation of counseling rests. Thus the scientific norms associated with its functional domain are determined as an a priori set of causative principles. This scientific professional dimension is inevitably the very idea behind good counseling in different contexts, including those of maladjusted anti-social behavior and depression. The latest growth spurt in counseling related work environments has been attributed to the existence of a variety of opportunities – jobs, training and learning, institutional expansion, research and development and government policy changes. When both the scope and institutional framework expand, there is the possibility of a parallel development of new methods and techniques. The modern techniques of diagnosis have been the result of this rapid transformation process. The latter development has been caused primarily by the changing international political scenario. For instance the number of US military operations abroad has been dramatically rising and with it has brought a rapid rise in Post Traumatic Stress Disorder (PTSD) among returning soldiers from the theaters of war abroad. The relative significance of diagnosis and treatment planning in counseling has to be considered against this backdrop and the subsequent category constructs in techniques of diagnosis and treatment planning have enabled the researcher to build up a contingency model of clinical counseling and therapeutic intervention. Thus a broader definition of counseling to include a multitude of procedural, professional, design, planning and implementing conceptualizations would be more feasible in this context. Category constructs and theoretical underpinnings that underlie each category construct in diagnosis and treatment planning in counseling, have to be delineated in order to understand the extent and the nature of the impact created by different procedural and clinical techniques adopted by the counselor or therapist. In this analysis a controversy that exists in between the definitions of counseling ought to be cleared, viz. counseling and psychotherapy have been treated by many researchers as identical concepts. For instance Snyder (1961) defines psychotherapeutic counseling as “the face to face relationship in which a psychologically trained individual is consciously attempting by verbal means to assist another person or persons to modify emotional attitudes that are socially maladjusted and in which the subject is relatively aware of the personality reorganization through which he is going”. This is part of a recent general trend to identify counseling with psychotherapy and is of extreme relevance here. This paper too would treat both counseling and psychotherapy as interchangeable concepts. Counseling and diagnosis Diagnosis is one of the most important structural determinants of counseling. As Hinkle (1994) states diagnosis in fact determines the outcomes of the counseling process. In the historical developmental process counseling has been going through major changes in the elements of its internal and external structures. This structural transformation has had a substantial influence on both the treatment methods and scope of such methods in the light of a strategic shift in the perception of diagnosis techniques and their broader application across a variety of “disorders”. With the development of diagnosis criteria like the Diagnostic and Statistical Manual (DSM), and the subsequent improvement of techniques for diagnosing and understanding of symptoms, the treatment design, planning and implementation process was revolutionized. This in turn produced a wider spectrum of positive outcomes including those associated with tangible and intangible benefits. While a more positive correlation was established between benefits and intervention outcomes, there were also some bottlenecks that evolved with the very diagnosis techniques. For instance as a corollary of the new developments individual and institutional freedom enjoyed by professional counselors increased but only to replace the converse parallel that prevailed before, i.e. the professional straightjacket. Despite the benefits there are also some concerns about the probable outcomes of diagnosis. In the first instance there are as many limitations and controversies as positive outcomes associated with the multicultural validity and compatibility of the diagnosis systems, the competence of clinicians in diagnosing and whether counselors should diagnose or not. Benson, for example, states that clinicians have a tendency to be liberal in diagnosis, even though they have years of exposure to only one of the diagnosis techniques (2002, p.30). Two of the most negative factors in diagnosis are the focus on confirming information, and self–fulfilling prophecy that jeopardize the validity of the diagnosis (McLaughlin, 2002 p,63). Another important issue is multicultural competence in diagnosis of mental disorders. Postmodern viewpoints, such as the one offered by D’Andrea, support the relativity of the psychological problems to the cultural environment (1999, p.44), stressing the importance of cultural differences and their reflected effect on the symptoms, attitudes, and behaviors of culturally different clients .On the other hand D’Andrea, Mc Laughlin and others acknowledged ways of using DSM as a multicultural tool of competence. Diagnostic and Statistical Manual of Mental Disorders DSM has been used by both laymen and professionals alike to diagnose mental disorders as a more reliable set of principles even in the most extreme cases. A nationwide survey, conducted in1997 by Mead, Hohnenshil, and Singh among certified clinicians, indicated that the DSM is the most chosen professional reference for diagnosis (Mead,Hohnenshil&Singh,1997, p.394). This finding is self conclusive, demonstrating the applicability and importance of the DSM as a diagnosis system. Initially published in 1952, the DSM contained 108 types of mental disorders, and was basically a psychobiological approach to emotional