PROCESSES INVOLVED IN COUNSELLING
Counsellors who are new to the field often do not know how to begin counselling, or what to do with the client after the initial few sessions. Often, counsellors-intraining lose their direction during therapy. It has also been observed that counsellors do not know how to identify when the process of counselling is approaching its end.
This section therefore presents a bird's view of the counselling process, from start to finish. The beginning and the end are considered in special depth because techniques for the middle phase of counselling are discussed in detail. After completing this you will be able to understand:
• the process involved in counselling;
• how a counsellor can learn to structure the course of therapy; and
• how a counsellor can locate his position and progress during the treatment process.
As more and more people with HIV are being detected, the need for counselling has become ever more increasing. Counselling can help the HIV infected to live a life of dignity and also help to prevent further spread of the infection. In fact, anyone who feels that he has been involved in risky behaviour, which can cause HIV infection, needs counselling. Similarly, those who have been already infected require counselling services, which will enable them to plan their future course of action to live a meaningful and productive life. In the previous Unit, we discussed the concept of counselling, the characteristics of a counsellor in various settings as well as about the possible characteristics of the client which suggest a favourable
outcome. In this unit let us concentrate on the process involved in counselling while dealing with various scenarios that are likely to arise during counselling.
Counselling comprises the following processes:
• Phase One: The IIiitial Interview
• Phase Two: The Assessment
• Phase Three: The Middle Phase .. Phase Four: The Termination
2.2 THEINITIAL INTERVIEW
The initial interview describes the first contact with the client who is the individual in need of counselling. It completes the intake process, a sort of admission of the client into the formalities of counselling.
Importance ofthe Initial Interview: The initial interview is of much importance for several reasons:
1) It helps the counsell or get to know the client better, and make appropriate plan for intervention. These plans include taking up the client for counselling or referring the client to another, appropriate, treatment service.
2) It helps the client to get to know the counsellor better, and to obtain reassurance and even crisis support, when necessary.
3) It affords the counsellor the opportunity to explain the nature and goals of counselling, and to agree upon the practical arrangements for counselling with the client.
In short, the initial interview will help the client and the counsellor to begin the process of understanding and accepting one another. The initial interview normally should proceed along the following lines: 1) Statement of the problem in clear, unambiguous terms 2) Systematic evaluation of the problem, its causes and its effects 3) Identification of circularity 4) Feedback to the client 5) Evaluation of the client's motivation for counselling 6) Clarification of expectations 7) Setting of goals 8) Establishing a contract
9) Making the practical arrangements for counselling. Let us examine each of these steps that will enable us to actually understand the process involved.
Statement of the problem in Clear, Unambiguous Terms
Clients who come into therapy are seldom clear and concise in their communication. More frequently, their thoughts are muddled, and heavily laden with emotional content. Clients do not say, "I am anxious", or "I am depressed". Instead, they frequently commence with an account of what happened, where and when and how. Often, a client comes for counselling because he has been compelled to do so by a family member, friend, or well-wisher. Such clients are, more often than not, unlikely to cooperate whole-heartedly with counselling.
Clients sometimes have difficulties in complying with the practical arrangements for counselling; for example, they may reside too far away, or may not be able to
obtain leave from work.
A greater problem, however, is that many clients are unwilling to make the personal or life-style changesthat are necessary if they are to benefit from counselling. For . example, a husband, who is convinced that all his problems originate in his wife's behaviour, may not be willing to accept that he is responsible in many ways for them, and that he needs to make certain changes in his attitudes and behaviour if his marriage is to survive. Or, while a drug addict may realize that his addiction is ruining his life, he may not be willing to give up the company of the friends who are encouraging him in his deviant habits.
It is important that the client realizes that the counsellor can only facilitate change; the client must make the primary effort. Breaking maladaptative habits is difficult. Making life~style changes is difficult. The client must be willing to make the necessary efforts with the guidance of the counsellor.
