Chapter 9 "Why Assessment?

Assessment means gathering and organizing information about a client and the

client’s problems. Helpers collect information in a variety of ways, beginning with

the first contact as the helper studies the client’s behavior and listens to the story.

Formal assessment methods include testing and filling out questionnaires and

forms. Informal assessment encompasses all the other ways a helper learns about

a client, including observing and questioning. Formal assessment may occur at a

specific time in the helping relationship, but informal assessment is an ongoing

process because a client’s progress and the temperature of the therapeutic

relationship must be tested throughout. "

"Because each client’s situation is unique, it is impossible to predict how much

time to give to each stage of the helping process. Still, a rule of thumb is to spend

one session primarily in relationship building, with the only assessment activities

being the collection of basic demographics, observation of the client’s behavior,

and whatever else you can glean from the client’s story. The second and possibly a

third session are spent in a more in-depth assessment before moving on to a goal-

setting phase, which might include testing. Therefore, if a client is seen for 10

sessions, about 10% of the time may be devoted to assessment. Beginning a

relationship with a formal assessment can be a mistake because the initial

moments of any human encounter are so important (Gladwell, 2005). Imagine

how you would feel if you went for a doctor’s appointment and were asked only

to fill out forms, contribute blood samples, and answer questions but were not

allowed to talk about the reason for your visit.

When clients have been invited to tell their stories, they give much more

information during the formal assessment period that follows. They leave the first

session believing that they have made a start on solving problems, instead of

feeling dissected by tests and probing questions. Key data need to be collected at

the first interview, but there are several ways to handle this. For clients who can

read and write, asking them to come in early to fill out paperwork can be an

effective way of collecting information about their background and current

functioning.

Assessment Is a Critical Part of Helping

Sometimes you will hear that gathering a lot of historical information about a

client is not worthwhile. Certain theories emphasize the present and the future

rather than the past, and so they ignore history and personality data. It is true that

some helpers do spend an inordinate amount of time gathering background

information and administering tests. On the other hand, by failing to collect

critical data, you take the chance of making a serious mistake. You must know

your customer thoroughly (Gelso, Nutt Williams, & Fretz, 2014; Lukas, 1993).

Once I interviewed a 65-year-old man who had been a shoe salesman in

Cleveland. He had led an interesting life before retiring about 2 years before we

met. He reported no real difficulties, and, as he was very convincing, I couldn’t

understand why he had consulted me. As a courtesy, I talked separately to his 28-

year-old son, who had waited patiently outside. The son told me his father had

been a physician in Texas and 5 years ago developed a syndrome, which was

thought to be Alzheimer disease, a severe brain disorder with a deteriorating

course. When the client could not remember, he simply filled in gaps in his history

with very convincing fiction. That incident (and many others) taught me that it is

best to get as much information about a client as possible and information from a

variety of sources. If I had tested the client’s memory or talked to his son first, I

might have saved some time. More important, had I relied on the client as the

sole source of information, I might have sent him away without treatment.

Conducting superficial assessments, however, does not always lead to such

spectacular embarrassment. It is very common, though, for helpers to accept the

client’s story without a critical thought. Even the most astute helper can make

drastic mistakes. It is important to listen to what clients leave out and where they

minimize or deny. Also, it is easy to forget to ask specific questions, so using a

structured form for assessment is advised. Just because a client is well groomed

and comes from a prominent family does not mean that you should not ask about

drug abuse, intimate partner violence, or suicidal thoughts. Our prejudices and

worldview color our definition of pathology. Even the Diagnostic and Statistical

Manual of Mental Disorders (DSM) of the American Psychiatric Association, the

diagnostic bible, recognizes that misdiagnosis can occur when the helper is not

familiar with a client’s cultural background and interprets symptoms within his or

her own cultural context (Alarcón, 2009). The next section indicates how

assessment can provide the helper with critical information about the client that

charts the course of treatment.

