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Journal of Creativity in Mental Health

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Teaching Diagnosis in Context: Guided

Imagery as a Contextually Sensitive
Pedagogical Technique
a a b
Victoria E. Kress , Matthew J. Paylo , Nicole A. Adamson & Eric
c
Baltrinic
a
Youngstown State University, Youngstown, Ohio, USA
b
University of North Carolina at Pembroke, Pembroke, North
Carolina, USA
c
University of Toledo, Toledo, Ohio, USA
Published online: 12 Jun 2014.

To cite this article: Victoria E. Kress, Matthew J. Paylo, Nicole A. Adamson & Eric Baltrinic (2014)
Teaching Diagnosis in Context: Guided Imagery as a Contextually Sensitive Pedagogical Technique,
Journal of Creativity in Mental Health, 9:2, 275-291, DOI: 10.1080/15401383.2013.854190

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 Journal of Creativity in Mental Health, 9:275–291, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1540-1383 print/1540-1391 online
DOI: 10.1080/15401383.2013.854190

Creating Space for Connection: Creativity

in the Classroom

This column is designed to underscore relationally-based creative teach-

ing practices used by counselor educators in the classroom. Our intention
is to provide examples of novel, innovative ways for counselor educators
and students to deepen their learning while colloborating toward a spirit of
connection and cooperation. If you have implemented a creative teaching
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method, or if you have adapted an existing method that you would like to
share with readers, please follow submission guidelines in the author infor-
mation packet available at http://www.creativecounselor.org/Journal.html.

Teaching Diagnosis in Context: Guided Imagery

as a Contextually Sensitive Pedagogical
Technique

VICTORIA E. KRESS and MATTHEW J. PAYLO

Youngstown State University, Youngstown, Ohio, USA

NICOLE A. ADAMSON
University of North Carolina at Pembroke, Pembroke, North Carolina, USA

ERIC BALTRINIC
University of Toledo, Toledo, Ohio, USA

In this article, the authors present guided imagery as a tech-

nique for use in teaching counselor trainees how to use the
Diagnostic and Statistical Manual of Mental Disorders-Fifth
Edition (DSM-5) in a way that is sensitive to contextual issues
and counselors’ personal biases. Specific guided imagery activities
and scripts that can be used in teaching DSM-5-related concepts

Address correspondence to Victoria E. Kress, Department of Counseling and Special

Education, Youngstown State University, Beeghley Hall, Youngstown, OH 44555, USA. E-mail:
victoriaekress@gmail.com

275
 276 V. E. Kress et al.

are provided. Guided imagery can facilitate the development of

counseling students’ skills in the areas of case conceptualization,
cultural empathy, self-awareness, and objective diagnostic decision
making. Guided imagery scripts can enhance counselor trainees’
multicultural competencies as related to the diagnostic process.
Practical considerations related to using the technique are pro-
vided.

KEYWORDS DSM-5, diagnosis, teaching, multiculturalism, cre-

ativity in counseling
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The Council for Accreditation of Counseling and Related Educational

Programs (CACREP, 2009) requires that clinical mental health counselors
and addictions counselors receive training in the use of the Diagnostic
and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5; American
Psychiatric Association [APA], 2013; CACREP, 2009). Not only must counselors
be well versed in the use of the DSM-5, but they must also have an under-
standing of the multicultural implications associated with mental health
diagnoses. The American Counseling Association’s (ACA) Code of Ethics
(2005) emphasizes that culture influences the way that clients’ problems
are understood, which must be considered throughout the process of diag-
nosis. Related to this, the ACA’s Code of Ethics (2005) also states that
“Counselors recognize historical and social prejudices in the misdiagnosis
and pathologizing of certain individuals and groups and the role of mental
health professionals in perpetuating these prejudices through diagnosis and
treatment” (E.5.c.).
Multicultural considerations can have a significant impact on counselors’
diagnostic decision-making processes (Hays, McLeod, & Prosek, 2009).
Counselors’ decision making is inherently influenced by their lived experi-
ences, cultural values, and developmental differences (Kress, Eriksen, Rayle,
& Ford, 2005). Likewise, clients’ perceptions of their mental health difficulties
and the way they are presented to the counselor reflect their context, which
includes their cultural values, past experiences, and current developmental
level. In this sense, it can be purported that all counseling is multicultural
counseling, regardless of how similar or different the counselor–client pair
may appear (Sue & Sue, 2008). As such, to adhere to the ACA’s Code of Ethics
(2005) and the CACREP (2009) standards, diagnosis must be understood in a
multicultural context that identifies and addresses the complexity of human
diversity.
The ACA Code of Ethics (2005) is clear that counselors are ethically
required to be aware of their own biases and prejudices as well as clients’
contexts when diagnosing mental disorders. Accordingly, it is important that
 Teaching Diagnosis 277

