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 Fifth Edition

Clinical Mental Health

Counseling in Community
and Agency Settings

Samuel T. Gladding
Wake Forest University

Deborah W. Newsome
Wake Forest University

330 Hudson Street, NY, NY 10013

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Library of Congress Cataloging-in-Publication Data available upon request.

1 17

ISBN 13: 978-0-13-438555-6

ISBN 10: 0-13-438555-1
 In memory of Shirley Ratliff, a clinical mental health counselor
and an inspirational professional who touched my heart deeply
and gave me many new insights.
—Samuel T. Gladding

In memory of Dr. Thomas M. Elmore (December 28, 1926–October 29, 2012),

my mentor, teacher, colleague, and friend. Dr. Elmore exemplified what it
means to be a counselor, in every sense of the word.
I also dedicate this book to our students—past, present, and future—who
make it a privilege and an honor to serve as a counselor educator.
—Deborah W. Newsome
This page intentionally left blank
 Preface

C linical mental health counseling is an exciting, evolving, and challenging profession.

If you are just now embarking on the journey of becoming a professional clinical
mental health counselor (CMHC), you are in for an exciting ride! We hope that this
text, which addresses many of the 2016 standards of the Council for Accreditation of Coun-
seling and Related Educational Programs (CACREP), will provide you with a strong founda-
tion on which to develop skills and knowledge in the field.
When we wrote the fourth edition of Clinical Mental Health Counseling in Community
and Agency Settings (2014), the 2009 CACREP standards had just been adopted. The stand-
ards no longer recognized community counseling and mental health counseling as separate
specialization areas. Instead, the specializations were merged into one: clinical mental health
counseling (CMHC). Counselor education programs that had separate community coun-
seling and mental health counseling tracks were given time to transition into the new single
CMHC track. As of July 1, 2013, CACREP recognizes only CMHC programs that have met the
accreditation standards. To that end, we have focused exclusively on clinical mental health
counseling in this fifth edition to provide you with a strong base in this specialty area.
Societal changes, changes in the global economy, high rates of unemployment and
underemployment, rapid advances in technology, increased incidences of cyberbullying,
issues confronting veterans, and an increased emphasis on treating clients from a holistic per-
spective (which is not always an easy task when clinicians are working in managed care envi-
ronments) represent just a few of the ways changes in our world compel changes in the way
we practice as clinical mental health counselors. We recognize that the CMHC profession will
continue to evolve and that by the time you read this text, even more changes will have taken
place. The Diagnostic and Statistical Manual-5 (DSM-5) was published in May 2013. The
American Counseling Association (ACA) revised its code of ethics in 2014. Unanticipated
changes to the world of clinical mental health counseling are inevitable. However, in the midst
of change, clinical mental health counselors will continue to perform a broad range of thera-
peutic services among diverse client populations in a variety of settings. Clinical mental health
counselors will use evidence-based approaches that promote prevention, early intervention,
wellness, and advocacy, taking into account the client, the environment, and the interaction
between the two. Clinical mental health counselors will continue to develop skills in working
with crisis and trauma. Furthermore, they will continue to work with teams of other mental
health and medical professionals to provide the best possible care for their clients.
In the fifth edition of this text, we address these and other topics. We examine the his-
tory and professional foundations of counseling, legal and ethical issues, counseling with
diverse populations, multiple roles and functions of clinical mental health counselors, and
the many settings in which clinical mental health counselors practice.

New to This Edition

The fifth edition features new content, which reflects some of the ongoing developments in
the clinical mental health counseling field, including the following:
●● Over 200 references have been added or updated, bringing this edition of the book
current with the research in the field of mental health counseling.

