Good clinical decision-making

"Go talk with someone. You'll feel better," is often what folks hear from loved ones or their physicians before seeking counseling. It's common for new clients to arrive at my office imagining that we're going to chat a little, drink some tea, and have a good cry after which, they'll be cured. We will chat a little. We may drink tea. We may have a good cry. But if that was sufficient to help with concerns like severe anxiety and depression, I'd tell everyone to save their money and talk with friends/family. 

It is every consumer's right to seek a counselor for supportive work. There's nothing wrong with supportive counseling but if you want clinical counseling work, you should expect that your counselor can make algorithmic clinical decisions while also providing a supportive environment for you to decompress in. 

When you show up to a clinical counselor's office, you should feel welcomed, supported, and allowed to share in a natural way about what you would like help with. Note though, that while you're telling your story to your counselor, this is happening in the background:

A Scientific Method

You're sitting down for a chat. I'm gearing up my decision-making brain. I quickly shift from telling you about my practice and explaining limits to confidentiality to "let's figure out how this pain works so we can get you some relief." Consumers should expect that a clinical counselor will be constantly engaged in the scientific method, throughout their treatment.

Understanding the presenting problem (Background research)

The "presenting problem" is why you're here. To understand it, you'll tell me about what symptoms have bothered you most, why you are seeking counseling now (as opposed to last month or last year), when the symptoms happen, and what impact all of this suffering has on your ability to live life fully. I will probably repeat the cliche, "tell me more about that," many times, asking you to elaborate on your experience so that I can fill in the details of how the pain you're carrying around developed so that I can figure out how I can help make it more bearable.

Differential diagnosis/functional diagnosis (Hypothesis)

As early as feasible (and preferably in the first couple of sessions), I try to understand how your suffering works. I'm constantly referencing your experience (and symptoms) against what I learned in school, against my continuing education, and against my clinical experience, coming up with theories of how I might help alleviate your pain, based on how it works. The "disease" model of mental health typically addresses this process like this:

Sometimes, I use that model to pick a specific intervention for a specific well-known type of suffering. In a mental wellness model, I do not need to be as specific about diagnosis. If the client's suffering is more generalized sadness or anxiety, I may choose a "mental wellness approach" to treatment. Some counselors who use wellness models exclusively, refer clients who need other types of treatment. Their decision algorithm might look like this:

 I use both specific cognitive behavioral treatments and more generalized wellness interventions so I would use both algorithms to determine a treatment, based on hypothesized diagnoses. 

Testing the treatment (Analyzing the data)

Once I've picked a treatment that I think is most likely to work for the client at hand, I inform the client of the risks and benefits of the treatment and if they consent, proceed. It often works and the diagnostic hypothesis is supported and treatment will continue until the client and I mutually agree that sufficient benefit has been attained. If the first treatment choice doesn't work, I may either try another possible treatment for the same diagnosis or may reconsider their diagnosis. If I get stumped along the way, I will either consult or refer. Consult means that I'll talk with colleagues to get new ideas for the case. I may also go get training in a specific topic area relevant to the client, Or, I may refer the client to a professional that has a different approach. 

Keeping it natural while practicing evidence-based psychotherapy

Here is the challenge: Most people don't want to be poked and prodded (mentally) every week for an hour for many weeks on end. So counselors may or may not share this scientific process with their clients overtly. An experienced counselor should be able to be as transparent or "behind the scenes" with this scientific method as is called for by the client at hand. Personally, I have some clients where I share almost every detail of this process with them throughout therapy while others have no idea what's going on behind the scenes. What I am passionate about, however, is that anyone who calls themselves a clinical mental health counselor SHOULD be practicing algorithmic treatment, informed by their intuition and experience. Every counselor SHOULD be able to consult with colleagues by explaining this process and by explaining particular decision points they are stuck on (we all get stuck!). 

So for clients and prospective clients, consider asking your counselor about their diagnostic process as a way to make sure you're getting the kind of professional service you should be getting from a healthcare worker. Therapy is supposed to be about a lot more than a chat, some tea, and a cry (although there should probably be a lot of those three things going on too).