counselor educators and supervisors apply dynamic instructional methods

that teach counselor trainees how to develop contextually and culturally
sensitive diagnostic skills. The DSM-5 is a substantial document spanning
more than 900 pages and containing upwards of 300 diagnoses (APA, 2013)
all with varied etiologies, contexts, gender, and multicultural considerations.
As such, it may be difficult for counselor trainees to comprehend the variety
of considerations, which need to be addressed when ascribing DSM-5 diag-
noses in a multicultural and contextually sensitive fashion (Eriksen & Kress,
2005).
Despite the importance of educating trainees on how to effectively
use the DSM-5, there is a paucity of research related to methods for
teaching the DSM-5 in general and from a multicultural and social con-
structivist perspective in particular. A review of the literature produced no
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articles related to useful techniques for teaching counselor trainees how to

use the DSM-5 in a culturally or contextually sensitive fashion. Innovative
pedagogical techniques that can help counselor educators and supervisors
enhance trainees’ knowledge of multicultural and contextual issues are
needed.
The use of innovative counselor education methods can help infuse a
social justice focus that addresses oppressive systems in counseling (Ratts
& Wood, 2011). More specifically, counselor trainees may benefit from an
increased awareness of their own internalized stereotypes and preconcep-
tions of people who have various DSM-5 disorders and how this impacts
their diagnostic decision-making process (Sue & Sue, 2008). An enhanced
understanding of clients’ experiences may help facilitate accurate diagnosis
and avoid the overdiagnosis and underdiagnosis of clients who do not fit
with the trainees’ internalized images or stereotypes, and it may ultimately
contribute to better consumer care.
In this article, we explore the benefits of using guided imagery as a
pedagogical technique to teach the DSM-5. The use of guided imagery as
a teaching technique may facilitate the development of counseling students’
skills in the areas of case conceptualization, cultural empathy, self-awareness,
and objective diagnostic decision making. Guided imagery scripts that can
be used in enhancing counselor trainees’ sensitivity to multicultural issues
as related to the diagnostic process are also provided. In this article, the
term instructor will be used to refer to counselor educators and supervisors
who are training their supervisees to use the DSM-5, and the term student or
trainee will be used to refer to students and supervisees.

CONSTRUCTIVIST LEARNING AND THE DSM-5

The task of teaching the DSM-5 to new counselors can be challenging;

logistics associated with reviewing criteria for almost 300 diagnoses in an
 278 V. E. Kress et al.