v
vi Preface

●● References to the DSM-TR-IV have been replaced by references to the DSM-5, making
the diagnosis of clients current with the latest standards in the field.
●● References to the American Counseling Association (ACA) 2005 Code of Ethics have
been replaced with a focus on the 2014 ACA Code of Ethics.
●● References to the 2009 CACREP Standards have been replaced with references to the
2016 CACREP Standards.
●● The book has been streamlined from 16 to 15 chapters to make it more in line with
semesters, which are usually 15 weeks long. (In making this change, the separate
chapters on the history of counseling and identity as a mental health counselor were
combined.)
●● More than two dozen tables, figures, and boxes have been added to summarize impor-
tant material in the book.
●● Key words and concepts in each chapter have been boldfaced to help students recog-
nize them.
●● Parts of previous chapters have been moved around and expanded upon to make
them more congruent in the chapters in which they have been placed. For instance,
“coaching” has been moved from Chapter 13 on college and career counseling and
placed in Chapter 15 next to private practice, which is more likely to be a setting that
employs this clinical mental health specialty. Likewise, in Chapter 8, the last half of the
chapter, dealing with crises and disasters, has been moved to the front of the chapter
since counselors are more likely to be involved in these activities than matters pertain-
ing to suicide.
●● Chapter lengths have been evened out, providing a more uniform flow to the text.
●● An epilogue has been added to contrast where the field of counseling and mental
health counseling was when it was first formulated in the late 1970s with where it is
today.

Organization of the Text

The content is designed to address pertinent topics in clinical mental health counseling.
Contents are organized in four parts:
●● Part 1: Historical and Professional Foundations of Clinical Mental Health
Counseling. In Part 1 of the text, we focus on the historical foundations of coun-
seling, beginning with a recounting of the historical roots of the profession and an
exploration of the concept of professional identity, particularly the specialty area of
clinical mental health counseling. We describe credentialing and licensure policies
associated with the profession (Chapter 1). In Chapter 2, ethical and legal issues, with
a focus on those that pertain to clinical mental health counseling, are examined. In
Chapter 3, we address counseling issues related to diversity. It is crucial for counselors
to develop skills in working with people of different ethnic and racial backgrounds,
sexual orientations, levels of ability, and social class. Other areas of diversity, including
gender and adulthood, are discussed elsewhere in the text.
●● Part 2: Roles and Functions of Clinical Mental Health Counselors. Clinical
mental health counselors are responsible for developing the knowledge and skills
needed to conduct a broad array of counseling services. Part 2 opens with a general
description of the counseling process and specific descriptions of activities that occur
 Preface vii

during the initial, working, and closing stages of counseling. In Chapter 5, we give
specific attention to two general functions that counselors need to conduct skillfully:
assessment and diagnosis. This chapter is followed with a description of holistic
approaches to counseling, which are becoming more prevalent in many clinical set-
tings. In Chapter 7, we focus on four important services clinical mental health counse-
lors provide: consultation, advocacy, client outcome evaluation, and program
evaluation. Part 2 concludes by addressing the significant topics of crisis and disaster
response, suicide assessment and intervention, and the need to maintain counselor
effectiveness, manage stress, and avoid burnout.
●● Part 3: Working with Specific Populations. Clinical mental health counselors
work with groups, couples, families, and individuals of varying ages. In Chapter 9,
ways to work with groups are discussed, and in Chapter 10, ways of working with
couples and families are covered. In Chapter 11, we focus on counseling children and
adolescents, giving attention to developmental issues, counseling techniques, and spe-
cific counseling concerns that face this age group. In Chapter 12, issues related to
counseling adults at different developmental levels are discussed. In addition to focus-
ing on counseling throughout the adult life span, special attention is given to working
with older adults, especially concerns related to the discriminatory practice of ageism
and to the specific counseling needs of women and men.
●● Part 4: Clinical Mental Health Counseling: Settings and Services. Clinical
mental health counselors are employed in many different for-profit and nonprofit set-
tings that operate in both public and private sectors. Chapter 13 explores the ways
clinical mental health counselors work in college settings and the services they offer
in career counseling, regardless of settings. In Chapter 14, we describe several set-
tings in which clinical mental health counselors might be employed, including com-
munity agencies, healthcare facilities, child and family agencies, and other specialized
clinical settings. Finally, Chapter 15 discusses the work counselors engage in when
they are in employee assistance settings, private practice, and managed care environ-
ments. The practice of coaching is also included in this chapter since some private
practitioners engage in this activity.
The content of the fifth edition is based on current research and practices germane to
clinical mental health counseling. Information presented in the chapters is supplemented
with narratives supplied by mental health professionals employed across counseling set-
tings, who share their views of the rewards and challenges associated with the services they
provide. In addition, case studies in each chapter, many of which were written by graduate
students practicing in the field, provide opportunities for students to grapple with challeng-
ing issues faced by clinical mental health counselors. Finally, boxes, figures, and tables sum-
marizing or clarifying information are included in individual chapters.

