Advanced Counselling Skills

1. Understand the process of a series of counselling sessions. 1.1 Identify the stages of a series of counselling sessions. A well-structured counselling session provides an essential framework for both counsellor and client. Many authors describe the structure of a counselling work in terms of a beginning, middle phase and end Jacobs (2004). Gray (2004) likens the structure to an artist’s frame encapsulating a picture stating “Just as the frame around a picture serves to enhance and contain the material within it, so the structure erected around a counselling arrangement supports the work the participants are engaged in”.

The beginning session is crucial for establishing trust, initial rapport and boundary settings. This is described in more detail in

1.2. The middle phase of the session is the working part where the exploration and the work takes place. It involves some or all of the key counselling skills. The main aims are ensuring using skills that support the client to feel secure enabling them to recognise their emotions, thought processes and behaviours and reflect on these.

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It gives space enabling clients to establish their own change. The ending is the third stage and is an action phase. It is result of the enhancement of the client’s self-acceptance and the associated internalising of his locus of evaluation. It contains elements of review and importantly effective closure for both client and counsellor.

1.2 Evaluate the importance of an appropriate opening of a series of sessions. The beginning of a session is important to establish trust, rapport and set boundaries.

The contract occurs to help establish a professional relationship. It includes confidentiality, time, money, complaints and client expectations of the counselling environment. Day and Sparacio (1988) describe this as “a joint understanding between the counsellor and client regarding the characteristics, conditions, procedures and parameters of counselling”. Establishing a solid professional relationship which is clearly boundaries reduces the chance of conflict in the future sessions. It empowers the client to feel secure and valued and protects the counsellor from possible issues such as over money or time keeping.

Opening sessions allow for the first positive and professional impression to be made. The client may feel unsure of the process and the opening session(s) allows for trust to develop alongside the client’s willingness to open up. At the beginning the power is on the side of the counsellor due to knowledge this shifts towards the client through explanation of the process as there are no hidden agendas. 1.5 Explain the importance of working towards the ending of a series of sessions. In person centred counselling the client generally dictates the end point although a counsellor may still initiate an ‘endings’ discussion inviting the clients opinion on this. There are three areas that can be defined in preparing for an ending of sessions. Reviews and restarts and preparation for ending

This is to explain to the client that although the current counselling process counselling is coming to an end it is not necessarily a cure all one-time event. It may be entered into again later in life or the client may not feel the need for future intervention.

Reviewing the counselling process

This is to develop and check a client’s cognitive understanding of what has transpired. Practical questions posed by Bayne (2008) could take the form of How does the client feel about the ending?

What has this counselling relationship been like?
What has been achieved?
What has the client learned to help in the future?
What might happen in the future?

Unfinished business

This is a chance for a client to voice questions or uncertainties that may have gone unsaid and focus on short work that still needs to be achieved. Both client and counsellor need to be able reflect on the ending for themselves, on what has been achieved, and what are their own reactions to an ending. In counselling endings may not go to plan and some clients may end sessions without notice. This could leave the counsellor feeling unsettled that the relationship has not been ended well for either of them. Clients may decide in the middle of a series of sessions the counselling is not for them because it’s not working or what it brings up is too difficult at that time. Financial or life demands may also stop the client from coming. Some clients may not realise they are ready for the ending and feel rejected by the suggestion this could come from rejections in previous life events and needs careful handling. This is similar to Egan’s (1986) model the “Three stage framework” which lists exploration, understanding and action in sessions.

1.3 Explain the purpose and importance of a working agreement for a series of sessions. A working agreement is important as the counselling relationship is a contract either as a private personal therapist or as part of an agency. There are guidelines and procedures from the British Association of Counselors and Physcotherapists (BACP) and the agency that need to be followed in order to protect the agency, client and counsellor. It is important that a contract is agreed and this includes practical considerations such as (money, time, location and frequency of sessions). It can also include the model and style of work that the counsellor and client wish to work within. Within the contract confidentiality is essential to help secure the client and build a sense of trust and professional relationship.

