Counseling Skills for Health Care Professionals AM Rajinikanth
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Introduction to CounselingCHAPTER 1

OVERVIEW
  • ❍ Definitions
  • ❍ Meaning
  • ❍ Deficiencies of Professional Communication
  • ❍ Counseling and Health Professionals
  • ❍ Application of Counseling in Health Care
  • ❍ Health Care Counselors
  • ❍ Need for Health Care Counseling
  • ❍ Right Counselors
  • ❍ Duration for Counseling
  • ❍ Future of Counseling
  • ❍ Relationship between Counseling and Psychotherapy
  • ❍ Counseling or Psychotherapy
  • ❍ The Counseling vs Psychotherapy
  • ❍ Counseling and Psychotherapy Today
Counseling is widely accepted as a valuable form of help for people in distress. In response to the increased demand for counseling services in the recent years, there has been a 2corresponding growth in provision of the different categories of counseling such as addiction, family, bereavement and relationships. The trend of treating the whole person rather than just the problem they present continues, and in medicine, business, education etc. Counseling is seen either a useful addition to primary expertise or as a specific additional qualification to be used within particular work setting.
 
Definitions
Following are some definitions of ‘counseling’ formulated by professional bodies and leading figures in the field:
  • The term ‘counseling’ includes work with individuals and with relationships which may be developmental, crisis support, psychotherapeutic, guiding or problem solving. The task of counseling is to give the ‘client’ an opportunity to explore, discover and clarify ways of living more satisfyingly and resourcefully. (British Association of Counseling, 1984)
  • Counseling denotes a professional relationship between a trained counselor and a client. This relationship is usually person-to-person, although it may sometimes involve more than two people. It is designed to help clients to understand and clarify their views of their life space, and to learn to reach their self-determined goals through meaningful, well-informed choices and through resolution of problems of an emotional or interpersonal nature (Burks and Stefflre, 1979: 14).
  • A principled relationship characterized by the application of one or more psychological theories and a recognized set of communication skills, modified by experience, intuition and other interpersonal factors, to clients’ intimate concerns, problems or aspirations. Its predominant ethos is one of facilitation rather than of advice-giving or coercion. It may be of very brief or long duration, take place in an organisational or private practice setting and may or may not overlap with practical, medical and other matters of personal welfare. It is 3both a distinctive activity undertaken by people agreeing to occupy the roles of counselor and client … and an emerging profession … It is a service sought by people in distress or in some degree of confusion who wish to discuss and resolve these in a relationship which is more disciplined and confidential than friendship, and perhaps less stigmatizing than helping relationships offered in traditional medical or psychiatric settings (Feltham and Dryden 1993: 6).
 
Meaning
It can be seen from these definitions that counseling can have different meanings.
For example, Burks and Stefflre (1979) stress the idea of the ‘professional’ relationship, and the importance of ‘self-determined’ goals. The British Association of Counseling definition places emphasis on exploration and understanding rather than action. Feltham and Dryden (1993) highlight the areas of overlap between counseling and other forms of helping, such as nursing, social work and even everyday friendship. The existence of such contrasting interpretations and definitions arises from the process by which counseling has emerged within modern society. Counseling evolved and changed rapidly during the twentieth century, and contains within it a variety of different themes, emphases, practices and schools of thought.
It is important to be aware that the definitions of counseling listed here share one important feature in common: they are framed from the point of view of the counselor. What this means is that they largely reflect the aim of professional bodies to establish counseling as a professional specialism within contemporary society. It can be argued that ‘counseling’ is a term in everyday use, and as such carries meanings that transcend such ‘professionalized’ definitions.
There are many definitions of counseling. One simple version is that counseling is a working relationship in which people are helped to explore and manage what is happening in their life.4
The overall aim of counseling is to provide an opportunity for people to work towards a more satisfying and resourceful experience of life. Naturally, each person's needs are different.
Counseling may be concerned with:
  • Personal development issues
  • Addressing and resolving specific problems
  • Making decisions
  • Coping with crisis
  • Developing personal insight and knowledge
  • Working through feelings of inner conflict
  • Improving relationships with others
  • … Or any number of other issues, large or small, which crop up in everyday life.
The counselor's role is to facilitate client's work in ways that respect their values, personal resources and capacity for choice within their cultural context.
Many of us use some counseling skills in our daily lives and often appreciate support from friends, colleagues and family members. Sometimes, however, our usual sources of support can be too close, inappropriate or sometimes part of the problem.
 