Also available with MyCounselingLab®

This title is also available with MyCounselingLab, an online homework, tutorial, and assess-
ment program designed to work with the text to engage students and improve results.
Within its structured environment, students see key concepts demonstrated through video
clips, practice what they learn, test their understanding, and receive feedback to guide their
learning and ensure they master key learning outcomes.
viii Preface

●● Learning Outcomes and Standards measure student results. MyCounselingLab

organizes all assignments around essential learning outcomes and national standards
for counselors.
●● Video- and Case-Based Assignments develop decision-making skills. Students
watch videos of actual client-therapist sessions or high-quality role-play scenarios
featuring expert counselors. They are then guided in their analysis of the videos
through a series of short-answer questions. These exercises help students develop the
techniques and decision-making skills they need to be effective counselors before they
are in a critical situation with a real client.
●● Licensure Quizzes help students prepare for certification. Automatically graded,
multiple-choice Licensure Quizzes help students prepare for their certification examina-
tions, master foundational course content, and improve their performance in the course.
●● Video Library offers a wealth of observation opportunities. The Video Library
provides more than 400 video clips of actual client-therapist sessions and high quality
role-plays in a database organized by topic and searchable by keyword.
●● Comprehensive online course content. Filled with a wealth of content that is tightly
integrated with your textbook, MyLab lets you easily add, remove, or modify existing
instructional material. You can also add your own course materials to suit the needs of
your students or department. In short, MyLab lets you teach exactly as you’d like.
●● Robust gradebook tracking. The online gradebook automatically tracks your stu-
dents’ results on tests, homework, and practice exercises and gives you control over
managing results and calculating grades. The gradebook provides a number of flexible
grading options, including exporting grades to a spreadsheet program such as Micro-
soft Excel. And, it lets you measure and document your students’ learning outcomes
and performance by standard.

Acknowledgments
It takes the efforts of a community to rewrite a textbook. We want to thank our professional
colleagues in the various communities in which we have worked—academic communities,
clinical communities, and professional communities, including the American Counseling
Association and its divisions. We also acknowledge the dedicated mental health profession-
als who supplied narratives or personal interviews for the text, including Kristina M. Acosta,
John Anderson, Tom Buffkin, Kelli Coker, Robin Daniel, Pat DeChatelet, Ann Dixon Cop-
page, Paige Greason, Jay Hale, Donna Hampton, Peggy Haymes, Tania Castillero Hoeller,
Pamela Karr, Anya Lainas, Nick Mazza, Peg McEwen, Ellen Nicola, Mary Claire O’Brien, Peg
Olson, Patti Patridge, Edward Shaw, Elizabeth Vaughan, and Laura Veach.
Several of our current and former graduate students contributed case studies for vari-
ous chapters, including Kavitha Dharmalingam, Elisabeth Harper, Corrine Harris, Lolly
Hemphill, Katie Lee Hutson, Karen Kegel, Shahnaz Khawaja, Beth Montplaisir, Amanda Rich
Morgan, Kevin Varner, and Brittany Wyche. Throughout the course of the text revision,
Wake Forest research and teaching assistants Kavitha Dharmalingam, Teresa Prevatte, and
Brittany Wyche provided invaluable assistance. Also we wish to thank James Raper and
Kavitha Dharmalingam, who combined with Dr. Newsome to write Chapters 9 and 15
respectively in the fourth edition of this text. Their research, writing, and expertise on these
matters contributed greatly to the comprehensiveness and readability of the book then and
we have built on their work since.
 Preface ix