It is important, for several reasons, to assess motivations that led the client to seek counselling. If the counsellor understands that the client is poorly motivated for counselling, he can provide an appropriate feedback to the client. Then, in consultation with the client, he can arrive at a pragmatic decision concerning whether or not to proceed with counselling.
If a client shows poor motivation and the counsellor decides not to go ahead with counselling, he saves for himself, and his client, a lot oftime. He also saves himself a lot of heartburn; had he proceeded with therapy, and had the client shown poor progress, he would in all likelihood have blamed himself, or questioned his competence. If a client shows poor motivation and the counsellor does decide to proceed with therapy, he would probably set far more modest goals than he would have had the client been more motivated.
It may be noted here that the evaluation of motivation is an ongoing process. A client may begin counselling enthusiastically but may later weaken his resolve when he realizes what behavioural changes are necessary.
Clarification of Expectations
The counsellor needs to find out what the client expects from counselling. Some clients tend to believe that once they tell the counsellor their problems, it is the counsellor's responsibility (and not their own) to fmd the solutions. Some clients believe that the counsellor will magically work out solutions for problems that have existed for years.
The counsellor should, right from the early stages of counselling, put his client on guard against unreasonable expectations, such as expectations of dramatic cures, total cures, one-sided compromises, etc.
From a practical perspective, it is imperative to ascertain what the client believes will occur during counselling. Some clients believe that the counsellor will put them on a couch and psychoanalyze them. Other clients believe that the counsellor will ask questions about their childhood. Doubts, misconceptions and myths that clients come with should, therefore, be probed and clarified.
Setting of Goals
General goals of counselling are to reduce emotional distress, to reduce dysfunctional behaviour, to promote adaptation, to develop potentials, and to assist in decision-making. After obtaining a general understanding of the client's problems and expectations, specific goals of therapy need to be set. The counsellor needs to guide the client in the setting of specific goals because the client is quite likely to be uncertain of what may be expected from counselling.
Such goals are best explicitly stated as specific emotional and behavioural changes that are acceptable and desirable to the client and to society. Thus, an ethical element exists in all goal-setting exercises.
It is important to break down important goals into their logical sub-components or sub-goals, which, by virtue of such identification, are more easily tackled.
For example, when engaging in marital counselling, goals may be stated as follows:
1) Mrs. A should feel less depressed.
2) Mr. & Mrs. A should improve their understanding and cooperation on the following issues:
a) Disciplining of their children;
b) Distribution of household responsibilities;
d) Relationship with the in-laws etc.
Stating goals in such a specific manner may generate a long, laundry-like list; however, there is no bar to the number of goals as long as all the goals are specific, clearly defined, reasonable, and attainable. There are many reasons why goals should be so specifically set. These are briefly discussed below.
Setting very specific goals allows an objective evaluation of the progress of therapy. Counselling seldom concludes with perfect results; and this could lead both the counsellor and the clients to consider the therapy a failure. By listing specific goals, both counsellor and clients can identify the goals that have been attained, and feel satisfied that some of these goals have been met partially or fully.
The goals of therapy should be modest; ambitious goals ofteu lead to frustration and end up discouraging both the clients and the therapist. It helps to have the goals stated in writing. Clients and counsellor alike should be aware of these.
Establishing a Contract
In fonnal psychotherapy, the therapist and client sign a contract with each other. While a fonnal contract is unnecessary during counselling, an inforrnal understanding between client and counsellor is essential and should be clearly established. The terms of this understanding are that the counsellor will work sincerely to accept, understand and help the client, while the client will cooperate to in the best possible manner in matters such as self-revelation, truthfulness, and adherence to the counsellor's suggestions.
Discussing the Practical Details of Counselling, and Making the Practical Arrangements:
The last step during the initial interview is to discuss practical details about counselling, and to make the necessary arrangements for counselling such as duration and timing of therapy, the frequency of sessions, payment schedule etc.
The counsellor needs to explain to the client what counselling can and cannot do. The client needs to be told in particular that while counselling does provide the guidance, working towards behavioural change and adaptation is the responsibility of the client.