Deficiencies of Professional Communication
Davis and Fallowfield, 1991 identified the following list of ‘deficiencies in professional communication’ which they use to preface their work on developing communication skills in the health professions.
  1. Failure to greet the patient appropriately, to introduce themselves and to explain their own actions.
  2. Failure to elicit easily available information, especially major worries and expectations.
  3. Acceptance of imprecise information and the failure to seek clarification.5
  4. Failure to check the health professional's understanding of the situation against the patient's understanding.
  5. Failure to encourage questions or to answer them appropriately.
  6. Neglect of covert and overt cues provided verbally or otherwise by the patient.
  7. Avoidance of information about the personal, family an social situation including problems in these areas.
  8. Failure to elicit information about the patient's feelings and perception of the illness.
  9. Directive style with the closed questions predominating, frequent interruptions and failure to let the patient talk spontaneously.
  10. Focusing too quickly without hypothesis testing.
  11. Failure to provide information adequately about diagnosis, treatment, side effects or prognosis or to check subsequent understanding.
  12. Failure to understand from the patient's point of view and hence to be supportive.
  13. Poor reassurance.
 
Counseling and Health Professionals
There are several occupational titles that refer to people who are practising counseling. A term that is widely used is counseling psychologist. This refers to a counselor who has initial training in psychology, and who uses psychological methods and models in his or her approach. This label explicitly imports the language of science into counseling, by associating it with a specific scientific discipline. There are also several labels that refer to counselors who work with particular client groups: for example, mental health counselor, marriage counselor or student counselor. The distinctive feature of these practitioners is that they will 6possess specialist training and expertise in their particular field in addition to a general counseling training.
There are also many instances where counseling is offered in the context of a relationship that is primarily focused on other, non-counseling concerns. For example, a student may use a teacher as a person with whom it is safe to share worries and anxieties. A community nurse may visit a home to give medical care to a patient who is terminally ill, but finds herself giving emotional support to the spouse. In these situations it seems appropriate to see what is happening as being a teacher or nurse using counseling skills rather than engaging in an actual counseling relationship. They are counseling, but not being counselors. This is a useful distinction to make, because it reserves ‘counseling’ (or ‘psychotherapy’) for situations where there is a formal counseling contract and the counselor has no other role in relation to the client. However, there are many situations where it can become difficult to draw a line between counseling and the use of counseling skills. The nurse in the example above, for instance, might be able to work with the spouse in a counseling mode over a fairly lengthy period, and anyone listening to a tape recording of their sessions might be unable to tell the difference between what the nurse was doing and what a trained bereavement counselor would have done. From the point of view of the client or patient, what he or she is looking for, and receives, is a counseling relationship, which for them serves exactly the same function as going to see a professional therapist in a consulting room.
It is probably not helpful to draw rigid lines of professional demarcation which deny that teachers, nurses, probation officers or social workers can ever be counselors to their clients. Nevertheless, it is also important to recognize that clients can become confused, or damaged, when the people who are trying to help them become enmeshed in role conflicts through attempting to be counselor as well as, for instance, teacher or nurse. It can also be damaging for both client and worker if the 7counseling process moves into areas beyond the training or competence of the helper. The difficulties involved in making clear distinctions between counseling proper and the use of counseling skills have been a matter of much debate (Bond 1989).
Even more difficult to define, as varieties of counseling and psychotherapy, are hypnotherapy and a whole range of activities in the area of healing. The use of hypnosis as a means of helping people with emotional or behavioral difficulties can be traced back to the eighteenth century. For a variety of reasons, however, hypnosis has never been accepted as part of the mainstream of psychotherapeutic or counseling thinking. Certainly, the training that most people who call themselves ‘hypnotherapists’ have had would tend not to be recognized or accepted by the main professional bodies in counseling or psychotherapy. Similarly, healing approaches, which may involve techniques such as meditation, prayer and the use of massage and herbal remedies, have generally been regarded as outside mainstream counseling. The theoretical basis and practical techniques associated with both hypnotherapy and healing do not, currently, fit readily into the ways that most counselors and psychotherapists think and work, although many counselors are interested in these perspectives and there have been many attempts to bridge this gap (Sheikh and Sheikh 1989; Graham 1990; Sollod 1993).
 