This can be explaining how records are kept, supervision and permission to share certain information with G.P with or without prior consent from the client. Other practical arrangements may be such as what procedure to follow if the client or counsellor cannot make a session or how they can contact each other or holidays. It is useful to set out what will and won’t happen in counselling is so there is a baseline of understanding. This may include issues such as physical proximity and touching. It may relate to chance meetings outside of the room and how they could be handled. It can include other sign posting and emergencies contacts if the counsellor is not available. The counsellor can explain his or her role and the expectations of this alongside the role and expectation of the clients such as time keeping and commitment to the process. It can involve the difficulty of endings and developing an agreement with the client if they chose to end the sessions early calls the counsellor for closure on both sides.

In conclusion the counselling relationship is based on the counsellor’s ability to identify the client’s expectations and anxiety about the service. To be able to clarify the clients and counsellors ability and limitations of the relationship. Laying the foundations of the contact protects the counsellor and client physically and emotionally and reduces the chances of conflict that could derail the therapeutic relationship. For example payments could affect the power relationship between counsellor and client. Without an agreement the client is less likely to feel secure and valued by the counsellor and be more likely to not commit fully to the therapeutic process.

1.4 Explain the purpose and importance of reviewing progress with the client (assessment).

Traditionally assessment is not generally emphasised in the person centred counselling approach as it disrupts the clients from focusing on themselves and working with their feelings, shifting the focus of attention from the client to the counsellor. However, given the nature of the counselling work and contract based work counsellor’s work within it is often necessary and required by an agency. I personally see assessment as key to gaining insight in to the client and building a plan of work. Counselling is a contractual relationship as part of this there needs to be regular review of the work being undertaken to ensure the goals or conditions established are being met and progress is being made. Assessment according to Gladding (2009) entails “the collection of information in order to identify, analyse, evaluate and address the problems, issues and circumstances of clients in the counselling relationship”.

This is then used to identify potential work needed, planning interventions and evaluation clients. Assessment is a process in counselling not just a beginning and end event. Brammer (1989) writes on assessment saying “the integration of assessment information requires a process of developing a description and explanation of the client’s problems that will be used as a basis for a therapeutic plan. The therapist is interested in linking the client presenting problems to the client personalised meaning of the problem, unique developmental history, family system interactions and formulate explanations that hypothesise about why the client has become symptomatic at this particular time”

At the beginning of a series of sessions time needs to be given over to an initial assessment it can use a number or practical tools such as assessment questionnaires. This, as stated above, can help identify possible areas of work. It can inform to the counsellor that their client requires more specialist help such as complex trauma work and a referral needed. Alongside this an initial assessment may take the following structure and can look for information on:

Current problems

Previous counselling experience
Occupation, relationship and children
Medical and health
Why choosing counselling now
What to gain form counselling
Historical information school, upbringing, memories and diversity issues
Support networks
Discussion on if counselling is suitable or referral made.

Some counsellors add a review into the end of every session this is particularly relevant with short focused based counselling. Evaluation sheets may be used every week as part of NHS contracted work to establish progress or value added for the organisation to justify funding. Reviewing of work may be just once in the middle of a series of sessions for less focus based work as around 8 to 10 sessions. With longer open ended contract whole sessions maybe given over to reviewing. These may use formal evaluation forms such as Clinical Outcome Routine Evaluation forms (CORE) or other methods such as Primary Health Evaluation of Mental Disorders Patient Questionnaire (PHQ-9). It may simply be a session dedicated to discussion over the clients progress overall.

Evaluation or assessment, as a process, can be useful to show the client the progress they are making. It is essential to relate back to the initial question as although counselling may have been useful, and the client feel better, but has it redressed the clients presenting problem? 1.6 Explain the importance of ensuring the environment is suitable and safe. The space in which the session takes place is important; it should be quiet, safe and above all confidential. All distractions such as mobile phones or interruptions should be minimised.

