Unit 3- FoC - Process of Counselling.pdf

5TH SEMESTER BA PSYCHOLOGY (NEP) Foundations of Counselling Unit- III Process of Counselling Syllabus: The counselling process- Intake interview, assessment (Standardized and Non- standardized measures); sett...

5TH SEMESTER BA PSYCHOLOGY (NEP) Foundations of Counselling Unit- III Process of Counselling Syllabus: The counselling process- Intake interview, assessment (Standardized and Non- standardized measures); setting goals; contracting; informed consent; formulation; conceptualization; referrals; issues of confidentiality; verbatim recording and analysis; interpretation; termination and reporting. 1.0 THE COUSNELLING PROCESS 1.1 INTERVIEW: Any counselling process, be it individual or group, starts with the interview stage. This stage could also be referred to as the familiarization, orientation or introductory stage. This stage is very important because as a counsellor, to start well determines the success of other stages and the entire counselling relationship. The counsellor and the client meet for the first time. The counsellor makes deliberate effort to get acquainted with the client by establishing rapport. This is done by asking the client to sit down, so that he or she would be emotionally relaxed in the counsellor’s office. The counsellor makes inquiries about the client’s name, class, parents, friends, progress in school and his mission to the counsellor’s office. This should be done with caution so that the client does not feel as if he or she is being interrogated. The counsellor further assures the client that whatever is discussed will be kept confidential. This is to win the client’s confidence and make him or her open up to say his purpose for coming to the counsellors’ office. The client may or may not present his problem during this stage. The counsellor should not be in a hurry to make him/her disclose his mission. During this stage, the counsellor needs to display in his behaviour all the qualities of an effective counsellor by being patient to listen carefully, show empathy, show unconditional positive regards that is treating his clients with respect, warmth, irrespective of his age, sex, race, colour, religion and socio-economic status. This is very important as counsellors are not expected to be discriminative. The intake interview has three prime objectives: –Identifying, evaluating and exploring the client’s chief complaint and associated counselling goals –Obtaining a sense of the client’s interpersonal style, interpersonal skills, and personal history –Evaluating the client’s current life situation and functioning 1.2 ASSESSMENTS Assessment is an umbrella term for the evaluation methods counsellors use to better understand characteristics of people, places, and things. Assessment in counselling provides the counsellor with information to understand clients, and may be therapeutic in the clients’ self-understanding. People are complex, and assessments can provide the counsellor a broader and more accurate perspective of the client. Utilizing a broad range of formal and informal instruments and techniques in variety of circumstances assures the counsellor of having the appropriate information necessary for case conceptualization, treatment planning, on-going therapy and tracking progress. Assessments provide information for initial and on-going evaluation with minimal personal bias as well as the data necessary for effective interventions. Assessments help counsellors judge their own effectiveness and how the intervention affects the client (Wall, 2004). Furthermore, assessments can be therapeutic, offering objective information for the client's self-discovery and may engage the client in self-reflection, which can be valuable in maintaining psychological health (Whiston, 2008). Without utilizing appropriate assessments, counsellors may limit the quality of care they provide to clients. Assessment process in clinical mental health counselling involves four key steps (Drummond, Sheperis, & Jones, 2015): (1) Identifying the nature of problems/reasons for assessment (i.e. cognitive, behavioural, emotional, social, academic, or vocational). (2) Choosing and implementing methods of assessment/instruments for data collections (i.e. interviews, tests, observation). (3) Evaluating assessment information (i.e. scores, interpretation, and information integration including documenting findings, identifying convergent findings, explaining discrepancies, formulating a hypothesis, and making an assessment report). (4) Reporting results of assessment and making recommendations (i.e. description of assessed client, making a hypothesis, providing supporting methods and sources data, recommending possible solutions). Assessment procedures can be divided into two categories Standardized measures include psychological tests that have a standardized norm groups. Initial Assessment of Client's Self-Reported Symptoms Ongoing Case Conceptualization Non standardized measures not have a standardized norm group and include strategies such as the clinical interview and assessment of life history. Initial Intake and Information Gathering Continuous Client Assessment 1.3 SETTING GOALS: Goals are important for everyone, whether they are in therapy or not. Goals help navigate through life whether they are personal goals, professional goals, a goal to replace a bad habit or simply a goal for achieving success. As a counsellor, it is required to set expectations with clients. Research shows that counselling is much more useful when it involves having a set plan for what one hopes to achieve or accomplish. Setting goals can also give the counsellor a better grasp of client growth as they proceed with the counselling process. Goals are meant to both motivate and challenge the client so it’s critically important that your client be transparent and forthright with what they hope to achieve. Three functions that goals serves in the counselling process: a) Motivational: The clients are involved in establishing the counselling goals. They may be more motivated when they have specific, concrete goals to work