The counsellor needs to impress upon the client that he could trust him, and that whatever is discussed during therapy remains absolutely confidential and will not be revealed to anybody else under any circumstance.
Duration of the Initial Interview
With a bit of experience, the initial interview can usually be concluded over a single session of about one hour in duration. Sometimes, the initial interview may spill over into a second session due to a variety of reasons could, such as the non availability of a key family member, and the ina0ility of the client or the counsellor to agree on the definition of the present problem etc.
Provision of Initial Support
Levels of distress are highest during the initial sessions of counselling. The counsellor should therefore ensure that the first session, that of intake, is not sterile. Further, he should be prepared to provide whatever for whatever emergencies may occur; and as the situation demands, offer support, encouragement and guidance to the extent possible.
For a few sessions after the initial interview, the counsellor will need to continue to assess the client's psychological framework and his problem situation. The procedure for evaluation is the same as that followed during the initial interview; however, more detailed clarifications are sought.
During this assessment phase, the counsellor modifies and updates his working model of the client's psychological build and the definition of the problem. During assessment, the counsellor continues to provide support, guidance and other elements of counselling as the situation demands.
Information in the assessment phase is obtained primarily from the client, but it may also be sought, with the permission of the client, from significant others in the client's life, if the counsellor deems it necessary.
Areas of enquiry include the following: 1) The primary problem, and its effects on the client and his environment;
2) Accessory problems, and their effects on the client and his environment;
3) Factors that generate and maintain these problems;
4) Factors that relieve these problems;
5) The client's understanding of these problems; and,
6) The client's efforts to tackle these problems.
Information should be obtained about the client's personality and life. Areas of enquiry include the following: 1) The client's adjustment at home, at work, with his friends, with members of the opposite sex, and with society in general; 2) The client's strengths and weaknesses, good and bad habits, likes and dislikes; and, 3) How the client spends his time or runs his life. Information should be obtained about the client's environment. Areas of enquiry include the following: 1) The family; 2) Friends, including members of the opposite sex; 3) The workplace; and 4) Other social, occupational and leisure areas. The information obtained should include not just the present but also the past.
Depending upon circumstances, the counsellor may request information about the client's early childhood, emotional development, education, work record etc. Family information may be obtained through the use of psychological tests; these, however, need to be administered and interpreted by an appropriately trained professional.
2.4 THE MIDDLE PHASE
The middle phase occupies the bulk of the period of counselling. It is the phase during which the counsellor analyzes the client's feelings and behaviour, provides a feedback to the client, and provides support and guidance to effect behaviour change.
Towards effecting behavioural changes, the following need to be considered. 1) What are the emotional factors that have to be corrected to resolve the dysfunctional behaviour? 2) What are the faulty ways of thinking that the client manifests that need to be corrected for a resolution of the dysfunctional behaviour? 3) What are the social and environmental factors that have to be addressed to resolve the dysfunctional behaviour? Therapeutic gains during the middle phase might include the following: 1) Resolution of the emotional crisis; 2) Resolution of the problem behaviours; 3) Improved self-confidence and self-esteem; 4) Improved self-control and frustration tolerance; 5) Improved reality orientation and appraisal of threats; 6) Improved communication and problem-solving skills; and 7) Improved overall adjustment, judgment, and emotional stability. These gains are obtained through the use of supportive, psychoanalytical, cognitive, problem solving and other techniques.
2.5 TERMINATION OF COUNSELLING
Counselling· should never be abruptly terminated; rather; it should follow a series of formal stages, letting the client down gradually, so to speak. The stages of termination are as follows: 1) Evaluate readiness for termination; 2) Provide advance notice of termination; 3) Discuss readiness for termination; 4) Review the course of therapy; 5) Emphasise the client's role in effecting change; 6) Warn against 't1ight into health'; 7) Give instructions for maintenance of adaptive functioning; 8) Discuss follow-up sessions; and 9) Stress'open doors'. Each of the above has a specific purpose or set of purposes, and is discussed in detail below; although the order specified is logically ideal, in practice, the counsellor may have to judiciously blend the components of the various stages to suit the need of the hour.
