Diagnosis and Treatment Planning in Counseling Second Edition Diagnosis and Treatment Planning in Counseling Second Edition Linda Seligman George Mason University and Center for Counseling and Consultation Fairfax, Virginia Plenum Press • New York and London L\brarv of Congr ••• CatalogIng-In-PublicatIon Data SeligMan, Linda. olagnosl' and traatlant planning In counseling I Linda Sellga.n. - - 2nd ed. p. ca. Includes bibliographical references and Index. ISBN-13: 978-0-306-45352~ 1. Mental he.lth counseling. 2. CounselIng. I. Tltl •. [DNLM 1. Counl.llng--I.thods. 2. Mantal ol.orders--dlignoili. S. Patlen. Ca.'. Pla •• n.n". HM 55 S465d 1996J RC466.S4!5 1996 818.89--dc20 oNLM/OLC for Library of Congress 96-29020 CIP ISBN-13: 978-O-306-45352~ e-ISBN-13: 978-1-4684-0013-7 001: 10.1007/978-1-4684-0013-7 e 1996 Plenum Press, New York A Division of Plenum Publishing Corporation 233 Spring Street, New York, N. Y. 10013 109876543 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher The first edition of this book was published by Human Sciences Press, Inc., New York, 1986 Preface Mental health counseling and diagnosis and treatment planning have grown enormously in importance since the 1986 publication of the first edition of this book. Licensure or certification for counselors is now available in all but a handful of states. Training in diagnosis and treatment planning is provided by nearly all graduate programs in Counselor Education. I have traveled throughout the United States and Canada, providing hundreds of workshops and courses that trained thousands of clinicians in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and in effective treatment planning. In the preface to the first edition of this book, I wrote, "To date, little of value to counselors has been written on diagnosis and treatment planning." That statement is no longer true; many articles and some books have been written since that time on the use of diagnosis and treatment planning by counselors. However, the field of mental health counseling is still young; more research and writing is needed to establish a sound theoretical base for the profession and to teach the skills of diagnosis and treatment planning. The purpose of the second edition of this book is to help counselors and other mental health professionals to acquire up-to-date information on diagnosis and treatment planning and to develop related clinical skills that are essential to their effectiveness. Chapter I, The Changing Role of the Counselor, reviews efforts to develop a definition of mental health counseling. An overview of the history of the counseling profession is provided, as well as information on the expanding role of the counselor, professional associations, credentialing for both counselors and counselor education programs, and the current impact of managed care on the profession. This chapter concludes with a review of important competencies of the mental health counselor. New roles for mental health counselors are the focus of chapter 2, Oppor tunities for the Mental Health Counselor. This chapter looks at new and growing client groups, employment settings, and problem areas of relevance to the mental health counselor. The chapter also discusses the types of mental health profes sionals and the mental health treatment team. v vi Preface The Diagnostic and Statistical Manual ofM ental Disorders is the focus of chapter 3, Diagnostic Systems and Their Use. This chapter provides an overview of the benefits and pitfalls of diagnosis and of its history. The chapter also reviews the diagnoses in the current edition of the DSM. The Use of Assessment in Diagnosis, chapter 4, discusses tools for quali tative and quantitative assessment that can enhance the process of diagnosis and treatment planning. The chapter also provides information on planning an assessment and on interpreting client information. Chapter 5, Intake Interviews, reviews the nature and importance of the intake interview and provides an outline for an extended intake interview. Also included in this chapter are a transcript of an intake interview and written reports of both brief and lengthy intake interviews. In addition, ways to conduct a mental status examination are described. Chapter 6, The Nature and Importance of Treatment Planning, presents qte DO A CLIENT MAP, a structured format for treatment planning. In chapter 7, Theories and Techniques o.f Individual Counseling, informa tion on the major theories of individual counseling is presented, including important concepts, key interventions, and appropriate use. Examples illustrate the information presented in both chapters 6 and 7. Diagnosis and Treatment Planning for Families, chapter 8, provides guide lines and tools for assessing family functioning. The important approaches to family counseling are discussed, including their appropriate use. An example of an assessment and treatment plan for a family is provided as well as cases for discussion. Chapter 9, Assessment and Treatment Planning for Groups and Organiza tions, encompasses ways to describe and diagnose the needs of groups, as well as discussing counselor roles in group treatment and important approaches to group counseling. An example of the assessment and planning of a counseling group is provided. Writing and Record Keeping in Counseling, chapter 10, discusses the importance of these activities in counseling. It provides models for progress notes, interim reports, assessment reports, professional disclosure statements, safe-keeping contracts, and other reports prepared by counselors. Future Trends and Projections, chapter 11, reviews the predictions made in the first edition of this book and discusses their current status. In addition, predictions are made about the counseling profession, based primarily on trends and issues discussed throughout this book. Acknowledgments I would like to express my appreciation to some of the people who contributed to the writing of this book.