Reasons to Spend Time in the Assessment Stage

Assessment Helps You Determine Whether the Client is a Good Candidate for the

Help You Can Provide

Counseling or psychotherapy from a trained professional is not the best treatment

for everyone. The client must have the capacity to form a relationship, motivated

to change, and able to attend sessions and understand what is going on (see

Truant, 1999). There may be better avenues of help for the client than “talk

therapy.” There are educational, online learning, occupational, chemotherapy, and

support group alternatives. When a client arrives for treatment, the first thought

should be: Is this the right place for this client? For example, in our university

clinic, counselors are only available one day each week. Thus, we need to assess

clients to make sure that they are stable enough to get along on their own

between sessions. We refer those who are not to a more intensive treatment

center.

Assessment Gives Crucial Information to Plan Useful and Realistic Goals

The main purpose of assessment is to gather information that will be useful in

planning the goals that will guide the helper and the client. Assessment must have

both breadth and depth. As far as breadth is concerned, the helper must throw

the net broadly enough to make sure nothing crucial escapes. That is why many

treatment facilities use a standardized assessment or psychosocial intake form

that requires details about the client’s medical, psychological, and social history as

well as current functioning. Depth refers to getting detailed information on

specific issues such as suicide, the existence of mental disorders, and the

“presenting problem” or specific issue that acted as a catalyst for the client’s

decision to seek help.

Assessment Helps Clients Discover Other Factors Related to the Problem

A woman came to a community clinic asking for help in dealing with problems at

work. She recognized that her job was stressful, but she found that she was

unusually irritable with her co-workers and wanted to work on that problem. After

some reflection and homework by the client, we discovered that her angry

outbursts all happened between 1:00 p.m. and 2:00 p.m. on days when she had

not eaten lunch. The client knew that she became grumpy when she was hungry,

but she had never connected this with her behavior on the job. A physician helped

the client to deal with a problem of low blood sugar, and her extreme irritability

diminished, which in turn helped in her relationships and her work. We might

easily have treated the problem as anger without ruling out physical causes. In

another case, we found that a client’s anxiety was at least partially due to drinking

eight cups of coffee per day.

Assessment Helps us Understand the Psychological Impact of the Client’s

Environment

For example, is the client living with family, in a shelter, or alone? Does the client

suffer isolation from not speaking the dominant language or belonging to a

religious minority? If the client is a child, what is happening at school every day

that might be affecting the problem? Is the child bullied, rejected by classmates,

or encouraged by a teacher?

Assessment Helps us Recognize the Uniqueness of Individuals

We all have the tendency to generalize and stereotype. Unless we ask clients

about family and cultural background issues, we may make assumptions about

them through our personal cultural lens. The behavior of people from different

cultural groups may be judged as being more pathological than of those who

share our own background. A systematic assessment helps us be less manipulated

by these strong social influences and more objective because we are recording the

answers to standard questions rather than merely relying on our own impressions.

Assessment can also be useful in helping clients recognize their own unique

personality, values, strengths, and interests (Armstrong & Rounds, 2010; Gallagher

& Lopez, 2019).

Assessment Uncovers the Potential for Violence

Assessment can identify individuals who are at risk for violence toward self or

others, especially by collecting a thorough history. Although it is not possible to

always accurately predict violent behavior, a history of self-inflicted injury or harm

to others can cue us to examine the client’s situation more thoroughly and take

precautions (see Granello & Granello, 2007; Juhnke, Granello, & Granello, 2011).

(See also Table 9.1.) School counselors are recognizing the need to identify

potential for violent behavior in the aftermath of school shootings and in the wake

of renewed interest in bullying (Bernes & Bardick, 2007; Felix, Sharkey, Green, &

Tanigawa, 2011)."

"Assessment Helps Clients Become Aware of Important Problems

Frequently, painful issues are pushed out of awareness or remain unrecognized

until brought to the surface through assessment (Granello, 2010). A common

example of this is substance use. When clients are asked to list and discuss the

problems that alcohol has caused, the results can be surprising. Many alcohol

treatment centers take thorough histories and use motivational interviewing as a

beginning step in breaking down the alcoholic’s denial system (Miller & Rose,

2009).