Evaluation of Readiness for Termination.
Counselling is always conducted with predetermined goals, set in consultation with the client, and modified as required during the course of therapy. The counsellor also approaches each case with a specific plan in mind. Accordingly, as therapy progresses and the goals of therapy are progressively attained, the counsellor must evaluate readiness to terminate by asking the following questions:
• Is the plan of therapy running its course?
• Has the client grasped the principles of the therapy?
• Are the goals of therapy in the process of being attained?
• Will the client's morale stand up to termination?
• Is the client able to maintain functional equilibrium?
The last question is particularly important because clients enter therapy with hope, and often show greater adaptation during active therapy than their degree of internal adjustment actually warrants. Therefore, iftherapy is prematurely terminated under the assumption that the client has attained functional equilibrium, disequilibrium and decompensation may occur soon after the modifying effect of the therapy is withdrawn if the answer to all the above questions is 'yes', then the counsellor can conclude that the therapy is approaching the termination phase.
Sometimes, therapy termination may depend not upon intra-therapy factors (such as are assessed by the above questions), but upon external influences, such as time constraints or unforeseen contingencies. Wherever possible, the counsellor would be well advised to keep such constraints in mind and plan for termination accordingly. However, even if the termination of therapy is unplanned, the steps of termination are best religiously followed to the extent permitted by the circumstances.
Therapy may also terminate because the client feels that he does not wish to continue; or, because both or either decide that no progress is being made towards the set goals. The counsellor must endeavour to adhere to the steps of termination again "as may be applicable under the circumstances, unless, of course, the client drops out of therapy abruptly.
Provision ofAdvance Notice of Termination
Many counsellors fail to realize that while they are following a specific plan during therapy, the client is merely following the counsellor's lead. The client has no concept of the phases of therapy. The client does not know what further assignments the counsellor wishes him to undertake, or what further techniques in therapy the counsellor wishes to employ. Therefore, unless the counsellor provides sufficient advance notice of termination, the fact of termination is likely to catch the client unprepared.
Adequate advance notice of termination is necessary so that clients can psychologically orient themselves towards independent functioning (i.e. unsupervised by the counsellor). This psychological orientation refers not only to an unconscious preparation for independence but also a conscious preparation as evidenced by seeking appropriate clarifications regarding handling of possible post-termination contingencies.
Adequate advance notice of termination is also necessary to give the client an opportunity to raise issues that he had hitherto left undiscussed, and to clarify doubts and misconceptions. Failure to provide adequate notice of termination may lead to crises in functioning when the subject is discussed. The crises are a result of poor self-confidence, which in tum, is a result of the unconscious and conscious unpreparedness for the termination.
Crises resulting from poor self-confidence must be differentiated from temporary storminess in the course of therapy when the beginning of the termination is announced; such storminess often occurs and is a result of repressed or uncommunicated issues suddenly taking on an important dimension in view of the beginning of the termination of therapy.
Discussion of Readiness to Terminate Therapy
The counsellor should always be aware that, while he may consider therapy to be approaching completion, the client might have many internal problems to resolve. Therefore, the client's appraisal of the situation is essential before termination is formally announced.
The discussion of readiness to terminate therapy should cover, inter alia, the client's understanding of what has transpired during therapy, his doubts and misconceptions, and his confidence to handle future situations on his own.
The counsellor should usually bow to the client's judgment if he wishes to prolong therapy. This is particularly applicable when' the client wishes to resolve certain additional issues that had not been previously specified. However, the counsellor must guard against dependency on the counsellor, and the counselling process that often underlie the wish to prolong therapy.
Review of the Course of Therapy
Assuming that the therapy has succeeded in establishing a functional equilibrium, it is necessary that the client understand the dynamics of such equilibrium. This understanding provides the client with the tools necessary to maintain this functional eqUilibrium after termination of counselling.