disorders (Selingman 2004). The second edition of the DSM, published in 1968, was influenced by the psychoanalytic theory and contained 185 types of mental disorders. The DSM 3, published in 1980, was the first of the updated versions on which there was strong collaboration between American Psychiatric Association and American Psychological Association. This led to several years of work resulting in a DSM that described 265 varieties of mental disorders. After two revisions of DSM 3, the DSM 4 describing over 300 mental disorders, was published in 1994, and in turn was replaced by DSM 4TR in 2000. This last revision of the DSM places emphasis on the multicultural sides of mental disorders. Given a great deal of theoretical orientations in the counseling field, all of the DSM versions had to be, and are, a theoretical guide to clinicians of all orientations in their diagnosis efforts (Seligman 2004). For each disorder the following spheres have to be addressed: diagnostic future; subtypes of the disorder; recording procedures; associated features and disorders; specific culture, age, and gender futures; prevalence; typical course of disorder; family patterns; and differential select. The DSM is a comprehensive tool, which if well understood and applied, provides a great deal of support in diagnosis and treatment planning to the clinician. The importance of assessment in diagnosis and treatment planning Assessment frameworks and processes in diagnosis and treatment planning occupy a very important place due to the fact that the relationship between the clinician/counselor and the client is a continuous one with each successive stage of the process of diagnosis and treatment. The assessment process is also a bilateral one in that the clinician happens to increase his awareness of the client’s mental disposition. According to Blocher and Biggs such processes help the counselor to understand the client with specific stress on the internal and external parameters of diagnosis and treatment (Blocher and Biggs, 1983, p.186). In the same vein it helps the client to understand and be involved in the counseling process as characterized by an inescapable mutually reinforcing relationship between the two (Selingman, 2004). The current assessment process was preceded by a variety of intelligence scales including Wechsler-Bellevue Intelligence Scale developed in 1938. These were followed by inventions and tests that assessed aptitudes, personalities and interests of clients. Structured assessment processes are nothing new in the sphere of counseling. It’s in fact the most important in diagnosis because it enables the counselor to identify the relative severity of symptoms, to define treatment goals and regimes and finally to enlist the client’s support for the overall treatment planning process. Modern counselors adopt contingency process building approaches in order to achieve long term client motivation and collaboration so that progressive treatment could either be scaled down or altogether discontinued if the client shows improvement. Termination of treatment however has to be carried out under strict supervision of symptoms through structured assessment. Intake interview The intake interview is one of the qualitative methods of assessment and is used with discretion by the counselor as the first method for gathering information about clients, their background, and their problems. It is the first step in the new relationship between the client and the counselor. However, the outcome of the intake interview can be negatively influenced by client resistance and interviewer inexperience. Along with tests, inventories and interviews, observation is another technique of qualitative information gathering, which provides insight into people's behavior in extra-counseling settings. Many qualitative methods of gathering information are necessary but not sufficient to complete a comprehensive assessment. Factors such as difficulty with self-expression, hostility and resistance, confusion, or severe disturbance are often impediments in the way of testing the client’s situation. In such situations quantitative approaches play an important role in assessment and diagnosis. Standardized inventories are divided into three categories based on the variable they are designed to measure. Inventories that measure ability are tests of inborn and learned capacities that measure intelligence, achievement, and aptitudes. They provide information regarding academic strengths and weaknesses as well as to indicate the level of learning of a client relative to a specific sample (Hinkel, 2005). A second category of inventories is the interest inventory. "Interest can be defined as constellations of likes and dislikes manifested through the activities people pursue, the objectives they value, and their patterns of behavior” (Seligman, 2004). This type of inventories, unlike the ability inventories, is more likely to be well accepted by the subject because of their non-threatening nature, which is relayed by the absence of a categorically right or a wrong answer. The last but not the least important category of inventories, is the personality inventory. This type of inventory provides either holistic information about one’s personality or concentrates on a particular aspect of personality. They provide information which might not be provided directly due to lack of ability or willingness. Personality inventories can be divided into general personality inventories, clinical personality inventories and specialized personality inventories (Marushi, Editor, 2004). Multi-axial Assessment Once the necessary data has been obtained through intake interview and standardized tests, they will help the counselor to initiate the diagnosis and treatment planning processes. The Multi-axial Assessment uses DSM to comprehensively analyze the client in a holistic way. This type of assessment uses five ways, or axes, to diagnose the client. Clinical disorders and other conditions that may be a focus