Assessment Helps the Helper Choose Which Techniques to Use

When you think about learning helping techniques, chances are that you have not

considered assessment as a critical part of that process. Yet how do you know

which techniques to use? The answer is derived from two sources of knowledge:

information about your client and information about the client’s problems. If you

know that your client is very religious, for example, you will be able to select

techniques that the client will embrace. If you know when and where your client

has panic attacks, you will be better able to identify an effective plan. We have to

think about what methods to use with which clients for what particular problem

(Paul, 1967). The next section covers the basic techniques of assessment that are

appropriate to use at all stages of treatment to gain knowledge about clients."

Chapter 10 Change Techniques

"Lowering and Raising Emotional Arousal

The fourth therapeutic factor in the REPLAN system is “L” for lowering and raising

emotional arousal. The purpose of this set of change techniques is to reduce the

impact of negative emotions and increase positive emotions. This goal is

accomplished in three different ways:

Reduce negative emotions: Helpers are called upon to help clients reduce

overpowering feelings of depression, anger, stress, and fear, primarily through

methods of stress reduction and cognitive techniques.

Facilitate expression of strong emotions that are being ignored: At other times,

helpers arouse emotions to act as catalysts for change: for example, helping

clients get in touch with repressed anger or sadness and allowing them to

recognize the powerful nature of unresolved feelings.

Activate positive emotions: Helpers also facilitate positive emotions such as joy,

gratitude, serenity, interest, hope, pride, amusement, inspiration, awe and love,

trust/faith, compassion, gratitude, and forgiveness (Fredrickson, 2009; Vaillant,

2013). Positive emotions also tend to weaken negative ones.

In this section, we will address each of these methods for raising or lowering

emotional arousal and identify some key techniques that helpers use in each

circumstance.

Reducing Negative Emotions

The three most common negative emotions that clients seek help for are

depression/guilt, anxiety, and anger. Earlier in this chapter, you learned the

countering technique, which is used to help clients reduce self-criticism. Reducing

negative thinking also tends to reduce depressive feelings, and cognitive therapy

has been the primary method for treating depression, by psychological means,

since the early 1990s.

Although depression, anxiety, and anger are treated differently, we only have

room here to talk about one of these troubling emotional states, so we have

chosen to present techniques for coping with anxiety. Anxiety is a very common

complaint, and there are several basic anxiety-reducing techniques that can be

learned and applied rapidly. In this section, we present two methods, relaxation

training via muscle relaxation, and meditation, which are both effective and low-

risk.

Reducing Anxiety and Stress

Although a little anxiety may actually enhance performance at times, it can easily

run out of control, causing distress and interfering with relationships and job

performance. Modern life, with more crowding, more work pressure, and more

choices, has led to greater stress levels for just about everyone. The emotional

arousal associated with anxiety or fear may have been useful in more primitive

times because the “fight or flight” syndrome chemically sparked physical

readiness to deal with potential harm, putting the amygdala in overdrive (Siegel,

2012). What once may have increased the chances for survival now threatens our

health because the physiological by-products of stress cannot be easily dissipated

in a sedentary lifestyle. Today’s helper is frequently called upon to help clients

learn to reduce the causes of stress by helping them acquire time management

skills; develop habits for self-care, including exercise and good nutrition; and gain

a healthier outlook on life. In addition, helpers assist clients in lowering stress by

reducing emotional arousal through quieting techniques. Helpers also need to

sustain their own mental health by utilizing stress-reducing resources such as

hatha yoga, meditation, being in nature, using religion and spirituality, and good

nutrition and exercise (see Corey, Muratori, Austin, & Austin, 2018)."

"The most fundamental and time-honored method for helping clients reduce

arousal is relaxation. Relaxation training brings about relief from symptoms of

anxiety and lets clients experience the positive sensations associated with

lowered muscle tension (Pagnini, Manzoni, Castelnuovo, & Molinari, 2013). This

technique is explained in detail here because it is part of most stress reduction

programs and forms the basis of systematic desensitization and biofeedback.