The counsellor, therefore, draws to the client's attention the problems with which he had initially presented himself, the goals that were agreed upon for therapy, techniques that were employed in therapy to attain these goals, assignments that were given, interpretations and insights that resulted, progress and setbacks in therapy, and other issues germane to the course of the therapy.
The client thus obtains a 'bird's eye view' of his therapy, or a somewhat objective perspective, much as though he were looking at himself from the outside. It hardly needs to be stressed that the counsellor should elicit the above from the client using appropriately worded questions rather than summarize the course of therapy himself.
Emphasis of the Clients Role in Effecting Change
Clients, particularly in India, tend to glorify the counsellor for having made them functional again. This may be gratifying to the ego of the counsellor. However, it is more important for the client to understand the role that he has himself played. As change of any nature is difficult to effect, the client should be complimented for having made a positive effort for effecting the change.
Such a compliment should positively reinforce the client's functional (as opposed to dysfunctional) behaviour, and should give him the confidence that he can handle crises in future without lapsing into a dysfunctional state. The counsellor should also explain that his role has been that of a guide to the client on his road to functional mental health.
Warning against 'Flight into Health"
'Flight into health' refers to the phenomenon of dramatic recovery occasioned ostensibly by therapy, but, in fact, by non specific factors such as hope, temporary benefits stimulated by the novelty of therapy, belief that a resolution of superficial issues has solved the entire problem, euphoria over minor or transient gains etc. Such a reaction is quite common early on in therapy.
However, there is a definite possibility that, although the goals of therapy may have been attained, they may not be long-lasting and the client may relapse shortly after he has been returned to the unsupervised environment with its former stressors. This often occurs because of the short duration of therapy courses.
Warning the client against the danger of 'flight into health' keeps him aware of the realities of the situation and guards against unwarranted euphoria; it most importantly serves to protect against discouragement should difficulties in adjustment resurface after therapy has concluded. Such difficulties are far more common than expected or acknowledged.
Giving Instructions for the Maintenance of Adaptative Functioning
Since the risk for setbacks, temporary or otherwise, after termination is high, the client should receive adequate counselling about how to handle potential troublesome situations. Such counselling should cover all levels ofprimary prevention aimed at precluding the development of crises, secondary prevention to identify destabilization early as well as to defuse the crisis with the minimum of disturbance, and the tertiary prevention to minimize the damage done, if any, and to set in motion the necessary steps for correction.
Types of situations and how they are to be dealt with are ideally discussed in detail with specific references to examples from the course of the therapy. As earlier, it is preferable that the counsellor elicits the examples and the solutions from the clients rather than didactically bringing them up himself.
Elicitation from the lips of the clients is always best because it tests and confirms the clients' understanding of the therapy and the therapeutic process, and because the clients tend to remember and accept best what they themselves have spoken of, and the clients are more likely to select the most important client-relevant contexts in the discussions.
Discussion of Follow-up Sessions
It is never advisable to conclude therapy abruptly. However well motivated the clients, however painstaking the efforts of the counsellor and however seemingly successful the therapy, many clients run into problems soon after termination. This can be attributed to issues that arise de novo, or simply to issues that were, for some reason or another, just not resolved during the actual therapy.
It is therefore, necessary for the clients to continue to maintain contact with the counsellor for continued assistance for the maintenance of the functional equilibrium. The frequency of such follow-up sessions is based upon individual circumstances, and can increase or decrease depending upon the need.
Stressing of 'Open Doors'
'Open doors' refers to continued, uncritical accessibility of the counsellor to the clients. The clients have to clearly understand that they need not feel guilt in case they relapse into dysfunction -guilt that they have 'failed' the counsellor. Instead, they should be made to feel that the counsellor will always be available to them, and that he will uncritically resume therapy as and when needed. This gives the clients the confidence that all is not lost even if they relapse.
When the above is completed to the satisfaction of both the clients and the counsellor, the therapy is terminated formally.