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ASSESSMENT AND DIAGNOSIS PROCEDURES

1. Clinical Interview Unstructured: flexible; suggestive leads from therapist; clinical judgment may be biased Structured: standardized questions; increased reliability and validity; model from DS !"#: Structured $linical "ntervie% &S$"D' and Diagnostic "ntervie% Schedule for $hildren &D"S$' 2. Mental Status Exam (ppearance)*ehaviour +hought ,rocesses),erceptions: flo%- continuity of thought- rational- speed- delusions- ideas of referencehallucinations ood)(ffect: appropriate; flat; blunted; inappropriate; prominent feeling "ntellectual .unctioning: vocabulary- insight- abstractions- memory Sensorium by person- time- place: oriented x /; a%areness of surroundings and reality 3. Behavioural Assessment: trac0ing by the clinician or the client &self!monitoring' or the client1s family; in the office or in real life &home or school': direct observation; specific context; (*$ model: antecedent behaviourstarget behaviourconsequences; 4. Environmental Assessment: rating the family system- the school- the community setting or a long!term care institution; example: See .amily *ac0ground 2uestionnaire 5. Ps cho!h siolo"ical assessment: measurement of one or more of the physiological processes that reflect autonomic nervous system activity: heart rate- s0in conductance- muscle activity- brain electric activity- pulse and body temperature3 #. $euroima"in": 4on!invasive technologies for imaging the brain: $(+methods 5"- ,6+- S,6$+ are most familiar

%. Ps cholo"ical &estin" Self!report inventories &see *ec0 Depression "nventory; $hild *ipolar (ssessment' 7Dra% a person8 ,sychological "nventories: ,"!9 and 46:!,"!5; ,(" ,rojective +ests: 5orschach- +(+ "ntelligence +ests: Stanford!*inet; ;("S!"""; ;"S$!"""; ;,,S" 4eurological assessment: *ender!<estalt- +rail a0ing +est- ;eschler emory; =alstead!5eitan; >uria! 4ebras0a '. &(E MI$$ES)&A M*+&IP(ASIC PE,S)$A+I&- I$.E$&),- /MMPI021 ?@A true)false statements related to self &behaviours- thoughts- and feelings' ,rovides ten clinical scales and three validity scales ! =ypochondriasis ! Depression ! =ysteria &psychosomatic symptoms' ! ,sychopathic deviance ! asculinity!femininity ! ,aranoia ! ,sychasthenia &obsessions- fears- guilt' ! Schizophrenia ! =ypomania &emotional excitement' ! Social introversion ! >ie scale &>' ! .alse ,ositive scale &B' ! .alse 4egative scale &.' Diagnosis of Pathology ;ith a medical model &related to "$D!CD' *y description rather than explanation *y category: either you do or you do not meet the symptom criteria &DS

and "$D use this approach'

*y dimension: %here do you fall along a continuum of mild- moderate- severe3 *y time: chronic- acute- continuous- episodic ;hy diagnoseE ( common language among professionals "ndication of etiology &cause' of a disorder 4arro%s do%n treatment modalities (llo%s for scientific research on syndromes 6nables third party payment +he Diagnostic and Statistical anual of ental Disorders- F th edition &DS !"#!+5' &9DDD': the diagnostic bible: the most %idely used diagnostic systems in the United States; approved by the (,(3 +his is a multiaxial classification system- %hich means that there are five axes &principle structures or dimensions' on %hich to diagnose: Axis I2 Clinical S n3romes3 +he traditional clinical labels are included on this axis3 +hese clinical disorders are the subject of any psychopathology course; i3e3- mood disorders- anxiety disorders- eating disorders- gender! related disorders- personality disorders Axis II2 Personalit 4isor3ers5Mental ,etar3ation3 +here are ten personality disorders included on (xis ""3 +hese disorders are generally observed in childhood or adolescence and may persist in stability over time3 "nsurance %ill not cover treatment for personality disorders3 +hese most often are secondary to an (xis " diagnosis3 ental 5etardation is included on (xis ""- perhaps because of its chronicity Axis III2 6eneral Me3ical Con3itions3 (ll medical problems that may relate to psychological problems are listed here Axis I.2 Ps chosocial an3 Environmental Pro7lems3 >isted here are any sources of difficulty during the past year- or anticipated events that %ould be stressful3 Axis .2 6lo7al Assessment o8 9unctionin" /6A91. +he present level of adaptive functioning in three areas: personal relationships- occupational functioning and use of leisure time3 Scale from C &suicidal- homicidal' to CDD &superior functioning'3 :ea;nesses an3 criticisms o8 the 4SM0I.0&, &7a strange mix of social values- political compromise- scientific evidence and material for insurance claim forms8' C3 +he subjectivity of the diagnostician 93 heavy reliance on the medical model &assuming symptoms of underlying pathologies' /3 ;ea0 empirical data for some categories of disorders &personality disorders' F3 Disorders are not mutually exclusive and may overlap into another ?3 Does not include etiology or treatment recommendations &descriptive- not explanatory' @3 Stigmatization of labeling an individual %ith a disorder A3 6ffect on individual1s sense of esteem or competence G3 ay produce a self!fulfilling prophecy H3 Subject to psychological or social influences; may be biased against %omen; are feminine personality characteristics perceived as pathological- i3e3 ,ersonality disorders such as histrionic and dependent CD3 "nsensitive to culture!bound disorders Ethical Issues in Counselling Practice 6thical decision!ma0ing is an evolutionary process that requires you to be continually open and self!critical3 5ecognizing the potential for countertransference: %hat are your o%n needsE Do you have areas of unfinished businessE (re there potential personal conflicts that %ould interfere %ith helping the clientE Do you recognize your o%n areas of prejudice and vulnerabilitiesE $ounsellor impairment often leads to countertransference3 +he more common characteristics of impairment are: .ragile self!esteem Difficulty establishing intimacy in one1s personal life ,rofessional isolation ( need to rescue clients ( need for reassurance about one1s attractiveness or one1s competence ( substance abuse $ountertransference can sho% itself in many %ays3 +he follo%ing are most common: C3 *eing overprotective %ith a client3 93 +reating clients in benign- superficial %ays3 /3 5ejecting a client3