It should remain consistent, comfortable and neutral in design. Both client and counsellor safety in terms of health and safety and lone working arrangements should be catered for. Green (2010) describes the importance of the room and lack of personal or religious aspects saying “the room is a kind of metaphor for what will take place between you. You the counsellor are going to be fully present, warm and available to the client but you are not going to being other aspects of yourself into the equation”.

2. be able to conduct a counselling session with a client in an ethical, effective and safe way. 2.1 Open the session, explaining the working agreement including 2.2 Develop the session using the following skills and interventions appropriate for the session and the model used. 2.3 End a session appropriately, usually the following where applicable See recording

3. Be able to reflect on the counselling session

3.1 Evaluate the effectiveness of the opening of the session This session was a continuation of previous sessions the need to open the session effectively and invite the client in still remains. In this session the contract was reviewed including the essentials of time boundaries, confidentiality, student status and ethical framework. In addition to this contract permission was sought to record the session. The contract was shorter than normal and on reflection could have been delivered slower and given invitation for the client throughout to ask questions. In the opening of the session I invited the client in and to do this briefly reflected and offered a summary of work that had taken place in the previous sessions. This was to show my attentiveness and show the client they had been heard previously and my attention was firmly on them from the outset of the session.

3.2 Justify the use of skills used during the session

Attentiveness and rapport building

The rapport with the client had been set in previous sessions and continued through this one. This was shown by a short summary at the beginning reflecting on topics from these previous sessions. The client was given an opportunity to bring one of these prior topics or something new to the session with the question “I was wondering which avenue you would like to go down today?” [3.45]

Active listening

Active listening is to show the client they are being heard. This is not only through verbal ques and reflecting but also in non-verbal ways. Throughout the session there were nonverbal examples of my attentiveness with nodding and smiling where appropriate and also the “Um” and “Okay” comments to encourage the client to continue with their story. Examples of this are at [10.52] after the client “I feel like I have to step in and get **** to see it from his perspective”. I use them “Um” instead of questioning as I sensed there was more to come from the client about this point. They start to question themselves so the nonverbal action was affective.

Empathic listening

Empathy is a way of being not just a professional role or communication skill it is attending to both the physical and psychological and listens to the clients view point. Empathy builds self-confidence and positive regard alongside promotes professionalism. Listening to the client and them feeling held in the session is crucial to allow them the space and security to open up. In this session there were several examples where I show the client they are being heard. This is around [13.30] minutes into the session where I ask the client “I wonder what you are left feeling?” At [16.10] I ask “Where do you see yourself?” The client throughout is focusing on their partner and their children but not on their own feelings.

Effective questioning

Open ended questions allow for the free flow of information, understanding the problem better and allows for rapport building. Closed questions that only elicit a yes or no elicit the opposite response of closing down the conversation. In the session there are a few open questions such as “I wonder what you mean by you know” [5.25]. This is to try and elicit what the client means in the context. Another example is “What does it feel like for you when the tensions going on?” The aim is to open up the clients feelings more at that point in their life and gain better understanding.

Summarising

My summary occurs 4 minutes from the end of the session. The client is made aware of this by the statement “If I could summarise”. The idea being to check the client felt heard and that there was no bits that I had missed from the session as the client should leave feeling heard and valued. The summary went over the salient points of the session allowing chance for reflection on the positives that came out of the conversation. The aim being to leave the client with a positive feeling relating to the work that have done. The client then reflects themselves back about something they have discovered about their relationship and how they may look at it differently. At the end the client is thanked and given an invitation to continue this exploration next session. Thus allowing the client time to think before the next session on what they would like to bring. This is to leave the session’s client centred.

Focusing and challenging

At [25.29] the client begins to bring in another aspect to the topic. Although potentially relevant there is little time to explore this topic. Focusing allowed for this session to stay on the track it I said “We only have a few minutes left of the session. Your Mum has been mentioned in several sessions but I’m wondering if we can stay focused on that moment”. By focusing the aim was to explore the feeling in more detail and not allow avoidance alongside not bringing a new topic when there was no time to fully explore this being so close to the end of a session.

