In order to discus counselling and its meaning both generally, and in my workplace, it is necessary to come up with a definition. The dictionary describes it in terms of advice but this interpretation is a traditional one and carries an immediate implication of inequality for those involved. It is a narrow interpretation of the concept when compared to modern attitudes, which usually include a psychological aspect.
Nevertheless, the traditional view still bears three of the fundamentals of counselling.
* That it involves at least two people, thus constitutes a relationship.
* That there is agreement about the nature of the interaction, i.e. it is cooperative.
* The aim is to help those involved.
According to Stephen Murgatroyd (1990, P.5) counselling is not the sole prerogative of professional counsellors. It is a process that is widely used in within a community, which can take many forms. I have found this particularly true in my own profession.
As a Paramedic within the NHS for ten years I have used techniques, which I now recognise as essentials of counselling practice, but have never considered myself a counsellor. Rather a professional who can learn much from the subject.
In my workplace I find frequent examples of the more traditional model of counselling, as described by Murgatroyd (1990 P.7) as “prescriptive or directive” but also of other the “facilitative or developmental” forms, which seek to encourage patient centred self-actualisation. These I will seek to analyse. I hope to draw out some of the problems involved and discuss ways in which to improve.
Counselling, Caring and the Ambulance Service
Once upon a time ambulance staff had a clear job specification, or at least their managers liked to believe so. Crews were told their mission was to “preserve life and transport to hospital with the minimum of deterioration in the patients well-being”. In reality things are not that simple and ambulance staff deal with a myriad of human responses and emotions every day.
In the past many of my colleagues thought of counselling as a nebulous concept, which had no place at the cutting age of ambulance work. More attention was paid to physical trauma than emotional. With hindsight we can see that the best ambulance staff were those that used the skills that we now identify and welcome, in a natural and confident way. Usually they were also those that had plenty of experience.
Just as my job covers a range of human conditions, so counselling and guidance demands a range of approaches to those being “counselled”. In my job these can be patients, their friends, relatives, bystanders or other professionals. Also though, it includes my colleagues.
I have discussed briefly the nature of counselling, now I would like to examine it in more detail.
Nelson-Jones (1983) talks of a distinction between skills and specialism or “counselling relationships”, whereby counselling is the primary activity, and “helping relationships” in which counselling skills form part of the helpers relationship with another person.
Clearly the latter applies to my own job as well as many others. Our primary role is not that of counsellors but we use some of those skills so as to be effective practitioners.
Davis & Fallowfield examine four models of psychological theory that have had a major impact on counselling. These are:
* Cognitive Behavioural
* Person Centred
Each of these allows us a better understanding of the processes of helping by affording us a different view of the human psyche. In my work I can recognise elements of all the models in patients and colleagues.
Rogers, (Person Centred), gives insight into the importance of the conditions necessary to create an effective relationship. Based on humanistic philosophy he espouses the belief that all people have the capacity to achieve self-actualisation, if the basic conditions can be created.
Freud, (Psychodynamic) demonstrates the importance of the relationship, the unconscious processes which arise from them and the insight into them in dealing with problems
The behaviourist theories espoused by Pavlov, Skinner, Ellis and others, deal with the nature of behaviours “learned” and observable, and how maladaptive thought processes can be “unlearned” by the use of cognitive processes.
A fifth model, that of Gerard Egan, integrates many of the ideas of the former to create an eclectic model that I believe has particular relevance to my workplace.
In “The Skilled Helper” (1994) Egan incorporates some of Rogers and Maslow`s humanistic ideas in a pragmatic way, to outline some of the counselling skills that we use so much as teachers or carers. As Egan’s model is concerned with problems other than just psychological it provides a more relevant ethical base for those in teaching or healthcare and has been increasingly embraced by those professions in recent years.(Burnard 1990 P.27)
Egan mirrors modern healthcare by treating the patient in an holistic way. He proposes a need for empathy, respect, genuiness and mutual respect. All of these are very necessary to accomplished ambulance staff.
The Three-Stage Model
Egan uses a three-stage model to outline the helping process. The first stage concentrates on the social skills that I find so important to my job, setting the scene and allowing a warm relationship to flourish through showing genuine empathy. Skills such as body language “active listening” and attention giving are prerequisites. Communication is established and advanced.
Stage two moves the process forward by drawing out themes to allow the subject a new perspective. The subject is gently challenged so as to recognise themes, feelings and experiences. .
Building on the previous stages, the third seeks to encourage a creative ambience. Problem solving drawing on points raised, maybe seeking solutions and encouraging the subject to establish a plan of action.
The establishment of communication is common to the whole process. This is a massively important. The process may also move backwards or forwards. It is not intended to be prescriptive but rather to draw out the empathetic “human” qualities that can help.
I can recall so many instances where Egan’s ideas have been used in my workplace that it is hard to select examples. We are often called upon to assess our patients well being in a very short time. Once we have established that avenues of communication are possible, i.e that the patient is able to communicate in a rational way, we embark on a dialogue that seeks to put them at ease, allow them insight and hopefully afford them a feeling that they have some measure of control over the situation. Power thus becomes an important issue.
In Davis & Fallowfield (P.15) the patient/practitioner relationship is discussed. They state that one of the most common problems encountered is the need for medical staff to take on the role of “expert” in order to reach conclusive goals. Very often this leads to neglect of the patient as a whole.
Sanders (1994) identifies two qualities that he describes as “non-counselling”. One of them, he describes as being “distant and expert”. Sometimes, in a medical emergency, this is a necessary quality but creates feelings of guilt. I have often left relatives at the scene of a cardiac arrest at home whilst taking the role of “expert” and wondered at the emotional carnage that we have just encountered as we speed towards hospital with their loved one. Many times I know that we have not even begun to address their needs.