of clinical attention. Personality disorders and mental retardation. General medical conditions represented by a physical disorder, possibly relevant for the emotional condition of the client. Psychosocial and environmental problems that are possible stressors for the client. Axis five is a scale of global assessment of functioning (GAF), which measures the client’s level of functioning. Determined by symptom severity and functioning, GAF is a 1-100 scale placing the better functioning at the higher end of the scale. The Multi-axial Assessment is the last step in diagnosing and the first step in establishing a treatment plan. Treatment Planning Next treatment planning follows the diagnosis process. This is the next step in a successful counseling process. Treatment planning, Seligman (1993) is “a road map” that maps out the interaction process between the counselor and the client from the point of start to the final healing phase. A circumspectly developed treatment plan would play an important role in the counseling process. First of all counseling is more likely to succeed when benefited by a clear and carefully developed treatment plan. Secondly, treatment plans and post-treatment evaluations make the counseling process a responsible one by systematically registering proof of progress. Thirdly, goals and procedures included in any treatment plan help both the counselor and the client to confirm progress and to determine whether the treatment plan needs revision or not. Finally, treatment plans empower the counseling process with substance and structure, thus helping the counselor and the client to establish realistic goals and expectations. However, before developing a treatment plan suitable for counseling, several factors have to be considered, such as motivation, characteristics of the person, and the nature of the problem. Motivation is an important factor that contributes to the counselor and client relationship ending in a successful counseling process. Various degrees of motivation can be determined depending on the nature of referral. Self-referred clients are the most motivated ones because their motivation is an intrinsic one empowered by self-determination and will to change. However, clients who are referred by family, and especially those who are court-mandated to treatment, are more reserved to engage in the counseling process. This reticence is caused by the external pressure. These clients are not motivated by a desire to change. They are persuaded by family members, friends or even by the law. However, clients motivated by another's achievement are likely to be strongly motivated, even though they may not fully understand the process of counseling. Another factor that determines the relevance and success of counseling is the nature of the problem presented by the client. In other words, the problems and concerns of clients must be amenable to treatment by counseling. Usually, these are common concerns and problems regarding relationship and communication difficulties, poor or unclear self image, depression or anxiety, trembling behaviors or habits, and so on. Though counseling can help people who have a variety of concerns, it is likely to be unsuccessful if used as stand-alone treatment in some cases. People struggling with severe personality disorders or with cognitive mental disorders and those who oppose the counseling, or those who exceedingly externalize the cause of their problems are more likely to pose a challenge for the counselor and the counseling process, by rendering it inefficient. This can be due to a lack of medication evaluations or other professional or social help resources. Treatment planning models Already a number of treatment planning models have been established and they are based on empirical and theoretical research. These models help clinicians develop structured treatment plans with a high grade of specificity for a given client. One of these models, which will be presented here, was developed by Linda Seligman. It is a 12-step model named by the first letters of each of the steps: DO A CLIENT MAP (Selingman.2004). The twelve steps of this model of treatment planning are: 1. Diagnosis according to the Diagnostic and Statistical Manual Of Mental Disorders 2. Objectives of treatment 3. Assessments 4. Clinician 5. Location of Treatment 6. Interventions 7. Emphasis 8. Number of People 9. Timing 10. Medication 11. Adjunct services 12. Prognosis Some of the steps in this treatment plan model have already been discussed here. Therefore this paper will now concentrate on discussing the most important steps and aspects of this model for the relevant purposes here. Especially it’s relevant to concentrate on the importance of diagnosis and treatment planning in counseling. This model serves as a representative contingency model for analysis. The first step of this model of treatment planning, “Diagnosis according to the DSM” has already been discussed. Next, “objectives of treatment” are usually established in the beginning of any counseling relationship. They are goals set in collaboration by the counselor and the client. Objectives of treatment often change or evolve into other objectives as the counseling process evolves and previous goals are achieved. Objectives motivate clients to be involved in the counseling process, mobilizing them toward active participation in the process. The difficulty to achieve these objectives is a particularly sensitive issue. Objectives which are moderate difficult to achieve might offer a sense of success and competence though. The objectives of treatment usually focus on improving subjective well-being, reducing symptoms, and improving functioning (Wiger and Solberg, 2001). However, efforts must be made, not just in improving one's life or alleviating symptoms, but in preventing problems and developing ways of working through problems and improving one's life. As it has been told earlier, the process of establishing objectives of treatment is a mutual one involving the