Picture the Destination

Walking through the steps of assessment and the client/counselor relationship.

Excerpted From
Assessment for Counseling in Christian Perspective By Stephen P. Greggo

Assessment starts by listening to someone’s life story, dream or personal experience and hearing the yearning underneath. The counselor listens earnestly for the key challenge that must be explored. From this point forward, each decision, instrument and inquiry flows out of the rationale for launching the investigation. The destination for change emerges as a response to the cry of a heart. Assessment then guides the journey.

Mental health evaluations by tradition are descriptive and technical. The scientific legacy of psychological measurement has produced objective means to investigate unique personal characteristics. Polished instruments identify symptoms, gauge functioning or detect personality patterns. Interviewers probe for detail and take notice of the full range of immediate behaviors. Results are merged into formal reports. This documentation outlines the reason for referral, summarizes background information, lists the measures applied, consolidates findings and builds to a conclusion with recommendations. Such evaluations rely on expert judgment to generate insight into the essence of the presenting problem. The purpose is to pinpoint an accurate diagnostic profile that tracks smoothly with the treatment options.

Descriptive assessment remains a necessity. For example, health systems allow for care to treat a disease, condition or injury. The evaluation at the outset justifies eligibility for treatment by establishing the state of the patient. Further, the severity of the detriment dictates the treatment setting, frequency, format and duration. Nevertheless, although important, this mainstream style of assessment contains a clinical hazard. Professional documents take on the tone of official pronouncements. The findings have power to inadvertently become limitations. The objective survey of the client’s past and present detects a location on a psychiatric map of mental illness. A pin is dropped; a monument is erected.

There is a way forward that embraces the methodology of assessment yet reduces the risk that it will hinder growth. Counselors would do well to view assessment as a real-time navigational system that can expedite the route to a place of flourishing. Instruments can do more than describe; they can estimate proximity to the achievement of change. Or, when treatment is underway, measures may reveal aimless wandering or warn of the dreaded dead end. Awareness of the need to reroute the care plan is far more beneficial than pushing on as if all were well. Assessment, like its biblical counterpart, discernment, needs to be an ongoing and dynamic routine to encourage movement in a productive direction, toward what is truly best (Phil 1:9–10).

This book will explore flexible and vibrant ways to gather and apply information. Assessment informs both counselors and clients. It can tighten the focus of the conversation, reveal the presence of obstacles, stabilize risk from nonproductive expectations, and safeguard good will in the helping partnership itself.

The intersection of psychotherapy and Christian ministry is primed for reconstruction. There are numerous shifts occurring in cultural and spiritual values. Clergy who care for constituents via counseling must reflect on their priorities and purposes. Pastors and congregations will determine an acceptable balance of care implementing interpersonal discipleship, group instruction or intercessory prayer. Is ministry counseling to be a comprehensive service, an entryway to mental health intervention or a referral route to formation exercises with a spiritual director? Professional roles and expectations are in flux as specializations continue to evolve. Christians with credentials in mental health settings are prepared to serve diverse clients without imposing faith values. Such neutrality may not be appealing to those with deep Christian convictions. Obviously, the stakes in counseling are high, both personally and socially. Resources continue to fall far short of critical needs. Clinicians, ministry leaders and medical professionals will continue to explore the potential for teamwork. Clinicians who follow Christ and have eyes to see those who are hurting, hiding or seeking will feel the compassion of our Lord awaken. The crowds appear harassed and helpless (Matt. 9:36).

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When educating others, the challenge is to teach forward—that is, to teach with an eye on what is on the horizon. There is little benefit accomplished by merely looking back on what one has come to understand as valuable in the field and then passing that along. Those perceptions may be accurate, insightful, explanatory and perhaps even entertaining. But unless guidance anticipates, it is functionally and pedagogically useless. The upcoming generation of people helpers and pastoral caregivers will not serve clients under the field conditions that existed five or more years ago. Experience generates knowledge, and this becomes wisdom when combined with vision to prepare learners for what’s looming on the horizon. The next generation needs to be ready to embrace the questions of their day.

Here’s the proverbial good news and bad news. The good news is that counseling is effective; therapy is a valid pathway for clients to resolve issues and pursue change. Clients who complete treatment generally improve. The supporting evidence for this claim is compelling (Lambert, 2013; Nielsen et al., 2004; Wampold & Imel, 2015). Furthermore, when therapeutic methods are accommodated to fit the faith traditions and commitments of religiously oriented clients, these approaches are generally effective (Worthington, Hook, Davis, & McDaniel, 2011). For those in the Christian tradition, there is a variety of therapeutic approaches available (Worthington, Johnson, Hook, & Aten, 2013).