It is certainly easier not to shoulder that sort of emotional involvement, as mentioned by Burnard (P.148), when he talks of the possibility of burnout. But sometimes assuming the role of expert can be used as an excuse to avoid emotional involvement.
I believe that in my workplace this is a very common problem and have many times taken issue with colleagues who have deliberately refused to move away from the “expert” mode and address the patient as a whole person.
In one such incident a young female patient was brought by chair into the A&E department by a crew. Wheeled into the centre of the busy department she sat hunched, clearly embarrassed, and hiding her face. One of the crew held a large collection of empty pill packets, making it obvious to those who could see that the patient had overdosed.
Overdoses are a very common emergency and can bring out negative attitudes from all medical workers.
Whilst the patient remained on public view the ambulance man walked up to the nursing station and ritualistically poured the packets onto the desk in an obviously condescending way. The patient began to cry quietly.
The behaviour of this colleague incensed me. He had ritualistically humiliated his patient presumably because of his intolerance and judgmentalism and a refusal to see the patient as anything but a “manipulator”. I believe that the ability to extract necessary information and perform tasks in an empathetic way is not only achievable using Egans techniques, but also vital to patient well-being.
During my time in the ambulance service time I have passed through stages that have been identified by Maynard & Furlong (1998) as distinct points in development, from early idealism to realism and occasional disenchantment.
I have found that after several years a degree of cynicism is a common “occupational hazard” and is probably to be expected.
Staff have to come to terms with what is achievable within the constraints of the job and workplace stress is common.
Very often in my workplace I witness a range of abilities in communication. Simple techniques such as positioning, eye contact and general body language can be taught but I am convinced that without a genuine “love” for ones fellow man these techniques are not convincing.
The humanistic approach that I have discussed is not always easy. It is easy to dismiss, especially when staff are tired and demoralised. Judgmental attitudes are commonplace and to some extent inevitable. The ability to rise above these and retain an open mind is something that can be massively affected by peer pressure in a working situation where crews work in two’s.
Usually one crewmember is senior and the dynamic of the relationship is affected by experience, sex, strength, (psychological and physical), age etc. This can often create an imbalance of power, between crewmates. This particularly affects less experienced younger staff in a workplace where experience is such a valuable commodity.
Sometimes staff suffer because of their role as unofficial counsellors. Burnard (1990) talks of the potentially “painful” relationship between the parties. I believe that prolonged exposure can lead to problems and in my workplace this had lead to the formation of a structure designed to aid the problem.
Five years ago the ambulance service started an in-house “Staff Support Scheme” network, in order to create a pathway to help to reduce the impact of psychological problems. It was thought that staff who had been trained to identify some of the symptoms of psychological or emotional problems were in an excellent position to “guide” the subject to help in the form of professional counselling.
Whilst I wholeheartedly supported the concept and became a member, I had doubts about some of conditions attached, particularly about the principles of confidentiality and supervision.
We were trained in “debriefing” techniques (not as counsellors) by a very experienced professional counsellor. However the trust felt bound to encourage us to disclose not only health & safety and legal confidences, but also those that may contravene trust rules. This I felt was unethical and impractical. They also had no formal supervision structure in place and no mechanism for further development. All these factors left the idea profoundly flawed.
I continue to serve as a staff support member but refuse to create reports on individuals or to pass on confidences. This is a position that is supported by Nelson-Jones (P.143) who maintains that breaking confidences is a “serious breech of ethics”.
Counselling and helping work colleagues outside the classroom can be a much more intimate affair. Crews routinely spend twelve hours in each other’s company, often on standby or on station, alone, un-chaperoned and unsupervised. Thus if there are emotional needs and issues
the workplace can become extremely intense. Staff obviously have issues themselves, quite apart from the problems they may face with patients and support can be close at hand. But the operational ambulance environment can also become a minefield of ethical limits and the process of helping can be impaired as well as enhanced.
Burnard (P.139) discusses the problems of transference and countertransference.
In the above-mentioned situation where an inappropriate relationship develops he suggests the transfer of the “client” to a more senior “counsellor”. Although the obvious solution, this is not always possible and it is obvious that problems will continue to occur.
The back of an ambulance is no respecter of class and ambulance work can be a great leveller.
As a developing teacher of ambulance staff I am in the privileged position of teaching those who I believe are routinely placed in a position of power and privilege that can be used or abused.
I believe a major part of my teaching role is to encourage the use of the humanistic approach, and to encourage students to reflect on their own attitudes and judgements in order to allow them to better use the skills described by Egan and the key aspects required as described by Carl Rogers in Kischenbaum & Henderson, (1989).
The humanistic approach is already practised in my workplace and has been by the more experienced staff for years. Even though they did not attach labels to their skills they were using the humanistic approach espoused by Egan, Rogers and others. In the emergency care setting they have honed these skills to bring benefit to their patients as quickly as possible. It remains a joy to watch
I see my future role as that of a champion for the humanistic approach, by my actions and my teaching methods. As more demands continue to be heaped on staff this may become more difficult.
We are in danger of becoming more concerned with the product than the process.
Murgatroyd. S (1985) Counselling and Helping. Haworth Press
Nelson-Jones.R (1997) Practical Counselling and Helping Skills. Cassell
Davis.H and Fallowfield.L (1993) Counselling and Communication in Health Care
Wiley & Sons
Burnard.P (1990) Counselling Skills For Health Professionals
Chapman & Hall
Borck.L and Fawcet. S (1982) Learning Counselling and Problem Solving Skills.
Kirchenbaum & Henderson (1989) The Carl Rogers Dialogues (From Course Handout)