academic term requires diligent planning and time management on behalf

of the educator. Constructivist learning principles can provide a framework
for understanding effective ways to teach the DSM-5 from a contextually
sensitive perspective (McAuliffe & Eriksen, 2011).
Constructivist learning principles emphasize two primary principles: (a)
Understanding and knowledge are constructed rather than discovered, and
(b) knowledge is constructed internally and is affected by its social context
(Gergen, 1985). As such, knowledge cannot be separated from contexts such
as ethnicity, social class, and gender. Constructivist learning principles also
highlight the idea that trainees differ in their learning preferences, styles, and
needs, which parallels the varying learning preferences, styles, and needs of
clients and their myriad symptom presentations. Therefore, it is important
for instructors to implement various course structures and teaching styles to
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match a variety of trainee learning needs and to ultimately see that student
learning transferred to their work with clients.
Additional demand is placed on instructors when trainees are taught to
use the DSM-5 through a multicultural, gendered lens (Kress et al., 2005;
Roten, 2007). Multiculturalism can include common factors such as race,
religion, and gender as well as more elusive concepts such as family roles,
oppression, privilege, and culture (Roten, 2007; Sue & Sue, 2008). It is not
feasible to address every life experience that contributes to counselor and
client culture, but counselor educators have an obligation to introduce cul-
tural issues when teaching the DSM-5, and constructivist learning principles
can help to this end.
The DSM-5 can be taught through a linear and concrete approach
(e.g., lectures) or by using more creative techniques that are consistent
with a humanistic perspective (Kress & Eriksen, 2011; Raskin, Rogers, &
Witty, 2008). As trainees are likely to have very concrete questions regard-
ing the structure, organization, and function of the DSM-5, more concrete
approaches may be helpful when first introducing the manual. Then, to facili-
tate abstract and formal learning, instructors may utilize varied approaches to
address trainees’ multicultural competency. Instructors might consider imple-
menting constructivist teaching techniques that invite trainees to understand
the intricacies of differential diagnosis and how mental health symptoms and
impairments are manifested in clients.
One constructivist teaching technique that may enhance trainees’ ability
to understand the complexities of diagnosis is guided imagery. Researchers
suggest that guided imagery is an effective tool when teaching such complex
concepts as psychopathology, stroke rehabilitation techniques, and neona-
tal resuscitation procedures (Braun et al., 2008; Fernandes & Speer, 2002;
Patterson & Van Meir, 1996). Each of the aforementioned topics is intri-
cate, can be approached in a myriad of ways, and requires accuracy and an
expert understanding entwined with an ability to intuitively and practically
 Teaching Diagnosis 279

apply information. Guided imagery is a technique that can be utilized by

counselor educators and supervisors to help fulfill their obligation to be
effective instructors of the DSM-5.

GUIDED IMAGERY AS A PEDAGOGICAL TECHNIQUE

Throughout recorded history, guided imagery has been used in various

capacities and by various people including the Greeks in the times of
Hippocrates, Native American and Tibetan healers, Hindu sages, and even
Sigmund Freud and Carl Jung (Rossman, 2000). Essentially, guided imagery
involves utilizing all or some of a person’s senses through directed thoughts
and suggestions with the aim of leading the person toward an imagined
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relaxed state that enhances his or her ability to focus and attend.
Rossman (2000) suggested that guided imagery consists of assisting a
person with reaching a desired, relaxed state. Often this is done through a
scripted dialogue, paired with rhythmic deep breathing and muscle relax-
ation. Guided imagery also involves encouraging visualization that may
focus on relaxation, pain control, healing, mental rehearsal, and decision
making (Rossman, 2000). In the case of this article, guided relaxation and
visualization efforts focus on diagnosis and the diagnostic decision making
of counseling students.
The benefits of guided imagery are numerous and well documented
(King, 2010; Rossman, 2000). Guided imagery has been connected with an
increase in relaxation, a decrease in stress, a decrease in pain, increased feel-
ings of empowerment, and an increased ability to take on new perspectives
(King, 2010; Seligman & Reichenberg, 2010). Although guided imagery’s use
in teaching and education is still in an infantile stage, some research has
suggested guided imagery is helpful in vocabulary acquisition (Cohen &
Johnson, 2011), developing number skills (Rouse, 2009), and even in facili-
tating students’ ability to learn general concepts (Drake, 2003). In relation to
the diagnostic process, guided imagery can enhance contextually sensitive
decision-making abilities (King, 2010; Seligman & Reichenberg, 2010).

FACILITATING GUIDED IMAGERY ACTIVITIES

It is imperative for counselors in training to be able to take new perspec-

tives, especially perspectives that are sensitive to contextual factors related
to diagnosing. As such, guided imagery may be a useful tool for training and
educating counselors on the DSM-5 and its usage. In the following section,
guided imagery examples and scripts are provided as tools that can be used
in teaching DSM-5 concepts and diagnostic decision making. The scripts can
be modified to fit with any specific diagnosis or context. All of the provided
 280 V. E. Kress et al.

activities serve as examples and can be altered to fit the curriculum and
needs of the instructor or supervisor.