F3 ?3 @3 A3 G3 H3

4eeding constant reinforcement and approval3 Seeing yourself in you clients3 Developing sexual or romantic feelings to%ard a client3 <iving advice compulsively3 Desiring a social relationship %ith a client3 Delaying termination

;hose needs are being met in this relationshipImy client1s or my o%nE "s it unethical to meet our personal needs through our professional %or0E Don1t %e benefit by being nurturing- feeling adequate- displaying competence- being respected and appreciatedE Steps in Ethical Decision Ma!ing C3 "dentify the potential problem3 "s the problem mainly ethical- legal- professional- clinical- or moralE 93 "dentify the potential issues for both you and the client3 /3 5evie% the ethical codes for your profession3 (re you o%n values and ethics consistent %ith or in conflict %ith the relevant guidelinesE F3 $onsider the applicable la%s and regulations3 ?3 See0 consultation from other professionals or from your professional organization3 @3 *rainstorm possible courses of action3 A3 6valuate the consequences of possible courses of action3 G3 Decide on the best possible course of action3 H3 .ollo% up to evaluate the outcomes In8orme3 Consent: $lients must be provided %ith information that they need to made informed choices; their rights and responsibilities must be given to them in paper form and they must sign that they have read and agree %ith the information3 "ncludes: goals of counselling- the responsibilities of the counsellor to%ard the client- the responsibilities of clients- limitations of and exceptions to confidentiality- legal and ethical parameters of the therapeutic relationship- the qualifications and bac0ground of the therapist- the fees involved- the approximate length of the therapeutic process3 See handout for model3 Con8i3entialit : "nformation shared in the clinical setting must be 0ept private- but confidentiality is not an absolute and exceptions must be explained to the client3 $onfidentiality must be bro0en %hen it is clear that the client may do serious harm to either themselves or others3 +here is a legal requirement to report incidences of child abuseabuse of the elderly and of dependent adults3 $onfidentiality must be breached if a client under the age of C@ is a victim of incest- rape- abuse or some other crime; %hen the client needs hospitalization- %hen information is made an issue of court action and %hen the client requests that records be released3 $lients must also be informed if the therapist may be discussing details of the relationship %ith a supervisor or a colleague3 4ual an3 Multi!le ,elationshi!s: $ounsellors must not assume t%o or more roles &sexual or non!sexual' simultaneously or sequentially %ith a client3 6xamples given include bartering for services- borro%ing money from a client- providing therapy to a friend- a relative or employee- accepting an expensive gift from a client- or going into a business venture %ith a client3 (ny multiple relationships that %ould impair the therapist1s objectivity- competence or effectiveness is not allo%ed; multiple relationships that do not cause impairment or ris0 exploitation are not unethical3 $an you give some examplesE Multicultural Com!etence: +heories and practices of counselling must ta0e into consideration the %orldvie%s of all populations that enter into a therapeutic relationship3 6xample: 6uro!(merican culture emphasizes the importance of individuality and independence as the foundation for maturity3 Some cultures value collectivist and communal ethics and consider the group more important than the self3 Assessment an3 4ia"nostic Com!etence: Diagnostic assessments are based on the DS !"#!+5 &9DDD'; correct diagnosis is central to the counselling process- although there are those %ho avoid diagnosis based on the notion that it is counterproductive: Jalom believes that 7diagnosis limits vision- diminishes a therapist1s ability to relate to a client as a person- and may result in a self!fulfilling prophecy38 &p3 FF' +o revie% the $ode of 6thics for the follo%ing professional organizations- chec0 out the %ebsite for: C3 (merican $ounselling (ssociation &($(' http://www.counselling.org/resources/ethics.htm#ce 93 (merican ,sychological (ssociation &(,(' http://www.apa.org/ethics/code2002.html /3 4ational (ssociation of Social ;or0ers &4(S;' http://www.naswdc.org/pubs/code/default.asp F3 (merican (ssociation for arriage and .amily +herapy &(( .+' http://www.aamft.org/resources/LRMPlan/index_nm.asp