· Many thanks to: • My husband, Dr. Robert Zeskind, for your love and support. • My friend, Bettie MacLennan Young, for your friendship, good advice, and understanding. • Bonnie Moore, Director of Educational Counseling Services, Office of Adult'and Community Education, Fairfax County Public Schools, and doctoral student at George Mason University, for your contribution to this book. • Stephanie Hardenburg, doctoral student at George Mason University, for your help with this manuscript. • My colleagues at George Mason University, especially Dean Gustavo A. Mellander, ~ssociate Dean Martin Ford, and Assistant Dean Clark Dobson, for your encouragement of my writing and research. • My clients, who helped me really to understand diagnosis and treatment planning. • The participants in my courses and workshops on diagnosis and treat ment planning, who contributed greatly to my knowledge. vII Contents 1. The Changing Role of the Counselor •••••••••••••••••••••••• 1 The Evolution of the Counseling Profession ................... . 1 Definitions of Counseling .................................. . 2 Early History of the Counseling Profession .................... . 3 Counseling in the 1940s, 1950s, and 1960s .................... . 3 Counseling in the 1970s and 1980s .......................... . 6 Development of the Counseling Profession in the 1990s ......... . 9 The Orlando Model Project ............................... . 10 Impact of Managed Care ...............•.................. 10 The Mental Health Counselor Today ......................... . 12 The Growth of Credentialing ............................... . 14 National Certification for Counselors ....................... . 14 State Licensure and Certification for Counselors .............. . 16 Accreditation of Counselor Education Programs .............. . 17 The Education of the Mental Health Counselor .. , .............. . 18 The Master's Degree in Counseling ........................ . 18 The Doctoral Degree in Counseling ........................ . 19 Professional Associations for Mental Health Counselors ......... . 19 Competencies of the Mental Health Counselor ................. . 21 2. Opportunldes for the Mental Health Counselor •••••••••••••.• 29 Overview of the Roles of the Mental Health Counselor .......... . 29 Client Issues of Special Interest to Mental Health Counselors ..... . 30 Multicultural Counseling ................................. . 30 Gender Issues .......................................... . 31 Issues of Sexual Orientation .............................. . 31 Trauma ................................................ . 32 Sexual and Physical Abuse ............................... . 32 Ix x Contents Substance Abuse ........................................ 33 Family Issues ..... ;..................................... 34 Age-and Stage-Related Issues .......................... , . . 34 Career Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Conflict Resolution ...................................... 36 Issues Related to Medical Conditions, Health, and Wellness . . . . . 36 Chronic or Severe Mental Disorders ........................ 37 Other Issues ............................................ 37 Employment Settings for Mental Health Counselors... ... . .. .... 37 Community Mental Health Centers ......................... 37 Marriage and Family Counseling Agencies . . . . . . . . . . . . . . . . . . . 38 Rehabilitation Counseling Agencies ........................ 38 Career Counseling or Employment Agencies ................. 40 Employee Assistance Programs ............................ 40 Schools... ............................................. 41 Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Other Medical Services/Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Residential Facilities ..................................... 43 Day Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Crisis Intervention Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Military and Government Settings .......................... 43 Religious/Spiritual Counseling Settings . . . . . . . . . . . . . . . . . . . . . . 44 Wellness and Prevention Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Specific Focus Agencies .................................. 44 Consulting Settings ...................................... 45 Private Practice ......................................... 46 Overview of Opportunities ................................ 46 The Mental Health Service Providers ......................... 47 The Mental Health Treatment Team......................... 47 The Mental Health Treatment Specialists .................... 48 3. Diagnostie Systems and Their Use •••••••••••••••••••••••••• 55 The Importance of Diagnosis ................................ 