toward. It is also important for counsellors to encourage clients to make a verbal commitment to work on a specific counselling goal. b) Educational function: From this perspective, clients can learn new skills and behaviours that they can use to enhance their functioning. For example, a counselling goal might be to become more assertive. During assertiveness training clients can learn skills to enhance their functioning in interpersonal situations. c) Evaluative function: Clear goals allow the counsellor and client an opportunity to evaluate progress. Process Goals: This establishes the conditions necessary to make the counselling process work. These goals relate to the issues of formulating positive relationship by promoting the core conditions. Process goals are primarily the counsellor’s responsibility. Outcome goals: This specifies what the client hopes to accomplish in counselling. The counsellor and client should agree on these goals and modify them as necessary. Five types of outcome goals: 1. Facilitating behaviour change: Some form of behaviour change is usually necessary for clients to resolve their concerns. The amount of change varies from client to client. For example, one client might need counselling to learn how to deal effectively with a child, while another might require psychotherapy to change an unhealthy, stressful lifestyle. 2. Enhancing coping skills: Several developmental tasks and associated coping mechanisms unique to the various stages of development. Coping skills are necessary to proceed through the life span. For example, intimacy and commitment are developmental tasks of young adulthood. Coping behaviours necessary to meet these developmental tasks include appropriate sexual behaviour, risk-taking behaviour, and value-consistent behaviour such as giving and helping. Client’s may have problems dealing with stress, anxiety, or a dysfunctional lifestyle. In these situations, clients may benefit from a stress management program that includes relaxation, meditation and exercise. 3. Promoting decision-making: Some clients have difficulty making decisions. They may feel that no matter what they decide, it will be wrong. They may even think that they are going crazy. Difficulty making decisions is often a normal reaction to stressful life situations. In these situations, the counsellor may want to reassure clients that they are not going ‘crazy’; helping clients feel normal can encourage them and alleviate unnecessary worry. 4. Improving relationships: A person who did not have a close relationship with anyone was at risk for mental problems. Counsellors can use a variety of counselling strategies to help clients improve their interpersonal relations. These strategies include social-skill training programs; group counselling that focuses on interpersonal relations; couple therapy; and marital therapy. 5. Facilitating the clients potential: Goals in this category are more abstract and relate to the concepts of self-realization and self-actualization. Self-realization implies helping clients become all they can be as they maximize their creative potential. There can be roadblocks to self-realization that require the counsellor’s attention. In these instances, the counsellor can help clients gain a more realistic understanding of what is required to be successful. Self- actualization is related to the need to fulfil one’s potential. Maslow believed that as peoples basic needs were met, they would move toward self-actualization. 1.4 CONTRACTING: The Counselling Contract is a mutual agreement negotiated between the Counsellor and the Client prior to the commencement of counselling. It articulates the responsibilities of the Counsellor and Client in the context of the therapeutic relationship they are going to undertake together. Confidentiality This is a key aspect of the counselling relationship. Everything discussed in the counselling sessions is kept in the strictest confidence#. From time to time the counsellor may need to share and discuss some of the information in our sessions with a qualified supervisor, always under a strict confidential and professional framework. The client identity is always kept anonymous. #Confidentiality can only be broken when there is evidence that the client may harm him/ herself or others. In this case the counsellor will most likely contact the appropriate services. The client will be informed in advance, and only in case of an imminent threat might the counsellor make this decision without consulting the client. Information of any medical treatment must be disclosed to the counsellor at the beginning of the sessions. Sessions: Sessions are usually 50 minutes long and held on a weekly basis*, although this can be negotiated to suit specific requirements. If the client’s circumstances change and the session time and day are no longer suitable the counsellor will try to offer alternatives more convenient to the client. Sessions will not take place if the client is under the influence of any misuse of alcohol or substances. Duration of Counselling The duration of the therapeutic process will depend on the type of difficulty or problem the client is facing. Some people prefer to work with an open contract, whereas other people prefer to work with a fixed number of sessions. Fees Fees will be agreed prior to the initial meeting. Payment options Payment for each session is to be received via cheque or cash at the beginning of each session. Cancellations and Holidays Cancellation of sessions with less than 48 hours’ notice will incur the full fee. The counsellor will always aim to give the client as much notice as possible of any holidays, training workshops, conferences or illness that might prevent her from being available at the time/day of the scheduled session End of the Contract Indications and signs that the therapeutic process is coming to an end. Sometimes the client may feel that counselling is not helping. In these circumstances it is best to discuss the difficulties rather than abruptly end counselling. This could evoke a sudden- loss experience that would not have the opportunity to be understood and resolved. In such circumstances the counsellor asks that the client give one week’s notice before ending counselling to have the chance to discuss the decision and to complete the process adequately. The client is always in charge of the decision to continue or stop counselling and will not be under any pressure to continue at any point. Contact outside the sessions: The phone number and email address provided are to be used exclusively for cancellations, changes or in case of emergency. 