We would also like to thank the reviewers who provided helpful comments and sug-
gestions for strengthening the text. They are Joyce A. DeVoss, Northern Arizona University;
Amy L. Reynolds, University at Buffalo; David A. Scott, Clemson University; Oscar Flores
Sida, University of Nevada Las Vegas; and Carlos Zalaquett, Ph.D., LMHC, Lic., University of
South Florida and The Pennsylvania State University. In addition, we recognize and are
grateful for the contributions of the staff at Pearson, especially Kevin Davis. Thank you as
well to our project manager at Aptara, Sadika Rehman. The patience and flexibility of these
individuals made the project manageable.
We are especially thankful for the contributions of our spouses (Claire Gladding and
David Newsome) for their patience and encouragement during the text revision. We appre-
ciate our children, our families, and our friends for the humor, love, support, and sensitivity
they provide on an ongoing basis. Finally, we are fortunate to work with several very special
colleagues and students, who listen, challenge, and inspire. Thank you to the faculty, staff,
and counseling students at Wake Forest University for their ongoing support.
This page intentionally left blank
 About the Authors
Samuel T. Gladding is a professor in the Department of Coun-
seling at Wake Forest University in Winston-Salem, North Caro-
lina. He is a fellow in the American Counseling Association and
its former president (2004–2005). He has also served as president
of the Association for Counselor Education and Supervision (ACES),
the Association for Specialists in Group Work (ASGW), the American
Association of State Counseling Boards, and Chi Sigma Iota. He is
the former editor of the Journal for Specialists in Group Work, a past
member of the American Counseling Association Foundation, and a
past member of the North Carolina Board of Licensed Professional
Counselors.
Dr. Gladding has authored numerous professional publications, including 45 books. In
1999, he was cited as being in the top 1% of contributors to the flagship periodical of the
American Counseling Association: the Journal of Counseling and Development. A National
Certified Counselor (NCC), a Certified Clinical Mental Health Counselor (CCMHC), and a
Licensed Professional Counselor (North Carolina), Dr. Gladding’s specialty in counseling is
creativity. He is married to Claire Tillson Gladding and is the father of three adult sons. In
his spare time, he enjoys swimming, writing poetry, listening to music, and reading humor
and history.

Deborah W. Newsome is an associate professor in the Department

of Counseling at Wake Forest University in Winston-Salem, North
Carolina, where she serves as the clinical mental health program
director. She served on the Executive Board of the Association for
Assessment in Counseling and Education (AACE) for six years and is
a member of several divisions of the American Counseling Associa-
tion (ACA). She is a National Certified Counselor (NCC), a Licensed
Professional Counselor (LPC), and a Licensed North Carolina School
Counselor. She teaches courses in clinical mental health counseling,
counseling skill development, assessment, and career development
and counseling. She also supervises graduate students’ clinical experiences and volunteers at
a local nonprofit counseling center.
Dr. Newsome has coauthored three books and over 25 book chapters and journal arti-
cles. She received Wake Forest University’s Graduate Student Association Faculty Excellence
Award twice. She and her husband, David Newsome, are the parents of two young adults—
David, Jr., and Jennifer. Debbie is an avid runner and swimmer and enjoys playing the flute
for various community organizations.

xi
This page intentionally left blank
 Brief Contents

Part 1 Historical and Professional Foundations of Clinical

Mental Health Counseling 1
Chapter 1 History of and Professional Identity in Clinical Mental Health
Counseling 2
Chapter 2 Ethical and Legal Aspects of Counseling 35
Chapter 3 Clinical Mental Health Counseling in a Diverse Society 63

Part 2 Roles and Functions of Clinical Mental Health

Counselors 93
Chapter 4 The Counseling Process 94
Chapter 5 Client Assessment and Diagnosis 127
Chapter 6 Holistic Approaches to Clinical Mental Health
Counseling 151
Chapter 7 Consultation, Advocacy, and Evaluation 172
Chapter 8 Dealing with Crises, Disasters, and Suicide, while Managing
Stress and Avoiding Burnout 193

Part 3 Working with Specific Populations 217

Chapter 9 Working with Groups 218
Chapter 10 Couples and Family Counseling 239
Chapter 11 Counseling Children and Adolescents 262
Chapter 12 Counseling Adults 294

Part 4 Clinical Mental Health Counseling: Settings and

Services 325
Chapter 13 College and Career Counseling 326
Chapter 14 Community Agencies, Medical Settings, and Other Specialized
Clinical Settings 350
Chapter 15 Employee Assistance Programs, Private Practice, Coaching,
and Managed Care 376