Relaxation Training

Edmund Jacobson’s progressive relaxation technique (1938) was, for many years,

the favored method for teaching clients deep muscle relaxation. Muscle relaxation

had been found to reduce anxiety in clients with phobias by pairing relaxation

with exposure to fearful stimuli, a process called systematic desensitization.

Jacobson’s method, if faithfully followed, enables the client to identify and relax

every major muscle group in the body. The traditional training process may

actually take several months in weekly sessions, but abbreviated versions have

been used successfully (Gatchel & Baum, 1983; Harris, 2003). Following is a simple

and even briefer format developed by Witmer (1985), which can be learned in

three or four sessions, each lasting about 20 minutes. Every session is identical

and provides a complete tensing and then relaxing of all the major muscle groups

(see Table 10.4). Please note that for most problems, relaxation alone is probably

not as effective as a treatment program that also incorporates mental or cognitive

control of anxious thoughts such as thought stopping or countering (Donegan &

Dugas, 2012; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011; Stevens et al., 2007).

Still, relaxation training has been consistently shown to work as a treatment for

various kinds of anxiety and can easily be included as an adjunct to other quieting

strategies.

The Technique of Deep Muscle Relaxation.

Step 1: Preparation. Ask the client to find the most comfortable position with eyes

closed. This position may be sitting or lying down, but in either case, there should

be support for the head. The legs and arms should not be crossed. The procedure

is best practiced without the distractions of noise or glaring lights. Instruct the

client to speak as little as possible and to avoid moving except as necessary to

achieve a more comfortable position. The client may be instructed to raise one

finger to indicate when an instruction has been understood or completed.

Step 2: Tighten and Relax. Ask the client to progressively tighten and then relax

each muscle. There are a variety of ways to move the body to tense each area.

Experiment and allow the client to try out different ways that feel best to tense

that area but do not hurt. Encourage the client to hold each tensed muscle about

6–7 seconds until the experience of tightness is fully felt. If the posture is held too

long, cramps and spasms may result. While a muscle group is tensed, ask the

client to focus attention on that area, simultaneously relaxing other parts of the

body and holding the breath. After tensing the muscle group, the client is asked to

relax and breathe diaphragmatically to let go of all muscle tension. It may take

some time to learn how these muscle groups are properly tensed."

"Step 3: Relax Fully and Breathe. Following the tensing of a muscle group, instruct

the client to exhale and relax fully and completely. This relaxation is to be

accompanied by slow, deep, diaphragmatic breathing and should last 20 seconds

or so. The tension and relaxation of the same muscle group is then repeated

before moving on. Diaphragmatic breathing consists of inhaling and exhaling

below the ribs rather than in the upper chest. It is the relaxed breathing

demonstrated by sleeping babies and practiced by singers. Help clients learn

diaphragmatic breathing by placing one hand on the chest and the other on the

diaphragm/stomach area. Diaphragmatic breathing occurs when the stomach

hand goes up and down, but the chest hand remains relatively immobile.

Step 4: The Body Scan. The most important phase of the lesson is the body review,

or body scan. This phase is critical because the client is learning to self-monitor. In

this step, the client is asked to return to specific, discrete areas of tension during

the relaxation procedure and relax them. This process allows the helper to

individualize the relaxation so that clients can spend time on the areas that they

tend to tighten. Tell clients that a body scan can be used on their own, at any time

during the day, to check bodily tension.

Step 5: Assign Practice. The first administration of the relaxation technique should

be recorded for the client, or a standardized commercially available version of the

technique should be provided. Ask the client to practice the relaxation technique

twice daily, usually once upon rising and once in bed before falling asleep. Have

the client note which of the six areas of the body show the greatest sources of

tension during the day, and ask the client to report this information at the next

session.