1.5 INFORMED CONSENT: Informed consent is the process of informing a client, patient, or research subject of the risks, benefits, expected outcome of a research project, medication, medical procedure, or therapeutic approach in which they have agreed to take part. The process of informed consent involves three parts: 1) The therapist must communicate the nature, risks and benefits of the procedure, treatment, research or any other eventuality that the client is consenting to. This also includes authorizing the therapist to release information, communicate by email, record a session, etc. At this phase the client gets to ask questions and be engaged in a dialogue or discussion with the therapist. The therapist should also outline feasible alternatives to the treatment (if there are any) and emphasize the element of choice (if there is any), so the client is clear on all options. 2) The therapist must evaluate whether or not the person has the capacity to understand the information and is competent to make an informed decision regarding his/her healthcare and treatment or other occurrences. Once this has been determined, and the therapist has provided the necessary information, the therapist must determine whether or not the information provided was understood. The therapist must be able to ensure that the client clearly understands and accepts the risks inherent in the procedure, release, or treatment. 3) Finally, the client must acknowledge the s/he has been informed and expresses their consent in some way. Types of consent: Expressed or Presumed Explicit or Implicit Verifiable or Conjectural Written, Verbal or Non-Verbal 1.6 FORMULATION AND CONCEPTUALIZATION: The ability to gather and interpret information, apply counselling and developmental theories, understand diagnostic frameworks, and engage in collaborative treatment planning are all important parts of the counselling process. Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers. It can be best understood as co-constructing the personal meaning of the client’s life story. It is ‘a process of ongoing collaborative sense-making’ (Harper and Moss 2003) which summarises the client’s core problems in the context of psychological theory and evidence and thus indicates the best path to recovery. Unlike diagnosis, it is not about making an expert judgement, but about working closely with the client to develop a shared understanding which is likely to evolve over the course of the therapeutic work. And, again unlike diagnosis, it is not based on deficits, but draws attention to talents and strengths in surviving what are nearly always very challenging life situations. Case conceptualization refers to how professional counsellors understand the nature of clients’ concerns, how and why the problems developed, and the types of counselling interventions that might be helpful. The ability to develop a case conceptualization can be considered a primary skill and a core competency for therapists (Eells et al., 2005; Betan & Binder, 2010). Case conceptualizations inform how therapists think and act in the therapy room. Sperry (2010) explained the importance of developing a case conceptualization as follows: “Basically, a case conceptualization is a method and process of summarizing seemingly diverse clinical information about a client into a brief, coherent statement or ‘map,’ which elucidates the client’s basic pattern and which serves to guide the treatment process” (p. 109). These maps allow for the active pursuit of information, integration of the data gathered from the family, and the implementation of a strategy of action. Case conceptualization refers to the way that professional counsellors make meaning out of the information they have gathered. Formulating a case conceptualization involves the following stages: Stage 1: a) Understanding the client’s background information b) Understanding and exploring presenting issues and symptoms c) Mental Status Examination of the client d) Assessing the type of help required Stage 2: Develop formulation a) Understand how issues develop b) Understand how issues are currently maintained c) Identify patterns and themes associated with the information gathered of symptoms Stage 3: Develop cultural formulation a) Understand cultural impact b) Take into consideration ethnicity, Socio-economic status, region, family structure, trauma and/or sexual and gender orientation impact a client’s presenting concerns Stage 4: Develop Treatment formulation a) Develop plan of action b) Employ strategy based on therapeutic model 1.7 REFERRALS: As community service workers one will often find oneself in situations where you can’t provide an appropriate or on-going service to your clients. It also might be because you don’t have the skills necessary to deal with certain issues such as child abuse, sexual assault, marital issues, loss and grief and so on. It is important to realize that acknowledging you haven’t the necessary skills isn’t a sign of failure but rather a professional assessment of your strengths and weaknesses. By referring a client on to someone who can help them with their particular issue you are effectively meeting your client’s need and thus helping them move a step closer to resolve whatever is troubling them. As a general principle regarding when to make referrals, make them if: you are in doubt of your own capabilities, you’re over-identifying with your client  you know or suspect that another agency or professional is more appropriate for a particular client. Referral means putting people in touch with services that have the resources to help them