However, despite much evidence for the effectiveness of therapy, there are still opportunities to improve the discipline. This desire for improvement has led to the call for standardization and customization. Standardization is uniformity in how counseling is delivered, while customization refers to how counselors fit approaches to unique clients. Additionally, there is a call for evidence that articulates the potential impact of specific models of treatment. The challenge, though, is that the reliability (e.g., consistency) of success is less predictable than those in the field might hope. Multiple factors contribute to the intricacies of delivering effective service, in particular the fact that no two clients are the same. Each client represents a specific background, family configuration, and cultural community, and skillful counselors recognize subtle distinctions in client presentation and openness. Adept counselors adjust interventions accordingly (Wampold & Imel, 2015). But the impediments to success are real.

How many mental health professionals (MHPs) does it take to change a light bulb? Only one, but the light bulb must want to change. The joke may be stale, but the myth it extols is worth exposing. Failures in counseling are not solely a matter of counselee factors or an unwillingness to commit. A motivational force brings a client in for that first appointment. It takes embracing that impetus to promote success. Extensive research into counselor actions offers insights into what’s likely to go right or wrong (Castonguay & Hill, 2017; Marini, 2016; Swift & Greenberg, 2015). Counselor behavior matters. How will MHPs address uncertainties regarding the reliable delivery of care? Counselors are challenged to recognize and employ information on how the collaboration is proceeding. This is a formidable responsibility. There is much to consider, and there are many aspects to observe—all constrained by limitations on time.

The Hope of Practice-Based Evidence

Still, there is reason for hope. A robust movement is building momentum in the field of counseling and psychotherapy, described by phrases such as “preventing treatment failure,” “feedback informed therapy,” “patient-focused assessment,” “psychotherapy quality assurance,” and “outcome monitoring” (Prescott, Maeschalck, & Miller, 2017; Duncan, Miller, Wampold, & Hubble, 2010; Lambert, 2010; Swift & Greenberg, 2015). These labels can be summarized by the term “practice-based evidence” (Green & Latchford, 2012). Practice-based evidence (PBE) involves systematically collecting information at all phases of treatment through the use of assorted assessment procedures. Using assessment to monitor and inform the process of change can strengthen the quality of service and increase the likelihood that the desired outcomes will be reasonably achieved. This style of assessment will increasingly inform and empower clients, demonstrate progress, and maximize success by clarifying expectations and focusing on tangible outcomes.

This form of assessment is not about making a diagnosis or discovering an elusive underlying pattern. Rather, this is doing assessment seamlessly, with ease and comfort for the sake of the client. Approaching a clinical case is similar to conducting a research study: Even though there is only one subject, it is essential to define the problem, develop a hypothesis, propose an intervention, deliver care, refine the plan as necessary and review the evidence to see how successful the outcomes are (Glicken, 2005). And rather than diminishing the interpersonal nature of the work, these assessment procedures can contribute to the durability and endurance of the human aspects of care.

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The past few decades have seen the establishment of evidence-based practice (EBP) in mental health care. This is typically defined as the implementation of the best current research into explicitly tailored methods to fit client characteristics, culture, and setting. EPB requires clinicians to engage clients with significant interpersonal skill (APA Presidential Taskforce, 2006). Using targeted approaches and adapting them to unique clients requires the application of assessment procedures posing these questions:

• What are the options?
• What’s the best plan?
• Will this work?
• How should we proceed?

In contrast, PBE shifts the focus to consider how things are working in a live, multifaceted therapeutic effort. PBE is a complementary undertaking that extends the principle of relying on evidence to determine the direction of care by mapping the progression of the change experienced by the client. PBE prefers these questions:

• Is this option working?
• What’s our best plan?
• Are we working?
• How can we adjust to improve our plan or partnership?

Both EPB and PBE seek improved quality of service, but the distinction between the two is that although EBP looks to researchers to demonstrate efficacy, PBE turns the spotlight on the counseling dyad, making the argument that quality care will provide the evidence that treatment was indeed effective. PBE is collected, calibrated and interpreted in the counseling room, not in the laboratory.

We live in an era when customers rate everything, from the burger they ate at lunch to a new piece of luggage to their medical services. It’s common sense to check with clients before they depart our offices to ascertain if our procedures and services were close to their expectations. In fact, this sort of evaluation can help shape counselee expectations, even from the earliest contact. Incorporating practice-based evidence allows counselors to evaluate progress alongside clients so that accomplishments and the ongoing strategy for growth are understood and agreed on mutually.

This form of assessment becomes a means to sharpen our craft while improving the connection and tracking results in real time. My goal in this book is to equip clinicians to come to terms with the necessity and advantages of bringing a productive blend of assessment strategies into our interpersonal helping conversations.

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Excerpted from Assessment for Counseling in Christian Perspective by Stephen P. Greggo. ©2019 by Stephen P. Greggo. Used by permission of InterVarsity Press, P.O. Box 1400, Downers Grove IL 60515-1426. IVPress.com