Introducing Students to Guided Imagery Exercises

The following is a script that can be used to introduce and describe guided
imagery to trainees:

In using guided imagery as a teaching technique, my intention is to sup-

port you in connecting with your thoughts, attitudes, and feelings as
they relate to using the DSM-5. This technique may or may not sup-
port you in better understanding the course material, but other students
have reported that this process has significantly improved their ability to
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relax and ultimately connect with their attitudes and feelings around. . .
(describe the aim of the chosen guided imagery technique). I am excited
about the benefits you may derive from this process. If at any time, you
feel uncomfortable with this process or with closing your eyes, please
feel free to stop the activity and open your eyes. I want to reinforce
that a grade is not associated with your participation in this activity and
that this technique is only being utilized to enhance your experience in
relation to the material.

Because counselor trainees may initially find it difficult to connect with

the visualizations and the sensory reactions that can accompany them, it
may be necessary to aid them in becoming relaxed and comfortable in the
classroom setting.

Inviting Students to Relax During Guided Imagery Exercises

What follows is a short relaxation script that can be utilized at the start of
any of the guided imagery techniques addressed in this article. The aim of
this script is to increase the trainee’s ability to relax and settle into the guided
imagery activity. It reads:

Please allow yourself to sink and settle into your chair. (Pause.) Feel
the chair as it wraps around you and as you attempt to find a com-
fortable position. (Pause.) Now begin to let yourself slowly drift off as
you do when you are falling asleep. (Pause.) As you begin to feel more
comfortable, allow your eyes to slowly close. (Pause.) Feel your eyelids
slowly slide down as if they are becoming heavier and heavier. . . feel the
relief of settling into your chair with an even more comfortable position.
(Pause.) As you become more relaxed, start to focus and pay increasingly
more attention to your breathing. (Pause.) Take a deep, slow breath. . .
and as you begin to exhale your breaths, begin to allow any tension to
 Teaching Diagnosis 281

be released through your breaths. (Pause.) Imagine that as you breathe

in, you are breathing in clean, fresh air that is filled with energy, hope,
and vitality. . . and as you exhale. . . you are pushing, casting out any
tension, grief, or discomfort that would seem to thwart your ability to
relax. (Pause.) As you continue to breathe deeply, envision that fresh air
is coming in through your nose then building with intensity down your
windpipe. . . eventually exploding into your lungs. (Pause.) Feel as the
newly filtered air is now being dispersed throughout your entire body.
(Pause.) Pay close attention to this clean air as it works its way to the
outermost regions of your body. . .

The aforementioned relaxation aspect of the guided imagery activities

should take between 5 min and 10 min.
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GUIDED IMAGERY TECHNIQUES

The guided imagery techniques presented in this article are divided into two
categories: stereotypes and diagnosis, and implications of having a diagno-
sis. The application of the various guided imagery activities discussed in
this article should take about 5 min to 15 min each depending on how
involved and detailed the instructor chooses to get with the application.
Explanations of the applications and questions that can be used in processing
are provided.

Stereotypes and Diagnosis

Trainees come to learn about mental disorders with various preconceived
notions about specific disorders (e.g., who has them, what these people
look like, prognosis, and additional associated characteristics). Related to
this idea, research suggests that diagnostic decision making is impacted by
counselors’ bias and stereotypes (Hartung & Widiger, 1998; Horsfall, 2001).
Increasing trainees’ awareness of internalized images of people with various
mental disorders may help alleviate stereotypes and broaden trainees’ ability
to effectively make diagnostic decisions.

Generic Stereotypes
Upon entering a counselor training program, many trainees have precon-
ceived notions of certain DSM-5 diagnoses and how they are manifested
in clients (Kress & Eriksen, 2011). Additionally, trainees interpret diagnostic
information in accordance with their individual abilities and the cognitive
tools to which they are accustomed (Hays et al., 2009).
 282 V. E. Kress et al.