achieve their goals. It is not just about handing out a number. You are responsible for bringing the person and the service together. Making referrals is a serious decision with significant implications and thus needs to be considered carefully. Referral barriers include client reluctance, restrictions imposed by insurance companies, unavailability of counsellors in a specialist area, and an inability to make prompt referrals for personal or agency related reasons (Tallent, 2011). Successful referral rests on the quality of the counsellor’s interaction with the client, and whether the counsellor has been able, with the client, to identify the client’s needs. It is then essential to refer sensitively since clients could see it as a form of rejection, an indication that they can’t be helped, or a betrayal of trust. Presenting clients with the options available to them and accept if they choose not to accept that referral. While also explaining the rationale for making the suggestion so that they do not feel rejected and can understand counsellor reasoning, while also empathizing with their own rationale for not wishing to take up the referral. 1.8 CONFIDENTIALITY: Client confidentiality is the requirement that therapists, psychiatrists, psychologists, and most other mental health professionals protect their client’s privacy by not revealing the contents of therapy. A patient who doesn’t trust the counsellor is unlikely to be honest about their feelings and problems, so he or she may never receive the necessary help to cope with these issues. Such a patient may be reluctant to really try any coping strategies or treatments that are recommended. Confidentiality includes not just the contents of therapy, but often the fact that a client is in therapy. It is common that therapists, for example, will not acknowledge their clients if they run into them outside of therapy in an effort to protect client confidentiality. Other ways confidentiality is protected include: Not leaving revealing information on voicemail, and seeking client permission before leaving any information at all on voicemail Not acknowledging to outside parties that a client has an appointment Not discussing the contents of therapy with a third party without the explicit permission of the client. Exceptions to Confidentiality: The most common includes when a client is a threat to himself/herself or others, in which case a therapist must notify the person in danger or notify someone who can keep the client safe. In these circumstances, therapists often seek hospitalization for their clients.  Therapists also have to reveal information about treatment to insurers in order for their clients’ treatment to be covered, but they do not reveal any more information than is necessary to ensure coverage. Typically, the information revealed is limited to the diagnosis being treated and any medications required. The confidentiality of children is a hotly contested issue. Because minors cannot consent to treatment, they do not have the strong confidentiality rights that adults have. However, this can interfere with the treatment process; so many clinicians seek the permission of their minor clients’ parents to keep therapy confidential. Even when parents do not agree to confidentiality, therapists will not typically reveal mundane discussions in therapy; instead, they will give information about broad treatment goals and progress. Counsellors need to be aware of laws such as The Protection of Children from Sexual Offences (POCSO) Act that make the reporting of violations mandatory, and also of the debates around mandatory reporting in order to ascertain their own position. 1.9 VERBATIM RECORDING: Counsellors take notes to refresh their memory, to remind themselves to carry out an agreed- upon plan, to show what they have done or left undone, and to discuss the content of the session with professional colleagues (Benjamin, 1981). In addition, note-taking during counselling sessions is often helpful to meet clinical and legal requirements to document case activity (Gutheil& Hilliard, 2001). Clinically, notes provide chronicles of clients’ treatment, which help counsellors to look back and assist other counsellors or clinicians in continuing the treatment in the absence of the original therapist. Counsellors maintain records in sufficient detail to track the sequence and nature of professional services rendered and consistent with any legal, regulatory, agency, or institutional requirement. They secure the safety of such records and create, maintain, transfer, and dispose of them in a manner compliant with the requirements of confidentiality and the other articles of this Code of Ethics. This can include: Basic information - name, address, telephone number of client(s) - name and phone number of persons to contact in case of emergency - name of referring agent/agency; Record of each professional contact - date of contact, length, name(s) of all present - counselling information sufficient to keep track of counselling issues and progress, correspondence, reports, third party information, informed consent forms; Record of consultations regarding client, including telephone calls, e-mails, and Fees charged, if any. In a Verbatim Report, the dialogue should be reported as accurately as possible, but there can be a wide range of expectations as to the precision of that reporting because there are different styles of Verbatim. True Verbatim format records every “ah,” “um,” and other non-verbal auditory information; Intelligent Verbatim filters out unnecessary filler words, environmental sounds, and non- verbal input; and Summary Verbatim captures the essential ideas within a conversation. For accuracy, the first two types are often done by transcribing a recorded conversation. Usually, a Summary Verbatim is written from a participant’s memory soon after a conversation. 