55 Benefits of Diagnosis .................................... 55 Controversies and Limitations ............................. 56 Maximizing the Benefits of Diagnoses ...................... 57 Diagnostic Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Development of the Diagnostic and Statistical Manual ofM ental Disorders ........................................... 59 contents xl Definition of a Mental Disorder ............................. . 60 Multiaxial Assessment ..•..•...•.............• '.' ........... . 60 Example of a Multiaxial Assessment ......................... . 61 The 17 Diagnostic Categories ............................... . 62 Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence ....•.................................... 62 Delirium, Dementia, Amnestic and Other Cognitive Disorders ..... 65 Mental Disorders Due to a General Medical Condition .•......... 66 Substance-Related Disorders .••..•.......................... 66 Schizophrenia and Other Psychotic Disorders .................. . 67 Mood Disorders .........•.....•........................... 68 Anxiety Disorders ........................................ . 69 Somatoform Disorders ...••................•................ 70 Factitious Disorders ....................................... . 71 Dissociative Disorders ..................................... . 71 Sexual and Gender Identity Disorders ............•........ '.' .. 72 Eating Disorders .......................................... . 72 Sleep Disorders ......•.................................... 73 Impulse-Control Disorders Not Elsewhere Classified ............ . 73 Adjustment Disorders ..................................... . 74 Personality Disorders ...................................... . 74 Other Conditions That May Be a Focus of Clinical Attention ..... . 76 Additional Codes .•........................................ 77 Making a Diagnosis ....................................... . 78 Decision Trees ....•..................................... 78 Key Questions for Diagnosis .............................. . 79 Application of the Key Questions .......................... . 79 Supplements to the DSM ....................•............... 80 Cases for Diagnosis ...................................•.... 80 Diagnoses of Cases .........•.............................. 82 4. The Use of Assessment In Diagnosis ••••••••••••••••••••••••• 85 Overview of the Assessment Process ......................... . 85 Areas of Assessment ..•..•................................ 87 Conducting an Effective Assessment ....................... . 87 Tools of Assessment ............•.......................... 88 Qualitative Approaches .................................. . 88 Nonstandardized Quantitative Approaches ................... . 90 Validated Quantitative Approaches ......................... . 92 "II Contents Types of Inventories ....................................... 93 Measures of Ability ....................•................. 93 Interest Inventories ...................................... 9S Personality Inventories ................................... 97 Projective Tests ......................................... 100 Planning the Assessment ................................... 102 Formulating Assessment Questions ... '. .... . ... ... . .. ... .... 103 Selection ofInventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104 Preparing People for an Assessment . .. . . . . . . . . . . . . . . . . . . . . .. lOS Frameworks for Understanding People ........................ t OS Developmental .......................................... 106 Social, Economic, Cultural, and Ethnic Frameworks ..•........ 106 Psychological Aspects--General ........................... 106 Psychological Aspects-Suicidal Behavior ................. " 107 Psychological Aspects--Violence .......................... 109 Psychological Aspects--Defense Mechanisms ................ 109 Individualized Frameworks ................................. 112 Process of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. t12 Questions to Guide the Analysis . .. . . . . . . . . . . . . . . . . . . . . . . . .. 113 Guidelines for Interpretation ............................ '. . .. 114 Example 1 .............................................. liS Example 2 .............................................. 115 Example 3 ...................... " ............. " ... .... tiS Example 4 . " ............... '" . .. . ..... ..... . ... . .. . ... It6 Discussion ............................................. 116 s. Intake Interviews.. . • . . . .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .... 119 Purpose of the Intake Interview .............................. 119 Overview of the Intake Process .............................. 120 Intake Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121 Information Gathering .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121 Depth and Duration ofIntake Process ..•.................... 121 Nature of Client ......................................... 122 Relationship ofIntake Process to Treatment .................. 123 Conducting an Intake Interview . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. 124 Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . • .. 12S Recording Information .........................•......... 126 Concluding the Intake Interview .................. '" .... . .. 127 The Extended Intake Interview .............................. 127