counselor and the client. Nevertheless, the counselor should facilitate the process of establishing objectives if necessary, suggesting to the client ways of establishing clear goals by questioning. This way, the counselor avoids imposing his beliefs on the client as to what is the best for the client while at the same time helping the client develop more realistic and personal objectives. All objectives, whether they are short, medium, or long-term goals, have to be as specific as possible, quantifiable and explicit. Often writing a list of objectives makes it easier for the counselor and client to assess the progress and provides a basis for confrontation. According to Seligman there is strong evidence that personal and professional qualities of the counselor are crucial for effectiveness of counseling (2004). Therefore, emotional stability, optimism, friendliness, flexibility and patience are indispensable to a successful client-counselor relationship and for a desired outcome of counseling. Furthermore she states that counselors should be skillful in communicating empathy and warmth, they should have realistic self-esteem, and they should have a problem-solving attitude. Many other variables, regarding a clinicians' personal characteristics, professional experience, or background are to be considered when the suitability of the counselor for the client is considered. Even when counselors refrain from imposing their own values on clients and avoid reflections of their previous life experiences, a gross value incompatibility may occur. In these cases a referral is preferable in such a way that the clients’ interests are regarded as the most important. Demographic criteria are also relevant in the process of matching the client and the counselor. Although these criteria are not as important as the previously discussed ones, they impact on the client-counselor relationship. Specifics like age, gender and technical background of the counselor may play an important role in the future relationship between the counselor and the client, although it is hard to show precise patterns. Even if a perfect matching algorithm is hard to find, it is important to pay attention to all the factors that might damage or make impossible a healthy and productive relationship between the counselor and the client. The decision of where the counseling process should begin is very important and depends on the nature and severity of the symptoms, on the case-specific circumstances, and on the possibility of an outpatient treatment regime. A chemically dependent patient would benefit from treatment conducted in a rehabilitation counseling center, whereas a patient diagnosed with Major Depression Disorder (MDD) would perhaps be better treated in an outpatient treatment environment. The significance of Interventions Next a treatment plan ought to be well balanced with all specificities in it. Interventions give meaning to the previous steps and signify the essence of treatment regimes. The nature and type of interventions are presented in two steps. First, in the theoretical framework it is indicated as to which will be the most appropriate theoretical basis for a particular counseling process. In the second step, the counselor determines tools and strategies that are sustained by the specific theoretical postulate. A single theoretical basis is rarely used during the treatment. Typically a different theoretical basis and their respective strategies are used in order to achieve different objectives at different stages of the counseling process. Although a concrete and valid reference system has not been yet developed, guidelines have been established by research that vouches for a high probability of effectiveness in approaching specific problems through specific theoretical models. The Emphasis step in this treatment planning model deals with the way in which the counselor adapts the specific techniques to the personality of the client and the nature of the problem presented by the client. Seligman (2004) structures the emphasis in three dimensions or levels. The “level of effectiveness and structure” is the way in which the counselor controls the counseling process depending on the client’s motivation and the nature of the problem presented.” The “level of confrontation” has to do with the intensity and frequency in which the counselor confronts the client in such a way that the client does not feel threatened, but encouraged to face and reflect on a specific attitude, behavior or problem. The third dimension of the emphasis is the “level of exploration”. This has to do with the holistic way in which the problems are viewed. It is the level of exploring the past problems, losses and experiences while the present problems are not forgotten. A motivated client with a strong will and determination for change and growth may be a good candidate, whereas for a very emotionally unstable client the process of exploration may be harmful. Seligman (2004) suggests that dimensions related to emphasis be not considered independently, as intervention strategies, but rather in a continuum scale ranging from very confrontational to very supportive. Thus, the counselor chooses the appropriate point of view on the scale reading the counseling with a particular client. The emphasis is an important factor on the treatment planning, helping the counselor to choose between techniques and interventions. The next step in treatment planning is to determine the best counseling setting for a particular client. Depending on how many people and which people are involved in the counseling process, the setting possibilities are as follows: Individual Counseling, Group Counseling, and Family Counseling. Again, depending on the personal resources, personality characteristics, and the nature of a client’s problem, it is to be decided if for the client it is more beneficial to participate in one-on-one counseling or if the support of group counseling is more beneficial. Sometimes the involvement of other