1.10 TERMINATION: Termination is the final stage of counselling and marks the close of the relationship. Termination is the counsellor and the client ending the therapeutic alliance. The termination stage can be as important as the initial stage in that it is the last interaction many clients will have with the counsellor. If the termination leaves on a sour note, then the client may look back on the time as a waste of effort and resources. If the termination goes well, then this has a multiplying effect, as the former client sees that their time was well spent and this will be one more person who is helping reduce the stigma of mental health. Ideally, termination occurs by mutual agreement when the goals set are achieved to the satisfaction of the client and counsellor. At this stage, the client should have a deeper level of elf-understanding and better coping skills. A positive termination can provide the client with a sense of ‘mastery and fulfilment’. Termination can also be a result of- independent decision of the client, unavailability of counsellor or other institutional factors. When clients voluntarily end counselling prematurely, they do so for two reasons- they have accomplished what they set out to do (even if the counsellor views it differently), or they feel dissatisfied with the counselling or counselling relationship and want to explore other options for solving their problems (Renk & Dinger, 2002; Todd, Deane &Bragdon, 2003). This highlights the need for active collaboration with the client. Readiness for termination: Signs for readiness include positive and identifiable changes in the client’s mood and behaviour, consistent reports of ability to cope with stress and clear expressions of commitment to verbalize plans for the future. Important, but less obvious signs include a sense of relief and an increase in energy. These signs of readiness for termination begin to appear before the final session, and counsellor need to prepare the client for termination before the last appointment. The amount of preparation required largely depends on the intensity and length of the counselling relationship. Regardless of the exact length of time devoted to termination, it is best to conceive of it as a process rather than a single event or session. Marx & Gelso (1987) suggest that clients experience more positive feelings of termination (calmness, health and satisfaction) more commonly than negative feelings. Readiness for termination may not be so easy to determine. The general principle is that if a client shows strong signs of insecurity about being able to maintain changes, he/she may not be ready for termination. This may suggest the need to explore other themes as part of the second-stage, or there is a need for more practice with interventions with third-stage work. Sometimes, termination can be an emotional experience- especially true when high-levels of intimacy is established and problems are related to dependency, intimacy or traumatic loss. Letting go under these conditions may cause the client to feel a sense of loss. Scheduling a follow-up session in the future may relieve some of the client’s fears about independently handing their issues. Counsellor responses to termination: According to Nystul (2003), ‘the ultimate goal in counselling is for counsellors to become obsolete and unnecessary to their clients’. Counsellors who are rewarded by helping others may be resistant to separation that comes with termination. Kovacs (1965), Mueller & Kell (1972) and White (1973) suggested that people who choose counselling as a career may be especially high in needs for intimacy, giving nurturance, gaining acceptance, and receiving acknowledgment for their competence. These needs that motivate people to become counsellors may create barriers when it is time to let go. It is not appropriate for counsellors to postpone termination in order to continue having their needs met. This stance violates the basic ethical principles of the profession- to do good and avoid harm. The final Counselling session is usually dedicated to three tasks (Marx & Gelso, 1987): i. Looking back- involves reviewing the major themes, changes and critical moments that have occurred during counselling. This includes helping the client gain deeper insight into the progress made during the counselling process. The counsellor may also offer honest expressions of support to encourage the client to maintain the changes implemented. ii. Looking forward- the counsellor helps the client with future developments and cope with unavoidable stress and minor setbacks that might occur. Normalising setbacks allows the client to mobilise new skills and respond effectively. iii. Saying goodbye Ending in a positive way: ✓ Remind clients of the approaching ending of the sessions with you. This should be done at least 2-3 sessions prior to the final one. This provides you an opportunity to ask clients to talk about relationships that have ended in their past, how they have ended, and how that might affect the end of this counselling relationship. You can also ask clients what they would like to focus on during their remaining time with you. ✓ If you and your client are not limited to a certain number of sessions, you have the option of spacing out your last few meetings. This is a good way to wean your client of the relationship and foster in them a sense of confidence in their ability to handle things without seeing you on a weekly basis before the relationship abruptly ends. ✓ Review the progress that you and the client have made during your sessions. Very often, clients will forget the advances they have made, or neglect to give themselves credit for their accomplishments. Doing this with them can instils confidence and provide them with a positive perspective on what counselling helped them to do. ✓ Allow clients to talk about their feelings surrounding termination. They will likely have many emotions to work through and time should be spent acknowledging and processing them. ✓ If possible, have an open-door policy. Once termination has ended, clients may want to return a few months or years later to refocus or to "check-in". The request for follow-up contact not only provides the counsellor information about long- term effectiveness of counselling strategies, but also provides the client a sense of respect and caring.