Epilogue 399

xiii
This page intentionally left blank
 Contents

Part 1 Historical and Professional Foundations of Clinical

Mental Health Counseling 1

Chapter 1 History of and Professional Identity in Clinical

Mental Health Counseling 2
Historical Roots of Clinical Mental Health Counseling 3
A Chronological Overview of Professional Counseling 5
Before 1900 5
1900–1909 6
1910s 7
1920s 8
1930s 9
1940s 10
1950s 11
1960s 13
1970s 14
1980s 15
1990s 18
2000–2009 19
2010 to Present 21
Professional Identity 26
Defining Professional Helping 26
Defining Professional Counseling 26
Legal Recognition of Counseling as a Profession 28
Professional Identification Through Credentialing 28
Inspection 28
Registration 29
Certification 29
Licensure 29
Identifying and Defining Therapeutic Professionals 29
Social Work 30
Psychiatry 31
Psychiatric Mental Health Nursing 31
Psychology 31
Clinical Mental Health Counseling 32

xv
xvi Contents

Clinical Mental Health Practice Settings and Services 33

Summary and Conclusion 34

Chapter 2 Ethical and Legal Aspects of Counseling 35

Definitions: Ethics, Morality, and Law 36
Ethics and Counseling 39
Purpose of Ethical Codes 39
The ACA Code of Ethics 39
NBCC Code of Ethics 42
Limitations of Ethical Codes 42
Making Ethical Decisions 43
Other Guidelines for Acting Ethically 44
Unethical Behavior 46
The Law and Counseling 47
Criminal, Civil, and Administrative Law 48
Malpractice 49
Other Reasons for Court Appearances 50
Common Ethical and Legal Concerns 51
Privacy, Confidentiality, and Privileged Communication 51
Informed Consent 55
Professional Boundaries and Roles with Clients 56
Professional Competence 57
End-of-Life Decisions 59
The Use of Technology 59
Using Technology-Assisted Counseling Responsibly 60
Summary and Conclusion 62

Chapter 3 Clinical Mental Health Counseling in a Diverse

Society 63
Culture and Ethnicity 64
Defining Culture and Multicultural Counseling 65
Challenges and Issues in Multicultural Counseling 67
Developing Multicultural Counseling Competencies 68
Becoming Ethnically Responsive Counselors: Integrating
Awareness, Knowledge, Skills, and Advocacy 70
Sexual Orientation and Gender Identity 72
Definitions and Terminology 73
Homophobia and Heterosexism 74
Sexual Identity Development and Coming Out 75
 Contents xvii

Other Counseling Issues and Implications 77

Working with Transgender Clients 80
Differing Abilities 81
Definitions and Terminology 81
Factors Associated with Increased Rates of Disability 82
Attitudes and Myths about Disabilities 82
Federal Regulation Related to Disability 83
Counseling Goals and Interventions 84
Training, Roles, and Functions of Rehabilitation Counselors 85
Counseling Issues and Implications 85
Socioeconomic Status and Social Class 89
Definitions and Terminology 89
SES as a Risk Factor 90
Poverty and Social Class Fluidity 90
Counseling Implications 91
Summary and Conclusion 92

Part 2 Roles and Functions of Clinical Mental Health

Counselors 93

Chapter 4 The Counseling Process 94

The Physical Setting of Counseling 95
Aesthetic Qualities and Room Design 95
Initial Sessions: Building a Counseling Relationship 96
Seriousness of the Presenting Problem 97
Structure 97
Initiative 101
Initial Counseling Interviews 104
Relationship Building during Initial Sessions 108
Case Conceptualization 110
Client Records 110
The Working Phase of Counseling 113
Treatment Plans 113
Interventions, Skills, and Techniques 114
Case Notes 118
Documenting Work with High-Risk Clients 119
Closing Counseling Relationships 121
Why Closing Is Important 121
xviii Contents

Timing of Closing 122

Facilitating Closing 123
Documenting Closing 124
Following Up 125
Referring and Recycling 125
Summary and Conclusion 126

Chapter 5 Client Assessment and Diagnosis 127

Assessment In Counseling 128
Assessment Defined 129
Methods of Assessment 129
Purposes of Assessment 133
Principles of Sound Assessment 135
Issues Related to Assessment 136
Diagnosis 138
Using the DSM-5 in Mental Health Counseling 140
Overview of Mental Disorders and Conditions 140
Diagnosing Using the DSM-5 145
Diagnosis and Treatment 146
Biopsychosocial Assessment and Diagnosis 147
Biopsychosocial Assessment and Reporting 148
Summary and Conclusion 149

