Counselling Procedure/Skills

Hitha.P.S II MSc Clinical Psychology

Counselling - Definition

An interactive process characterized by a unique relationship between the counselor and client that leads to change in one or more of the following areas: Behavior Beliefs or emotional concerns relating to perceptions Level of emotional distress

Counseling Process Structure

Rapport and Relationship Building 2. Assessment / Problem Definition 3. Goal-setting 4. Initiating Interventions 5. Termination
1.

Rapport and Relationship

Psychological climate resulting from the interpersonal contact of client and counselor. Living and evolving condition. Relationship includes respect, trust, and relative psychological comfort. Impacted by Counselors personal and professional qualifications. Clients-interpersonal history, anxiety state, interrelation skills, and previous ability to share,

Clinical Assessment
Involves specific skills

Observation Inquiry Associating facts Recording information Forming hypotheses (clinical hunches)

Observation
1. 2. 3. 4. 5.

Take notice of the clients general state of anxiety. Establish sense of clients cultural context. Note gestures / movements that denote emotional / physical dysfunctions. Hear how the client frames his / her problems. Note verbal and non-verbal patterns.

Formal Diagnostic Assessment

Interview format:
Focus

Basic

Screening Questions Detailed Inquiry

Focus Presenting problem and context

Basic Questions What concerns brought you here? Why now? Has this happened before? How is it impacting your daily life? Detailed Inquiry Clarify stressors Elicit

coping skills, social support, and resources Clarify life function work family health intimacy

Focus Mental status

Basic Questions

How do you feel now? How is your mood affected? Had any unusual experiences? How is your memory? Do you think that life isnt worth living?

Detailed Inquiry Note

age & mannerisms dress & grooming orientation

Probe
anxiety symptoms form, content, thought. suicidal ideation violent impulses

Focus Developmental history and dynamics

Basic Questions How would you describe yourself as a person? Shift to the past, how were things when you were growing up? Detailed Inquiry Clarify
current self-view level of self-esteem personality style

Note
developmental milestones experience in school best friends educational level

Focus Social history and cultural dynamics

Basic Questions What is your current living situation? What is your ethnic background?

Detailed Inquiry Elicit

job or military legal problems social support system race, age, gender sexual orientation religion language dietary influences education

Focus Health history and behaviors

Basic Questions Tell me about your health? Health habits? Detailed Inquiry Identify
prescriptions substance usage health status health habits

Focus Client resources

Basic Questions How have you tried to make things better? Results? How do you explain your symptoms? What is your / my role in your treatment? When will things change / get better? Detailed Inquiry Probe
Efforts to change Efforts vs. successes

Clarify client explanatory model Identify treatment expectations Specify readiness for change

Focus Wind down and close

Basic Questions What else would be important for me to know? Do you have any questions for me? Detailed Inquiry Use an open-ended query
Allows the client to add information. Creates sense of reciprocal and collaborative relationship.

Conceptualizing Problems

1.

2.

Recognize a client need. Understand that need. Meet that need. Beliefs may Contribute to the problem. Impede the solution. Become the problem. Feelings / responses often Exaggerate the problem. Impede comprehension of the problem. Become the problem.

3. Behavior / responses may Be inappropriate. Contribute to the problem. Complicate the problem. 4. Interaction patterns include Miscommunication channels, Expectations, Self-fulfilling prophesies. Coping styles. 5. Contextual factors Time Place Cultural and socio-political issues.

Goal Setting
1. Indicates how well counseling is working. 2. Indicates when counseling should be concluded. 3. Prevents dependent relationships. 4. Determines the selection of interventions. 5. Mutually defined by the client and counselor.

Counselor Greater objectivity Training in Normal and Abnormal behavior Process experience

Client Experience with the problem History of the problem Potential insights Awareness of personal investment in change

Process goals Related to establishing therapeutic conditions for client change. Includes: Establishing rapport, Providing a nonthreatening setting, and Possessing and communicating accurate empathy and unconditional regard.

Outcome goals Are different for each client and directly related to clients changes. Always subject to modification and refinement. To begin, formulate tentative outcome goals. Modify goals as needed to support effective change.

Interventions

Objective -- initiate and facilitate client change. After assessment and goals setting, answers the question, How shall we accomplish these goal? Must be related to the problem. Selecting an intervention may become an adaptive process. Skills to initiate include 1.Competency with the intervention; 2.Knowledge of appropriate uses; 3.Knowledge of typical client responses; 4.Observation skills to note client responses.