Immediacy

There is a good example of immediacy in the session. It is important as a counsellor to not only hear what the client is saying but also be aware of their body language. At [10.42] I say to the client “You gestured with your hands that sense of balance” then I reflect on the balance between the children and partner that the client has been talking about.

Working at an appropriate pace

Pacing in this session was good. As a counsellor mine matched that of the clients throughout. This had already been established in the previous sessions although the contract could have been slowed down. The idea is to match the clients pace, pitch, tone and speed. A counsellor can use their own tone of pitch to slow the client down if they are running away with their story rather than taking the time to pause and think. Checking understanding with the client

There were several examples of checking understanding with the client. The first occurred at [3.00] where I asked “Would you mind briefly going through…….” This was seeking clarity of a historical event. The second occurred at [9.00] with the question “Remind me how long ……..” Although covered in a previous session it was important that the time frames being worked with were accurate. The aim being to also focus the client on the actual length of time they have been with their new partner.

3.3 Explain why other skills were not used during the session

Managing silence

There was no silence in the session this was due to my need to develop this skill. The spaces still feel unnatural and there were several chances where it could have been used. At [23.15] after the client responds they pose their own question “What will happen if I don’t?” I respond “Good question what will happen if you don’t”. At this moment the client should have been given time to think. Instead of this I looked to direct the conversation instead of holding the client in that moment and giving them the space. A second example was when the client comments “Why am I doing it”. I jumped in instead of leaving the space. If the silence had continued beyond the client’s reflection then I could have paraphrased this back to them to highlight their thinking at that time. These interruptions potentially could cause the client to get nervous, stop the flow of information or feel intimidated. They could lose confidence in the process and by not feeling heard could prevent communication in the future.

Challenging

During this session there was a very poor example of challenging where I asked the client “You’ve spoken about protecting the teenagers I was wondering if it was about protecting your relationship as well”. This was about my addenda to find out if there was a link and did not add value to the conversation at that point instead it detracted from the clients work. An example of missed challenging occurred at [6.39] the client uses the word “worried” four times in a minute. I could have challenged them on what the word worried meant to them as each of us carries our own perception.

Working with diversity as it impacts on the session

Within this session I sis not bring in diversity. Although working with this client there is normally an element as they are not British born and moved to the UK as an adult. So culturally in terms of relationships and family dynamics there is a possibility of needing to understand the difference. Language has in previous sessions been a barrier with needing to clarify my understanding of how Evaluate the effectiveness of closing the session

This session was closed well the client was given a warning that was near the end of time with me saying “We only have a few minutes left”. They were then offered “If I could summarise”. The summary covered the main points from the session and allowed the client to affirm these. It gave opportunity to leave a positive point for the client to think upon to leave them secure after the session. It also opened up the possibility for the topic for the next session allowing them homework of reflection. The client by responding and affirming the summary gave rise to the fact they felt heard in the session. The session was within the time boundaries and the client was thanked for the session. Recognition was given to the next meeting with the client.

Bibliography
Brammer, L. Shostrom E and Abrego, P. (1989) Therapeutic Psychology
Fundamentals in Counselling and Psychotherapy. 5th Ed. New Jersey: Prenice Hall. Bayne, R. (2008). The counsellor’s handbook. Cheltenham, U.K.: Nelson Thornes. Day, R.W and Sparacio (1988) Structuring the counselling process in Dryden (2008) Key Issues for Counselling in Action. London: SAGE Egan, G (1986) The skilled helper. Pacific Grove, Calif: Brooks/Cole Gray, A (2004) An introduction to the Therapeutic frame, London: Routledge Green, J and Claringbull, N. 2010 Creating the therapeutic relationship in counselling and psychotherapy. Exeter: Learning Matters Gladding, S.T (2009) Counselling: A Comprehensive profession (6th Ed.). Upper Saddle River, NJ: Pearson Education. Jacobs M (2004) Psychodynamic Counselling in Action (3rd Edition) London: Sage