Application of Counseling Skills in Health Care
Counseling involves listening, helping, empowering and debriefing. In these respects, it is the central feature of the work of all health professionals. Example of the application of counseling skills are numerous and some of them are:
  1. Medicine:
    • Helping patients and clients to describe their symptoms
    • Helping clients experiencing emotional, social and relationship problems8
    • Facing family crises and difficulties
    • Helping and empowering the ‘worried well’.
    • Advising people who are worried about HIV/AIDS
  2. Nursing
    • Helping to plan nursing care
    • Identifying patient's needs and wants
    • Coping with dying and bereaved people
    • Reassuring relatives and colleagues
    • Handling other people's anger and fear
    • Helping students to work through their courses
  3. Occupational therapy:
    • Talking through personal issues with clients, individually and in groups
    • Discussing coping strategies
    • Enabling clients to regain their ability to live independently
    • Helping clients to talk about their reactions to their disabilities
  4. Physiotherapy:
    • Helping clients to adopt to long-term disability
    • Helping people to cope with their treatment
    • Helping people to regain their motivation in the rehabilitation process
  5. Teaching
    • Talking through course work and academic problems
    • Helping students to write essays and dissertations
    • Vocational guidance
    • Pastoral work
    • Helping students to reflect9
  6. Voluntary work:
    • Listening to clients problems in living
    • Supporting other health professionals
    • Coping with other people's emotional release
    • Learning more about yourself
  7. Social work
    • Enabling the client and family group to clarify problems and identify goals
    • Helping parents and their children
    • Enabling client advocacy
  8. Speech therapy
    • Discussing problems with clients
    • Talking to parents and other relatives
    • Working with other health professionals
It is clear that counseling skills form an integral part of the daily work of all health professionals
 
Health Care Counselors
The following people have tried to say who should counsel.
Pearce (1989) offers the following list for consideration:
  • Counseling skills training should be a normal and necessary part of the training of all professionals. The depth of training in those skills is likely to be greater for those engaged in the helping professionals such as nursing, teaching and social work than those who are lawyers, dentists, estate agents and so on.
  • At a lower level the foundation for counseling skills training should be laid in schools with an increasing emphasis on providing training for students in active listening and on helping them to understand and practise the concepts of respect, empathy and genuineness which contribute towards building effective relationships.10
  • Managers in industry and elsewhere need counseling skills training in order to understand how counseling integrates with their other function in working with people.
Elsewhere, counseling has been advocated in at least the following settings:
  • Helping those with serious disabilities (Herbert,1996; Mullins et al,1998; Swain et al, 2003)
  • Sex education for young people (O'Driscoll, 1997)
  • Empowering oncology rehabilitation patients (Smith et al, 1998)
  • Enabling student midwives (Crowley, 1997)
  • Preparing people for retirement (Langer, 1997)
  • Enabling older people to cope with change (Sennoll-Miller, 1992)
  • Helping people through writing (Wright, 2002)
  • Informing people about contraception (Moskowita and Jennings, 1996)
  • Breaking bad news (Winbolt, 1997)
  • Teaching spiritual care to health care students (Bradshaw, 1997; Gallia, 1996; Ross, 1996)
  • Health promotion amongst those who are HIV positive in the country (Discenza et al, 1996)
  • Helping people to cope with bereavement (Youll and Wilson, 1996)
  • Helping those who are incontinent (Longlay, 1995)
  • Helping in mentoring (Stokes, 2003)
  • Advising in dietetics (Licavoli and Hahn, 1995)
  • Coping with sudden infant death syndrome (McClain and Mandell, 1994)
  • Helping with giving up smoking (Hurt et al, 1994; Leininger and Earp, 1993)11
  • Helping to educate those working in the cancer and palliative care fields (Fawlkner et al, 1991)
  • Pastoral counseling (Woodrff, 2002)
  • Help in armed conflict (west, 2003).
 
Need for Health Care Counseling
People can contact health care professionals in the following situations and they will respond, but it may be that they will be guiding them towards a more suitable form of assistance, for example, when there is:
  • An emergency
  • A risk of violence
  • Suicidal or homicidal intent
  • Value in a face to face assessment of the situation
  • Evidence that they may have a mental illness
  • A group or family response which is likely to be more effective
  • A clinical indicator that reasonably suggests that telephone or e-mail support is not in their interests
  • Where they are finding the telephone or e-mail process unhelpful.
 