GENERIC STEREOTYPE EXERCISE

In this activity, trainees are invited to close their eyes and the instructor
then describes the name and criteria of a given disorder. The trainees are
asked to develop an image of the person who comes to mind as the crite-
ria are discussed. Trainees are asked to consider the person’s race, gender,
socioeconomic status, and personal characteristics such as their style of dress
and personality traits. To enhance the exercise, sections of the DSM-5 that
describe the characteristics of a person with this disorder might also be
read (leaving out demographic characteristics). Once they open their eyes,
trainees can be asked to write down 10 characteristics of the person. A vari-
ation of this activity includes having the trainees draw a picture of this
person.
Related to this activity, the instructor might also share a story about a
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client whose situation conflicts with popularly held beliefs about a given
diagnosis (e.g., a middle-aged adult woman has attention-deficit hyperac-
tivity disorder without hyperactivity, was always a daydreamer in school,
and her diagnosis was always missed, but now that she has children, her
functioning has become impaired due to competing demands).

PROCESS QUESTIONS FOR GENERIC STEREOTYPE EXERCISE

Group process questions might include the following:

● What were the characteristics that you chose for that given disorder?
● What is the rationale for your answers—are they based on experience?
● Could an accurate diagnosis for an individual be missed due to your
preconceived notion?
● What was your reaction to the story that went against the norm with the
demographics of that given disorder?
● What can be done in the future to not fall into that diagnosing stereotype?

These process questions can provide a valuable opportunity for students

to become aware of and explore the origins of personal stereotypes about
specific diagnoses.

Stereotypes of Disorders
Counselors sometimes assign more severe diagnoses to clients who belong
to oppressed cultural groups (Hays, Prosek, & McLeod, 2010; Kress et al.,
2005). Additionally, there are certain diagnoses that are more often diagnosed
in one gender over the other (Eriksen & Kress, 2008; Hartung & Widiger,
1998; Horsfall, 2001). An awareness of internalized stereotypes of different
disorders may be helpful to trainees’ decision making.
 Teaching Diagnosis 283

DISORDER STEREOTYPE EXERCISE

In this guided imagery activity, trainee bias is explored and contextualized

in relation to mental health disorders. The counseling trainee is invited to
consider the following scenario:

On her 1st day at work as a new counselor, the counselor is confronted

with two extremely different clients: one client who is not as challeng-
ing and one who is challenging. With regards to the less-challenging
client, the counselor perceives the client as having a diagnosis that is less
difficult to manage.

Ask the trainee to conceptualize what diagnosis the client may have,
the age of this client, the client’s gender, and the client’s personality traits.
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Additionally, ask the trainee to provide the rationale for why he or she
believes this diagnosis would be less complicated to treat. Next, ask the
trainee to consider the second client as having a diagnosis that would be the
most difficult to, as a counselor, treat. Again, ask the trainee to conceptualize
this diagnosis, the age of this client, the client’s gender, and the personality
traits of this client. Encourage the trainee to explore his or her own reactions
to the client with this challenging diagnosis.

PROCESS QUESTIONS FOR DISORDER STEREOTYPE EXERCISE

Process questions for this activity might include the following:

● Why does the trainee perceive the diagnosis as difficult, and what exactly
would be the most challenging aspect of counseling this individual?
● Also, what is it about his or her own personality/culture/temperament/skill
set that makes this client feel challenging?
● How does the trainee plan to work with this population in the future?
● The trainee might also be asked to construct a personal growth plan to
address areas that will eventually enable him or her to more adequately
work with this client—or similar clients—in the future.

This activity can be useful in helping students to identify potential

trainee bias in diagnosis and to process personal reactions to working with
clients with challenging diagnoses.

Multicultural Stereotypes
Diagnostic error can result from the various ways in which culture affects
clients’ diagnostic presentation and counselors’ interpretation (Hays et al.,
 284 V. E. Kress et al.

2009). In fact, many counselors do not consciously integrate cultural factors

into their diagnostic considerations, but clients from oppressed populations
may receive more severe diagnoses than their less-oppressed counter-
parts (Hays et al., 2009, 2010). In the following multicultural activities,
trainees are encouraged to consider how cultural issues can relate to mental
health disorders. Descriptions and process questions are illustrated for each
activity.