clients is considered to be beneficial for the counseling process. Many counselors consider, the family dynamics, which are at the root of many of the personal problems presented by the clients. The timing, length of the session, frequency of counseling, and duration of counseling are important technical aspects of the counseling process. The severity of symptoms, existence of self-endangering tendencies, the motivation of the client, and impediments such as limitations of insurance coverage are all key factors in deciding the length of the sessions and frequency and duration of the counseling. However, all this is decided in concordance with the client’s needs and possibilities. Even though counselors are not competent to prescribe medication, there are a number of reasons for which counselors should be familiar with the medications frequently used to treat mental disorders and their effects. First, at the point when the counseling starts the client may have already been taking medication, which might give an idea not only of the present and past status of the client, but would help the counselor avoid a bias in diagnosis. Knowing what a medication can or cannot do and knowing its side effects helps the counselor to monitor closely the client’s progress, so he is able to decide whether to send the client for a medication evaluation or not. During treatment planning, and often during counseling, the counselor recommends adjunct services to improve the efficiency of the counseling process. A wide range of adjunct services are available to improve social life and personal growth in general for the society, and especially for those people who are in need. Seligman states that “these (adjunct services) can enhance and contribute to the effectiveness of counseling and accelerate progress toward goals” (2004). Therefore the needs of the client are the most important determinant in when, how and which adjunct services will be used in addition to counseling. Finally, the last step in treatment planning is the prognosis. Considering the generally accepted prognosis for a specific mental disorder, and taking into account the personal resources and motivation of the client, the prognosis may be terminologically established as follows: very good, good, fair, poor or guarded. However, seeking for a treatment plan with an optimistic prognosis by establishing realistic goals and valid interventions increases the likelihood of the desired outcome of the counseling process. All the processes unanalyzed above are necessary for efficient counseling though which particular one carries more weight than which particular one is rather difficult to establish. Theoretical model building done on the Seligman model is more appropriate here because the underlying paradigm constructs for the evaluation of the relative importance of diagnosis and treatment planning in counseling have received a broader perspective-based analysis. In this context the following conclusions have been drawn and the subsequent recommendations have been presented with a view to enlarging the scope of discussion on the subject. Conclusion Throughout this analysis the researcher focused on the theoretical underpinnings and contingency models with a strong delineation of paradigm constructs to substantiate the importance of diagnosis and treatment planning in counseling. While focusing on the constructive role played by the counselor in diagnosing the potential client’s symptoms and mapping out the subsequent treatment plan, the researcher has placed emphasis on the probable outcomes related all aspects of the counselor-client relationship (Boylan and Scott, 2008). The conceptualizations related to the counselor’s diagnosis process and the subsequent planning process of the treatment regime have been sought to be qualified with the mutually empowering dynamic relationship with the client as well. This mutual impact on the relationship between the counselor and the client is emphasized with equanimity to bring out the various perspectives on the counseling environment (Hersen and Porzelius, Editors, 2001). The theoretical parameters which have been outlined in support of this paradigm-related model construction effort have to be acknowledged as the latest available and most helpful in constructing a contingency model for understanding the importance of diagnosis and treatment planning in counseling. Recommendations The virtual complexity of theoretical constructs apart, there is less appreciation of the DMS system by counselors in practically daunting circumstances of clinical practice. There must be a greater degree of participation in workshops and seminars by such counselors to understand the complex implications of the DMS system in a counseling environment. A truly dynamic model of metrics based on algorithms of counselor-client relationship dynamics should be established to measure various values attributable to controllable variables such as mood switching behavior of clients (Watts, 1999). A parallel set of criteria must be set up in order to establish positive or/and negative correlations between the theoretically determined treatment models as enunciated by Seligman, the strategic choices available to the counselor and outcomes thereof. Finally it’s all the more imperative to engage the individual and institutional involvement in a continuous process of dialogue to create a paradigm continuum for an effective counselor-client relationship. REFERENCES 1. Benson, E. (2002. December). Thinking clinically. Monitor on Psychology, Vol.33, pp. 30-31. 2. Blocher, D.H and Biggs, D. A. (1983).Counseling psychology in community settings. New York: Springer. 3. Boylan, J. and Scott, J. (2008). Practicum and Internship: Textbook and Resource Guide for Counseling and Psychotherapy, Fourth Edition. New York: Routledge. 4. D`Andrea, M.(1999, May).Alternative needed for the DSM-IV in a multicultural- postmodern society. Counseling Today, Vol. 44, p. 46. 5. 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