The Right Counselor
Choosing the right counselor is the client's choice. For this, client must trust his/her own instincts. The following some questions can be used to choose the suitable counselor.
  • Whether client would feel comfortable telling counselor intimate details of his/her life?
  • Do clients feel safe with counselor?
  • Do clients like the counselor's manner towards client and could client be completely open with counselor?12
  • Personal recommendation from someone he respect is a good start but counseling is very personal and he may not get on with someone even his best friend finds suitable.
  • Code of Ethics which some people may find a useful alternative source of information.
 
Duration for Counseling
This depends on client, the counselor and the problem. While deep rooted problems like eating disorders may need longer (one hour a week for several months) short-term counseling for a specific problem or later follow-up may take only a few weekly sessions.
Counseling is when a counselor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life or their current circumstances. It is always at the request of the client and no one can properly be ‘sent’ for counseling.
 
Future of Counseling
Different times bring different needs, and today the need appears to be for help in coping with stress, with feelings of lack of identification, which choice in the face of myriad career options, with a search for stability when the old values are shaken. When advice or example was sufficient, then this was available from family or friends; now that coping or supportive skills are needed, it would appear that these can be learned more effectively from professionals. Paul Halmos described counselors as ‘the moral-cultural elite(with) far-reaching influence on the ideological trends of our time…’, and further suggested that ‘the influence of this professional group is far greater than their numbers’.
Counseling, therefore, is seen as being important today and in the process of becoming more important tomorrow. Bill law 13suggests that counseling is a new social movement, coming as the logical result of the developing trends in our society and creating its own demands for structures and personnel. This new set of ideas forms a link between (or common element in) the different helping professions, and highlights a larger picture of influence than many counselors might be aware of, or might be willing to admit, for it postulates very great input by counselors into the social welfare of the future and an accompanying responsibility for social change.
Social and economic turmoil creates in people a need and desire for stability and they often seek this stability through counseling. Perhaps counseling is giving back to people a feeling of being in charge, of being in control, of being empowered to make their own choices and decisions, and a sense of identity, of being unique, of mattering.
Carl Rogers stated that the case for counseling and counselors most eloquently, as far back as 1958:
If we are thoughtfully trying to understand our tasks as counselors, therapists then we are working on the problem which will determine the future of this planet. For it is not upon the physical sciences that the future will depend. It is upon us who are trying to understand and deal with the interactions between human beings who are trying to create helping relationships.
 
Relationship between Counseling and Psychotherapy
Counseling is provided under a variety of different labels. To employ a metaphor from the world of business, there are a range of competing products that offer the consumer or client more or less the same service. The upmarket version of the product is sold as ‘psychotherapy’, which is provided by practitioners who are usually very highly trained specialist professionals, often with a background in medicine. Psychotherapy can be a lengthy process. Although there is an increasing interest in 14forms of ‘brief’ psychotherapy, which may consist of a series of ten or twelve sessions, it is probably fair to say that most psychotherapists would consider it necessary for clients to be in treatment for a year or more for beneficial results to occur. The most expensive and exclusive version of psychotherapy remains classical Freudian psychoanalysis.
There has been considerable debate over the difference between counseling and psychotherapy. Some would claim that a clear distinction can be made between the two, with psychotherapy representing a deeper, more fundamental or involved process of change with more disturbed clients. Others maintain that counselors and psychotherapists are basically doing the same kind of work, using identical approaches and techniques, but are required to use different titles in response to the demands of the agencies that employ them. For example, traditionally psychotherapy has been the term used in medical settings such as psychiatric units, and counseling the designation for people working in educational settings such as student counseling centers. One significant difference between counseling and psychotherapy is that much counseling is conducted by nonprofessional volunteer workers, whereas psychotherapy is an exclusively professional occupation. However, both counseling and psychotherapy can be viewed as activities distinct from advice-giving, caring and teaching.
 