MULTICULTURAL GUIDED IMAGERY EXERCISE 1: WALKING IN THE CLIENT ’ S

SHOES

The trainee is invited to consider a scenario in which he or she is experienc-

ing difficulty determining a diagnosis for a client from a different culture and
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brings this difficulty to the attention of a supervisor. The supervisor invites

the trainee to step into this client’s world and guides the trainee through a
day in the life of the client. The instructor may begin by having the trainee
wake from bed in the morning. For example, the supervisor or instructor
may ask the trainee process questions such as the following.

PROCESS QUESTIONS FOR WALKING IN THE CLIENT ’ S SHOES

What does the client see? What color are the sheets? What objects are in the
room, and is there a window? What does the client do next? Is the bathroom
clean? What objects are in the bathroom? The client pauses to look in the
mirror; what thoughts go through her head? Does the client eat breakfast?
Where is the kitchen? What is she wearing? Is there anyone else around?
What does she eat for breakfast? What is her goal for the day? What emotions
does she have as she thinks of the day ahead? What does she anticipate doing
during this day? What is she excited about today? What are some things that
will be difficult? Does she worry about anything in particular? Who will be
there to help her through the day? And, who will make her day difficult?
Further questions can be incorporated and students can be encouraged to
use their creativity to further describe the client’s day.
Continuing in such a pattern of visualization can allow the counselor
to gain a deeper understanding of the client’s presenting issues in the con-
text of culture and life circumstance. This may clarify areas of concern that
are related to the client’s culture and those that are more universal across
all cultures. Diagnosis-related issues may become clearer when they are
couched in the client’s day-to-day reality. The use of this activity may also
help counselors identify support systems for the client and individual client
strengths. This exercise may also allow the trainee to sift through the many
details provided by a client to identify what is currently relevant and helpful
to the counseling process.
 Teaching Diagnosis 285

MULTICULTURAL GUIDED IMAGERY EXERCISE 2: EXPLORING TRAINEE BIASES

In this second multicultural activity, a trainee’s bias is explored and
contextualized in relation to mental health disorders and culture. The trainee
is invited to consider the following scenario: A counselor is working with a
client who is grieving the loss of a loved one and is currently not able to
sleep, eat, or otherwise care for himself. The client’s loved one died more
than 3 months ago, and according to DSM-5 standards, this grieving is bor-
dering on psychopathology. The client describes a high level of anxiety over
the burial process and informs the counselor that his loved one has not yet
been buried. Stop the process, and ask the trainees to—in their mind—be
aware of their reactions to this client and the situation.
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PROCESS QUESTIONS FOR EXPLORING TRAINEE BIASES

What is the trainee thinking diagnostically? What questions might the trainee
ask to confirm a diagnosis? Now resume the story and relay that the client’s
family recently came to the United States from Kenya. This client informs the
counselor that in the Kenyan culture, it is common to mourn the death of a
loved one for an extended period of time. The trainees might be asked to
evaluate themselves on a scale of 1 to 10 (i.e., 1 = not at all and 10 = abso-
lutely) regarding whether they considered cultural implications pertaining
to death and burials as they evaluated the client. Trainees might be asked:
Did you consider that more information about the client’s culture and back-
ground would be needed before pathology was diagnosed, and how would
such information impact a diagnosis? Activities such as this can encourage
trainees to be mindful of cultural implications in diagnosis in the future.

Gender Stereotypes
Gender-specific stereotypes are also involved in diagnostic decision mak-
ing (Bijl, deGraaf, Ravelli, Smit, & Vollebergh, 2002; Eriksen & Kress, 2008;
Wetzel, 1991). Eriksen and Kress (2008) suggested that women are often
overdiagnosed with mental illness secondary to oppressive cultural circum-
stances and that oftentimes, cultural contexts are not thoroughly considered
before diagnoses are ascribed. Conversely, men are often diagnosed with dis-
orders that reinforce oppressive male stereotypes involving sex and addiction
(Eriksen & Kress, 2008). An enhanced understanding of trainee stereotypes
that relate to gender may be helpful in enhancing solid diagnostic decision
making.