Termination

1. 2.

No clear cut ending, but no need to continue beyond usefulness. Awareness by the counselor and the client that the work is accomplished. May take the same number of sessions as rapport building. Types of Termination Suggested termination, with client agreement Imposed termination Continuing is against client best interest Client is deteriorating, not progressing Incompatibility with the therapist Client using therapy in place of life

3. Situational termination Client moves Employment changes 4. Early termination, clients just dont return. Methods Gradual tapering off of sessions. Therapeutic vacations, taking a break without breaking the connection.

Direct (imposed) termination.

Basic skills of Counselling

Listening is not passive. It is important to indicate that the person is being heard Good counselling skills means listening before acting to solve problems Verbal listening skills

Show interest Gather information Encourage speaker to develop ideas Communicate our understanding of ideas Request clarification of understanding Build the therapeutic alliance

Listening Skills

Using good verbal listening skills, you increase the chances that: You will understand what the other is saying and they will understand you You will create a situation where you will be able to develop a helping relationship

Non verbal attending and observation

1. 2.

3.

4.

5.

Take notice of the clients general state of anxiety. Establish sense of clients cultural context. Note gestures , movements that denote emotional / physical dysfunctions. Non verbal behavior include eye contacts, head nods, facial discrimination, body posture and physical distance between counselor and client Hear how the client frames his / her problems. Note verbal and non-verbal patterns.

A Good Listener

Maintains eye contact Makes few distracting movements Leans forward, faces speaker Has an open posture Allows few interruptions Signals interest with encouragers and facial expressions

Bad listening

Makes little eye contact Makes distracting movements Faces away from speaker Has a closed posture (eg:arms crossed) Interrupts speaker Does too many other things while listening Has a flat affect, speaks in a monotone, gives few signals of interest

Looking Like Your Listening is Not Enough

Responding
Ask

open and closed questions Use encouragers Paraphrase what you have heard Reflect on feeling Summarize

Asking questions Open Questions

Open questions Generally start with what, how, why or could Questions serve to: Gather lots of general information Encourage discussion Eg: Nurse: How has the baby been eating? Nurse: What is the bedtime routine? Nurse: Could you tell me about giving the baby medicine in the morning?

Closed Questions
Generally start with is, are, or do Serve to: Gather lots of specific information quickly Tend to close down discussion Eg: Nurse: Are you giving the medicine every day? Nurse: Is the baby able to tolerate the medicine in the morning?

Encouragers

There is a category of responses that fall between non verbal attending and actual responses ,termed by Ivey & Ivey(1999) as minimal encouragers. Eg: Yes, I understand or repeat a word or two of what was said, uh-huh, hmn hmnand?and then..? Serves to: Encourage further discussion

Reflection of Feelings

Focus on feelings (stated and unstated) Serves to: Communicate understanding of emotions When combined with a paraphrase, confirms the accuracy of understanding (Check out the the other person) Encourages discussion of feelings

Paraphrasing

Briefly summarize the content of the discussion Reflective listening

Check your understanding Show that you heard what was said

Acknowledge and accept feelings without judging Eg: Patient: I am worried that the medicine is making my baby sick Nurse: It sounds like you are worried about how the baby is reacting to the medicine.

Summarizations

Finally pull together ideas from the interview Serves to Organize the structure of the interview Check the accuracy of understanding

Influencing or Changing Behavior

Influencing or Changing Behavior

Directives Reframes and interpretations Advice Feedback Logical consequences

Directives

Requests to clients to perform some actions. Counselors might give home assignments to keep track of times when clients felt on the verge of losing control or to note what conditions seemed to lead to a greater sense of productivity at work. Works best if clear and concrete Serves to: Move a person to take a specific act

Reframing and Interpretations

Attempts to replace an old, maladaptive response with a newer, more useful (usually positive) one Serves to Increase insight and understanding Shift emotional or intellectual response

Advice
Provides information to help client make a decision. Can be very directive or less so Serves to: Share information that would be relevant for a persons decisions, actions, or understanding Disadvantages of advice Its often disempowering (You cant solve this on your own) People may say (but not really mean) that they want advice

Feedback
Gives information about how the person is experienced by others Serves to: Help client see self more objectively (as others see him or her) Feedback works best when It is requested or desired It is concrete It is positive If negative, it addresses something changeable or controllable

Logical Consequences
Focuses on the logical consequences of a persons behavior, actions, thoughts, or feelings Serves to:

Increase awareness of consequences

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