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

1. Rapport and Relationship Building

2. Assessment / Problem Definition

3. Goal-setting4. Initiating Interventions5. Termination

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 Counselor’s personal and professional

qualifications. Client’s-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”)

Observation1. Take notice of the client’s general

state of anxiety.2. Establish sense of client’s cultural

context.3. Note gestures / movements that

denote emotional / physical dysfunctions.

4. Hear how the client frames his / her problems.

5. Note verbal and non-verbal patterns.

Formal Diagnostic Assessment

Interview format:

FocusBasic Screening QuestionsDetailed Inquiry

FocusPresenting 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 isn’t

worth living?

Detailed Inquiry Note

– age & mannerisms– dress & grooming– orientation

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

FocusDevelopmental 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

FocusSocial 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

FocusHealth history and behaviors

Basic Questions Tell me about your

health? Health habits?

Detailed Inquiry Identify

– prescriptions– substance usage– health status– health habits

FocusClient 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

FocusWind 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

Recognize a client need. Understand that need. Meet that need.1. Beliefs may

• Contribute to the problem.• Impede the solution.• Become the problem.

2. 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 andAbnormal 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 non-

threatening 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.

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 Termination1. Suggested termination, with client

agreement2. Imposed termination

• Continuing is against client best interest• Client is deteriorating, not progressing• Incompatibility with the therapist• Client using therapy in place of life

Termination

3. Situational termination• Client moves• Employment changes4. Early termination, clients just don’t

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. Take notice of the client’s general state of anxiety.

2. Establish sense of client’s cultural context.3. 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

4. Hear how the client frames his / her problems.

5. 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 heardReflect 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 hmn””and…?”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 person’s decisions, actions, or understanding

Disadvantages of advice It’s often disempowering (You can’t

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 person’s behavior, actions, thoughts, or feelings

Serves to: Increase awareness of consequences

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