Meditation for Lowering Emotional Arousal and Increasing Positive Emotions

Meditation may be one of the most effective means for decreasing anxiety, panic,

and persistent anger and depression (Burns et al., 2011; Kabat-Zinn et al., 1992;

Lane, Seskevich, & Pieper, 2007; Young, 2012). Moreover, meditation is not merely

a method for reducing tension; it actually produces positive states of happiness,

alertness, improved concentration, fearlessness, optimism, joy, and feelings of

well-being (Chandler, Holden, & Kolander, 1992; Fredrickson, Cohn, Coffey, Pek, &

Finkel, 2008; Singh, 2003; Smith, Compton, & Beryl, 1995). Meditation has been

used to treat and prevent substance abuse (Dakwar & Levin, 2009; Gelderloos,

Walton, Orme-Johnson, & Alexander, 1991; Shafii, 1974, 1975; Young et al., 2011;

Zgierska et al., 2009). Along with prayer, meditation is a key tool in the 12 steps of

Alcoholics Anonymous. Meditation is utilized in about 60% of addiction treatment

programs (Priester et al., 2009).

There are several forms of meditation, but we will talk about two: mantra

meditation and mindfulness. Mantra meditation has a long history in Western and

Eastern thought. A mantra is a word or phrase repeated slowly and at intervals,

mentally, not aloud but with the “tongue of thought” (Singh, 2003). For those who

are spiritually inclined, any name of God can be used. Others have found it

effective to repeat a word such as one or peace (Benson, 1984). If you are

interested in learning more about mantra meditation, read Rajinder Singh’s book

Inner and Outer Peace through Meditation (2003). It contains complete and

simple instructions for nondenominational spiritual meditation and exercises for

getting started. A recent study of this technique finds that it is an effective way for

counselor trainees to reduce stress (Gutierrez, Conley, & Young, 2016). For those

who are not attracted to a spiritually oriented meditation, Patricia Carrington’s

The Book of Meditation (1998) and Meditation for Dummies (Bodian, 2016) are

good resources.

Mindfulness is a form of Theravadin Buddhist meditation that has found its way

into a number of new therapies without its religious accoutrements. These include

mindfulness-based stress reduction (Kabat-Zinn et al., 1992), mindfulness-based

cognitive therapy (Segal, Williams, & Teasdale, 2002), dialectical behavior therapy

(Linehan, 1993), and acceptance and commitment therapy (Hayes, Luoma, Bond,

Masuda, & Lillis, 2006). Mindfulness is not merely an activity conducted in a

meditation sitting; it is also a way of life. It involves paying strict attention to what

is happening in the present moment without judging. Mindfulness as a

therapeutic tool contrasts with traditional cognitive therapy because mindfulness

does not challenge or replace negative thoughts. It substitutes “present

awareness” for negative thinking. As a negative thought enters, it is noted without

judgment and allowed to pass through the mind. Mindfulness practitioners think

that arguing with thoughts tends to strengthen them, whereas allowing them to

flow through consciousness unchallenged reduces their potency.

Whether one uses mantra or mindfulness-based meditation, a noticeable benefit

is a reduction in the constant chattering of the mind and the mental images that

produce anxiety. For example, have you ever tried to sleep and found plans for the

next day going around in your head? Meditation is a means of putting such

thoughts to rest for a while. Unlike relaxation techniques, meditation has the

effect of producing mental quietude, not just physical rest. Like relaxation,

meditation must be practiced on a regular basis for at least 15 minutes per day for

several weeks before real benefits can be realized (Benson, 1984). After that, at

least 30 minutes per day should be devoted to meditating. Regularity is crucial,

and longer meditations are considered to be more beneficial than several short

meditations. Like any skill or technique you learn, a teacher is essential (Singh,

2003). Refer clients to a class if you are not qualified to teach them or you do not

practice meditation yourself.

Raising Emotional Arousal and Facilitating Expression

Be aware that emotionally stimulating techniques can be traumatic and

potentially harmful to clients. Arousing techniques, in their simplest and most

benign form, include encouraging clients to talk about troubling experiences and

feelings rather than avoiding them. At the extreme, helpers may evoke powerf