The Role of Assessment and Diagnosis in Counseling

Assessment and diagnosis are integrally related to the practice of counseling and
psychotherapy, and both are often viewed as essential for planning treatment.
Regardless of their theoretical orientation, therapists need to engage in assessment,
which is generally an ongoing part of the therapeutic process. Assessment should not
precede and dictate intervention; rather, it is woven in and out of the therapeutic
process as a pivotal component of therapy itself (Duncan, Miller, & Sparks, 2004). This
assessment may be subject to revision as the clinician gathers further data during
therapy sessions. Some practitioners consider assessment as a part of the process that
leads to a formal diagnosis. Assessment consists of evaluating the relevant factors in a
client’s life to identify themes for further exploration in the counseling process.
Diagnosis, which is sometimes part of the assessment process, consists of identifying a
specific mental disorder based on a pattern of symptoms that leads to a specific
diagnosis. Both assessment and diagnosis can be understood as providing direction for
the treatment process.

Although some clinicians view diagnosis as central to the counseling process, others
view it as unnecessary, as a detriment, or as discriminatory against ethnic minorities
and women. Irvin Yalom (2003), who is a psychiatrist, recommends that therapists avoid
diagnosis based on his belief that “diagnosis is often counterproductive in the everyday
psychotherapy of less severely impaired patients” (p. 4). Yalom contends that diagnosis
limits vision, diminishes a therapist’s ability to relate to a client as a person, and may
result in a self-fulfilling prophecy.

Dual and Multiple Relationships in Counseling Practice

Dual or multiple relationships, either sexual or nonsexual, occur when counselors

assume two (or more) roles simultaneously or sequentially with a client. This may
involve assuming more than one professional role or combining professional and
nonprofessional roles. The term multiple relationship is more often used than the term
dual relationship because of the complexities involved in these relationships. In the
latest revision of the ACA Code of Ethics (ACA, 2005) both of these terms have been
replaced with the term nonprofessional interactions to indicate additional relationships
other than sexual ones. Many forms of nonprofessional interactions or nonsexual
multiple relationships pose a challenge to practitioners. Some examples of nonsexual
dual or multiple relationships are combining the roles of teacher and therapist or of
supervisor and therapist; bartering for goods or therapeutic services; borrowing money
from a client; providing therapy to a friend, an employee, or a relative; engaging in a
social relationship with a client; accepting an expensive gift from a client; or going into a
business venture with a client. Some multiple relationships are clearly exploitative and
do serious harm both to the client and to the professional. For example, becoming
emotionally or sexually involved with a current client is clearly unethical, unprofessional,
and illegal. Sexual involvement with a former client is unwise, can be exploitative, and is
generally considered unethical.
Although dual and multiple relationships do carry inherent risks, it is a mistake to
conclude that these relationships are always unethical and necessarily lead to harm and
exploitation. Some of these relationships can be beneficial to clients if they are
implemented thoughtfully and with integrity (Lazarus & Zur, 2002; Zur, 2007). An
excellent resource on the ethical and clinical dimensions of multiple relationships is
Boundaries in Psychotherapy: Ethical and Clinical Explorations (Zur, 2007).

WAYS OF MINIMIZING RISK IN DUAL AND MULTIPLE RELATIONSHIPS

• Set healthy boundaries early in the therapeutic relationship. Informed consent is

essential from the beginning and throughout the therapy process.

• Involve clients in ongoing discussions and in the decision-making process, and

document your discussions. Discuss with your clients what you expect of them and what
they can expect of you.

• Consult with fellow professionals as a way to maintain objectivity and identify

unanticipated difficulties. Realize that you don’t need to make a decision alone.

• When dual relationships are potentially problematic, or when the risk for harm is high,
it is always wise to work under supervision. Document the nature of this supervision and
any actions you take in your records.

• Self-monitoring is critical throughout the process. Ask yourself whose needs are being
met and examine your motivations for considering becoming involved in a dual or
multiple relationship.
THE STAGES IN COUNSELING

Stage one: (Initial disclosure) Relationship building

The counseling process begins with relationship building. This stage focuses on the
counselor engaging with the client to explore the issues that directly affect them.

The vital first interview can set the scene for what is to come, with the client reading the
counselor’s verbal and nonverbal signals to draw inferences about the counselor and
the process. The counselor focuses on using good listening skills and building a positive
relationship.

When successful, it ensures a strong foundation for future dialogue and the continuing
counseling process.

Stage two: (In-depth exploration) Problem assessment

While the counselor and client continue to build a beneficial, collaborative relationship,
another process is underway: problem assessment.

The counselor carefully listens and draws out information regarding the client’s situation
(life, work, home, education, etc.) and the reason they have engaged in counseling.

Information crucial to subsequent stages of counseling includes identifying triggers,

timing, environmental factors, stress levels, and other contributing factors.

Stage three: (Commitment to action) Goal setting

Effective counseling relies on setting appropriate and realistic goals, building on the
previous stages. The goals must be identified and developed collaboratively, with the
client committing to a set of steps leading to a particular outcome.

Stage four: Counseling intervention

This stage varies depending on the counselor and the theories they are familiar with, as
well as the situation the client faces.

For example, a behavioral approach may suggest engaging in activities designed to

help the client alter their behavior. In comparison, a person-centered approach seeks to
engage the client’s self-actualizing tendency.

Stage five: Evaluation, termination, or referral

Termination may not seem like a stage, but the art of ending the counseling is critical.
Drawing counseling to a close must be planned well in advance to ensure a positive
conclusion is reached while avoiding anger, sadness, or anxiety (Fragkiadaki & Strauss,
2012).

Part of the process is to reach an early agreement on how the therapy will end and what
success looks like. This may lead to a referral if required.

While there are clear stages to the typical counseling process, other than termination,
each may be ongoing. For example, while setting goals, new information or
understanding may surface that requires additional assessment of the problem.