T"E COUNSE##OR$ PERSON AND PRO%ESSIONA# Bno%ledge and s0ills are essential but not sufficient for establishing and maintaining effective therapeutic relationships3 +he human dimension is one of the most po%erful determinants of the therapeutic encounter3 *e a%are of your o%n needs- motivations- values and personality traits that may enhance or interfere %ith your effectiveness as a counsellor3 <enuineness- aliveness- realness- self!actualizing- becoming- psychologically healthy- appropriate self!disclosure: characteristics that build trust and enhance client honesty and change Personal Characteristics of Effecti&e Counsellors$ An I'eal C3 $omfortable sense of self 93 Strong sense of self!%orth and strength /3 (ble to accept their o%n po%er and the po%er of others F3 :pen to change- to revise early decisions that have proven %rong ?3 >iving fully rather than settling for mere existence @3 (uthentic- sincere- honest A3 Sense of humour G3 ;illing to recognize and admit mista0es H3 >iving in the present CD3 (ppreciative of o%n culture and those of others CC3 Sincere interest in the %elfare of others C93 Deeply involved in their %or0 but not consumed by it C/3 $apable of maintaining healthy boundaries $ounsellors should participate in their o%n therapy before they become practitioners3 ;hy %ould this be such a strong recommendation from $oreyE !s"#ounsellors"we"can"ta$e"our"clients"no"further"than"we"ha%e"been"willing"to"go"in"our"own"li%es. 8 p3 9D Jalom- &he"gift"of"therap':"!n"open"letter"to"a"new"generation"of"therapists"and"their"patients"(200)* : 7+elf, exploration"is"a"lifelong"process-"and"."recommend"that"therap'"be"as"deep"and"prolonged"as"possible/and"that" the"therapist"enter"therap'"at"man'"different"stages"of"life.0 ( major reason for some form of therapy is to help students learn to deal %ith countertransference &the process of seeing themselves in their clients- of over!identifying %ith their clients- or of meeting their needs through their clients'3 1nless"#ounsellors"are"aware"of"their"own"conflicts-"needs-"assets-"and"liabilities-"the'"can"use"the"therap' " hour"more"for"their"own"purposes"than"for"being"a%ailable"for"their"clients-"which"becomes"an"ethical"issue." p3 9C (alues an' the Therapeutic Process +herapy cannot be value!free3 +he $ounsellor1s values should enter into a therapeutic relationship- and- at the same time- he or she must maintain a sense of objectivity3 +herapists %ill not impose their o%n specific values; their therapeutic goals and methods are an expression of their philosophy of life3 "t is the client1s responsibility to decide on the goals of therapy; the goals of the therapist should be congruent %ith the personal goals of the client3 Setting goals is inextricably related to values3 +he inta0e session can be used to produce goals or lac0 of them: ! ;hat brings you to therapy at this timeE ! ;hat %ould you li0e to accomplish hereE ! ;hat1s not %or0ing for youE ! ;hat are your expectations hereE ! ;hat %ould you li0e to change about your lifeE )eco*ing an Effecti&e Multicultural Counsellor "t is an ethical obligation for counsellors to develop sensitivity to cultural differences "t is necessary to understand your o%n cultural conditioning as it relates to ethnicity- race- gender- age- religionsexual orientation- physical and mental abilities and socioeconomic status3 *ecoming a diversity!competent therapist is an on!going process in three areas: beliefs and attitudes- 0no%ledge and s0ill3 *e %illing to identify and examine your o%n %orld vie%- assumptions- and personal prejudices about other racial)ethnic groups3

(s0 clients early in the therapy process ho% they identify their race)ethnicity- %hether racial)ethical differences bet%een therapist and client might affect the therapy process- %hat they can teach us that %ill help us %or0 %ith them more productively3 "t is not necessary for practitioners to have the same experiences as their clients3 See (,( guidelines to %or0ing %ith diverse populations3 ulticultural $ounselling and +herapy & $+' Issues %ace' +y )eginning Therapists C3 Dealing %ith the normal anxieties that come %ith uncertainty 93 *eing real and monitoring self!disclosure /3 (voiding being perfect F3 Bno%ing your limitations- but %illing to ta0e ris0s ?3 <etting comfortable %ith silence @3 Dealing %ith the demanding and presumptuous client A3 +olerating ambiguity G3 Setting reasonable boundaries so you don1t lose yourself in the client1s problems H3 Developing a comfortable sense of humour CD3Sharing responsibility %ith your client for effective change CC35efusing to give advice or ma0e decisions for the client C93Understanding %hy you are utilizing a technique %ith a client C/3>earning to develop your o%n unique style CF3Beeping yourself alive by paying attention to your personal and professional %ell!being "