Chapter 6 Holistic Approaches to Clinical Mental Health

Counseling 151
The Biopsychosocial Model 152
Biological Components 152
Psychological Components 154
Social Components 155
Assessment and Treatment Planning 155
Spirituality 157
Terminology 158
Benefits Associated with Spirituality 158
Spirituality and the Counseling Process 159
Mindfulness 160
Wellness 162
Wellness Models: The Wheel of Wellness and the Indivisible
Self 163
Ways to Use the Indivisible Self Model in Counseling 164
 Contents xix

Prevention 165
Definition of Prevention 165
Rationale for Prevention 167
Prevention Models 168
Stress Management 169
Summary and Conclusion 170

Chapter 7 Consultation, Advocacy, and Evaluation  172

Mental Health Consultation 173
What Is Mental Health Consultation? 174
Caplan’s Four Types of Mental Health Consultation 175
Key Characteristics of Successful Consultants 177
Advocacy 178
What Is Advocacy? 179
Empowerment 180
Social Action 181
ACA Advocacy Competencies 182
Advocacy Skills and Attributes 183
Challenges of Advocacy 183
Advocacy for the Profession 184
Client Outcome Evaluation 184
Definition and Purpose of Client Outcome Evaluation 185
Multifaceted Approaches to Client Outcome Evaluation 185
Challenges and Benefits of Client Outcome Evaluation 187
Program Evaluation 187
Purposes of Program Evaluation 188
Steps in Evaluation 189
Process and Program Outcome Evaluation 189
Quality Assurance 191
Issues and Challenges of Program Evaluation 191
Summary and Conclusion 191

Chapter 8 Dealing with Crises, Disasters, and Suicide,

while Managing Stress and Avoiding
Burnout 193
Crisis and Disaster Response 194
Definition of Crisis 194
Definition of Crisis Intervention 197
Crisis Assessment 197
xx Contents

Six-Step Model of Crisis Intervention 200

Disaster Mental Health Training 202
Compassion Fatigue, Secondary Traumatic Stress, and Vicarious
Traumatization 204
Suicide Assessment and Intervention 205
Talking with Clients about Suicide 205
Identifying Risk and Protective Factors 207
Immediate Interventions 208
Responding to Risk Assessment 209
Maintaining Effectiveness as a Counselor: Managing Stress and
Avoiding Burnout 210
Stress and Burnout in Counseling 210
Establishing Limits 212
Modeling Self-Care 213
Cultivating Self-Awareness 214
Maintaining a Sense of Humor 215
Summary and Conclusion 216

Part 3 Working with Specific Populations 217

Chapter 9 Working with Groups 218

The Place of Groups in Counseling 219
Types of Groups 220
Psychoeducational Groups 220
Counseling Groups 221
Psychotherapy Groups 221
Task/Work Groups 222
Mixed Groups 222
Realities and Misperceptions About Groups 223
Uses, Advantages, and Limitations of Groups 224
Uses of Groups 224
Advantages of Groups 224
Limitations of Groups 225
Theoretical Approaches in Conducting Groups 226
Stages in Groups 227
Issues in Groups 228
Selection and Preparation of Group Members 228
Group Size and Duration 232
Open versus Closed Groups 233
 Contents xxi

Confidentiality 233
Physical Structure 233
Coleaders 233
Self-Disclosure 234
Feedback 234
Follow-Up 235
Qualities of Effective Group Leaders 236
Group Organizations 237
Summary and Conclusion 237

Chapter 10 Couples and Family Counseling 239

What is a Family? 240
Family Life and the Family Life Cycle 240
Different Types of Families and Their Issues 242
Minority Ethnic Families 243
Dual-Career Families 243
Single-Parent Families 243
Childless Families 244
Remarried Families 244
Gay and Lesbian Families 244
Aging Families 245
Multigenerational Families 245
Military Families 246
Family Life Stressors 247
Expected Life Stressors 248
Unexpected Life Stressors 248
Couple Counseling 249
Psychoanalytic Theory 249
Social-Learning Theory 250
Bowen Family Systems Theory 250
Structural–Strategic Theory 251
Rational Emotive Behavior Theory 251
Emotionally Focused Therapy 251
Family Counseling 252
Psychodynamic Family Counseling 254
Experiential Family Counseling 255
Behavioral Family Counseling 256
Structural Family Counseling 256
Strategic Family Counseling 256
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