Counseling or Psychotherapy
It is not possible to make a generally accepted distinction between counseling and psychotherapy. There are well founded traditions which use the terms interchangeably and others which distinguish between them. If there are differences, then they relate more to the individual psychotherapist's or counselor's training and interests and to the setting in which they work, rather than to any intrinsic difference in the two activities. A psychotherapist working in a hospital is likely to be more 15concerned with severe psychological disorders than with the wider range of problems about which it is appropriate to consult a counselor. In private practice, however, a psychotherapist is more likely to accept clients whose need is less severe. Similarly, in private practice a counselor's work will overlap with that of a psychotherapist. Those counselors, however, who work for voluntary agencies or in educational settings such as schools and colleges usually concentrate more on the ‘everyday’ problems and difficulties of life than on the more severe psychological disorders. Many are qualified to offer therapeutic work which in any other context would be called psychotherapy.
Counseling is considered an exchange of opinions and ideas to effectively problem solve an individual's daily living issues associated with his or her emotional, cognitive, or behavioral problems.
Psychotherapy is a form of treatment for emotional problems in which a therapist establishes a relationship with an individual for the purpose of modifying self-defeating patterns of behavior and promoting positive personality growth and development. Psychotherapy is generally undertaken to gain self-knowledge. Most people come to therapy because defences which have served them in the past are no longer working or useful.
Technically speaking, “counselor” means “advisor”. It involves two people working together to solve a problem. It is a term that is used in conjunction with many types of advice giving. For example, financial planning and spiritual guidance are both types of counseling. Just about anyone at all may claim to be a counselor if they are in the role of giving advice. The term counseling may also properly be used to refer to what occurs in a relationship with a psychotherapist.
In the context of mental health, “counseling” is generally used to denote a relatively brief treatment that is focused most upon behavior. It often targets a particular symptom or problematic situation and offers suggestions and advice for dealing with it.16
“Psychotherapy” on the other hand is generally a longer term treatment which focuses more on gaining insight into chronic physical and emotional problems. Its focus is on the patient's thought processes and way of being in the world rather than specific problems.
In actual practice there may be quite a bit of overlap between the two. A therapist may provide counseling with specific situations and a counselor may function in a psychotherapeutic manner. Generally speaking, however, psychotherapy requires more skill than simple counseling. It is conducted by professionals trained to practice psychotherapy such as a psychiatrist, a trained counselor, social worker or psychologist. While a psychotherapist is qualified to provide counseling, a counselor may or may not possess the necessary training and skills to provide psychotherapy.
 
The Counseling vs Psychotherapy Divide
It was largely in response to the US prejudice against lay therapists that Carl Rogers adopted the word ‘counseling’, originally used by social activist Frank Parsons in 1908. As a psychologist, Rogers was not originally permitted by the psychiatry profession to call himself a ‘psychotherapist’. Ironically, Rogers himself became renowned as one of the most influential empirical scientists in the fields of psychology and psychiatry, introducing rigorous scientific methods to psychology and psychotherapy that psychoanalysts themselves had long resisted (and, in the view of many, still largely resist today). He became a joint Professor in the Departments of Psychology and Psychiatry at the University of Wisconsin as well as Head of the Psychotherapy Research Section of the Wisconsin Psychiatric Institute.
In the field as it now stands, the argument as to whether counseling differs significantly from psychotherapy is largely academic. Those from psychodynamic traditions sometimes equate ‘psychoanalysis’ and ‘psychotherapy’ — suggesting that 17only psychoanalysts are really psychotherapists — but this view is not common anywhere else. Others use ‘psychotherapy’ to refer to longer-term work (even though some psychotherapists offer brief therapy) and ‘counseling’ to refer to shorter-term work (even though some counselors may work with clients for years). The two terms are commonly used interchangeably in the US, with the obvious exception of ‘guidance counseling’, which is often provided in educational settings and focuses on career and social issues.
There is a great deal of overlap between these ‘talking therapies’ and the skills used are very similar. Both can help to deal with problems in a fresh way. Counseling tends to focus on a specific life problem, while psychotherapy tends to deal with more deep-seated personal issues which may bring about really profound changes. Fortunately, the distinction between counseling and psychotherapy is not a matter which need greatly concern anyone seeking help. Most practitioners of either activity, before any commitment is made on either side, will want to be sure that the help they can offer is appropriate for the individual concerned. In both forms of work, what is essential is a relationship of respect, support, and deep honesty
 
Counseling and Psychotherapy Today
Modern counseling and psychotherapy have benefited tremendously from the empirical tradition which was given such impetus by Carl Rogers, even though the research agendas of psychology and counseling have diverged greatly over the last half century. Additional work in cognitive psychology, learning theory and behavior has informed many therapeutic approaches. The richness of the bodies of both empirical and theoretical work which are now available, coupled with the raw complexity of human beings, has led to a profusion of different approaches to the field. By some accounts, the different strands of counseling and psychotherapy now number in the hundreds.18
Mainstream approaches, however, are much fewer in number, and over time it is likely that many of the less well-grounded schools of thought will fade away, while more new ones will emerge to take their place. While the main approaches continue to develop, and others appear and then fade away, clients are left to choose for themselves what might be best for them.