GENDER STEREOTYPE EXERCISE

In this activity, gender stereotypes—as they relate to conceptions of nor-

mal and abnormal behavior—are explored and contextualized in relation to
 286 V. E. Kress et al.

mental disorders. This guided imagery activity can also highlight the values
inherent in the use of any classification of mental disorders. Trainees are
invited to imagine the following two cases: a man diagnosed with antisocial
personality disorder and then a man diagnosed with dependent personal-
ity disorder. Trainees are then asked to imagine a woman diagnosed with
antisocial personality disorder and, conversely, a woman diagnosed with
dependent personality disorder. Trainees are invited to consider their percep-
tions of men and women and how they differ even when they are diagnosed
with the same disorder. As a part of the guided imagery experience, the
instructor can walk the trainees through the DSM-5 criteria as they consider
these separate cases.

PROCESS QUESTIONS FOR GENDER STEREOTYPE EXERCISE

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Process questions for this activity might include: What are the personality
characteristics associated with a given disorder (i.e., antisocial personal-
ity disorder) and being a man? What are the personality characteristics
associated with a given disorder (i.e., antisocial personality disorder) and
being a woman? What similarities exist? What gendered differences emerged
in this activity? And, what effect could your perception of gender and gender
differences have on your ability to accurately diagnosis a given disorder (i.e.,
antisocial personality disorder)? These process questions can help trainees to
become more aware of their own biases related to gender that could impact
diagnosis.

Implications of Diagnosis
Various stigmas are associated with different DSM-5 diagnoses. As such, it is
important that counselors do not objectify clients and remember to exercise
empathy and cultural awareness when determining appropriate diagnoses
(Eriksen & Kress, 2005; Sue & Sue, 2008). An awareness of the implications of
receiving given diagnoses may help counselors in their diagnostic decision-
making processes (Eriksen & Kress, 2005).

CLIENT EMPATHY EXERCISE

The following activity is intended to encourage client empathy related to

diagnostic labeling. Trainees are invited to visualize and imagine what it
would be like to be ascribed a mental health diagnosis. They are then asked
to consider what diagnosis they would least like to be diagnosed as hav-
ing. They are asked to discuss attributional words that they associate with
each diagnosis (e.g., good, loveable, concerned, bad, lazy, weak, struggling).
The instructor then chooses several diagnoses and presents a richly contex-
tualized story of a person so diagnosed. The trainees then reconsider their
 Teaching Diagnosis 287

attributions and explore how their perspectives may have changed after the
whole person was considered. The following is an example of a narrative
that can be used:

Close your eyes and imagine you are a consumer of counseling ser-
vices. Visualize a counselor presenting you with his or her assessment of
your presenting problem. The counselor indicates that you have histrionic
personality disorder (or substitute any other disorder).

PROCESS QUESTIONS FOR CLIENT EMPATHY EXERCISE

Process questions that could be used with this activity might include: What
was it like to receive this information? What did this feel like? What questions
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or concerns did you have? What did you want to do with this information?
What did this information mean to you? How did this diagnosis make you feel
about the counselor? How did it change your perspectives on your life or on
possible solutions to your struggles? Were you concerned about how others
might relate to you if you had this diagnosis? Did you fear others’ reactions
if they found out about the diagnosis? And, who were you most concerned
about knowing you had this diagnosis? Trainees can become more aware
of the ways that clients may feel upon receiving a diagnosis, which may
foster empathy and impact the ways in which they diagnose clients in
the future.
Guided imagery can be helpful in assisting counselor trainees in iden-
tifying personal beliefs and stereotypes related to specific DSM-5 disorders
and in considering the implications of receiving a diagnosis. Instructors can
use the guided imagery techniques presented in this article to stimulate self-
exploration, foster empathy, facilitate the development of new perspectives,
and process personal reactions in trainees. These innovative pedagogical
techniques can help trainees to develop culturally sensitive diagnostic skills
and can therefore promote proper diagnosis and advocate for social justice.
Although incorporating guided imagery techniques into counselor training
can be beneficial, these exercises may not be appropriate for all trainees;
there are some risks involved.

CAUTIONS AND DISCLAIMER FOR INSTRUCTORS

Closing one’s eyes is a normal part of most guided imagery techniques

(Heinschel, 2002; Rouse, 2009). Some trainees may become psychologically
activated when closing their eyes during an imagery activity (Arbuthnott,
Arbuthnott, & Rossiter, 2001). As such, the instructor should provide trainees
with a qualifying statement that participation in the activity is voluntary and
 288 V. E. Kress et al.

if for any reason they feel uncomfortable, they can stop participation in the
activity and open their eyes. It should also be reinforced to the trainees that
this technique will not be tied to a grade and that it is only being utilized
to enhance their experience and ability to connect with the course mate-
rial. The instructor can also concede that to derive the most benefit from the
techniques, the trainees will need to maintain sustained concentration and be
able to appropriately relax into the activity. After these concerns have been
addressed, the instructor may want to encourage each trainee to approach
guided imagery with an open attitude.
This section presented several creative activities that can be used in
teaching counseling students how to sensitively apply DSM-5 diagnostic
concepts. The presented guided imagery descriptions are intended to raise
trainee awareness of the stigma associated with diagnosis and multicultural
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considerations and to highlight the value inherent in the use of any classifi-
cation of mental disorders. Exercises to increase trainee empathy to clients’
diagnoses, explore trainees’ biases, and address gender stereotypes were
also included. Cautions for instructors and a script to address any trainee
anxiety while participating in guided imagery exercises are also provided.
In the following section, general considerations related to this topic will be
presented.

CONCLUSION

In this article, guided imagery was presented as a technique that may

be helpful in teaching trainees about the nuances and complexities of
the DSM-5 ascription process. Guided imagery can be conceptualized as
a constructivist learning method that may help trainees develop a deeper
understanding of the diagnostic process. As presented in this article,
guided imagery may facilitate counselor growth in the areas of case con-
ceptualization, cultural empathy, self-awareness, and objective diagnostic
approaches.
When using any type of guided imagery, a good rapport, trust, support,
and mutual respect are factors that enhance one’s ability to optimally benefit
from the technique (Heinschel, 2002; Kwekkeboom, 2001). If trainees feel
comfortable, secure, relaxed, and unhurried, guided imagery will be opti-
mally successful (Scherwitz, McHenry, & Herrero, 2005). Trainees who do
not possess an ability to relax, those who are impatient, and/or those who
struggle to pull up images may have trouble optimally benefiting from this
teaching technique (Heinschel, 2002). As previously stated, it is important
that a relaxation exercise is used prior to using visualizations, as this will
help trainees relax, settle into the imagery activity, and ultimately benefit
from its use.
 Teaching Diagnosis 289

Future research should empirically evaluate the usefulness of guided

imagery as a teaching technique in general, and as a means of enhanc-
ing diagnostic decision-making processes in particular. Because there is a
lack of published research on this topic, qualitative research investigations
that examine trainees’ experiences and perceptions of using guided imagery
might be especially useful. Scherwitz et al. (2005) and Heinschel (2002) offer
suggestions for surveys and interviews that can be used in assessments
to measure the effectiveness of guided imagery techniques—assessments
that could be integrated into future research on the effectiveness of guided
imagery as a teaching tool.
Because the DSM-5 systems are difficult for many trainees to fully
comprehend (Eriksen & Kress, 2005), dynamic teaching methods that help
trainees understand both DSM-5 diagnoses and good diagnostic practices
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are needed. By implementing guided imagery as a pedagogical technique,

an instructor may be able to enhance trainees’ contextual sensitivity when
using the DSM-5 and reduce bias and prejudice concerning gender and cul-
tural stereotypes. Additionally, the use of guided imagery when teaching the
DSM-5 could begin to alleviate the stigma and lack of empathy sometimes
associated with the diagnostic process.

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Victoria E. Kress, is a Professor in the Department of Counseling,

Special Education, and School Psychology at Youngstown State University,
Youngstown, Ohio.

Matthew J. Paylo, is an Assistant Professor in the Department of Counseling,

Special Education, and School Psychology at Youngstown State University,
Youngstown, Ohio.

Nicole A. Adamson is an Assistant Professor in the Department of School

Administration and Counseling at the University of North Carolina at
Pembroke, Pembroke, North Carolina.

Eric Baltrinic is an Assistant Professor in the Department of School

Psychology, Higher Education, and Counselor Education at the University of
Toledo, Toledo, Ohio.