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Diploma in Counselling Leeds City College

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    Advanced Counselling Skills

    1. Understand the process of a series of counselling sessions 1.1 Identify the stages of counselling sessions

    A counselling relationship is likened to being on a journey – a beginning, middle and end (Smallwood, 2013). During the beginning phase the client develops sufficient trust in the counsellor and the relationship ‘to explore the previously feared edges of his awareness’ (Mearns and Thorne, 1988, p.126). According to Mearns and Thorne (1988) the middle period is characterised by: intimacy, when the client experiences the counsellor as showing complete understanding, trust and valuing; What Buber describes as ‘I-Thou’, mutuality and reciprocity (Sykes and Rashid, undated). When the client moves from being ‘nourished’ by the counsellors acceptance to being able to replace that with their own developing self-acceptance (Mearns and Thorne, 1988, p.145). The end of the process is characterised by action (Mearns and Thorne, 1988). Therapeutic movement has occurred leading to enhancement in the clients self-acceptance; the emotional factors preventing a more active life have been reduced; and there is recognition of a new freedom to make choices (Ibid. p.161).

    1.2 Evaluate the importance of an appropriate opening of a series of sessionsAt the beginning, an introduction and greeting is pivotal in putting the client at ease. An abrupt or insincere welcome might prevent or hinder the establishment of the relationship. The beginning should convey acceptance, valuing the client, a willingness to understand without judgement, openness and honesty, and a hope that “we shall be able to work together for as long as you feel it to be helpful and worthwhile” (Mearns and Thorne, 1999, p.126). As a counsellor I am committed to empowering the client. To do this I make clear that she is in control of what material she brings. I often posit an opening question like: “We have an hour together, have you considered what you would like to talk about today?” In doing so I am trying to place control with the client and not elevating myself to the role of expert, advice giver or problem solver.

    1.3 Explain the purpose and importance of a working agreement for a series of sessions

    The BACP (2002, p.4) states ‘good (ethical) practice involves clarifying and agreeing to the rights and responsibilities of both the counsellor and the client at appropriate points in their working relationship’. As this is a consultative process it helps create a balanced relationship free of any hierarchical structures or limitations such a structure might normally impose on a relationship. As Mearns and Thorne (2007) state, “For the counsellor to impose boundaries without a consultative process with the client would be a denial of the essential equality of the relationship which it is hoped to establish . . .”

    Nonetheless, a working agreement must differentiate the client/counsellor relationship from any other the client may have. In so doing it can protect the client from any kind of exploitation, making clear exactly what role each party plays in the relationship. These agreed ‘boundaries’ provide both parties a framework in which difficult thoughts, feelings, and emotions can be expressed and processed safely.

    Within the contract, the type of counselling being offered, number of sessions, the frequency of sessions, timing of sessions, length of sessions, payment and confidentiality should be discussed and agreed to by both the counsellor and client.

    1.4 Explain the purpose and importance of reviewing progress with the client

    “There is no learning without action and no action without learning” (Revans 1983). ‘Reviewing the process’ helps both client and counsellor to check their cognitive understanding of the events and process they have been through (Mearns and Thorne, 1988, p.165).

    Progress reviews with clients are important as a way of monitoring therapeutic progress and counsellor effectiveness. Reviews enable client and counsellor to consider progress allowing clients greater say in designing and amending their own counselling programme (Sutton, 1997). For the counsellor’s part, reviews provide an opportunity to consider feedback about the therapeutic relationship, positive and negative; the counsellor’s approach; whether the client feels their needs are being met and provides information and ideas on how best to use available resources (Elton Wilson, 1997).

    Praising clients for their effort and commitment to change and a continual, subtle focus on empowering the client can assist them to rely on their own internal beliefs as they progress (Smallwood, 2013).

    1.5 Explain the importance of working towards the ending of a series of sessions

    Working towards an end for each session and, indeed, the long-term therapeutic relationship is an effective way of sticking to boundaries agreed within the contract. This ensures the relationship remains professional and ethical. It gives the client an indication that our time together is coming to an end, and provides them with the opportunity to consider and discuss those most pertinent and pressing issues before the sessions conclude.

    It is necessary to give the client a time warning when the sessions are nearing completion, especially if the client is starting to disclose something new for the first time. Should the client choose to divulge something of great significance during the final session, I may have to bend or enforce the time parameters. Extending the period of therapy would need to be approved by my clinical supervisor.

    It is important, during these final stages, that the counsellor and client can resolve any unfinished business and have time to consider the complex feelings about endings. According to Dryden and Feltham (1994), ‘a fear of loss may cause some clients to cling on to relationships in life and this
    will obviously have some bearing on the therapeutic relationship.’ As the counsellor, I need to be aware of what an ending might signify for the client, and for me, and manage these ethically and with the guidance of my supervisor.

    1.6 Explain the importance of ensuring than an environment is suitable and safe
    As Bond (1993) states, we must protect the client from any harm caused by attending counselling. To ensure emotional and physical safety, practitioners are strongly encouraged to ensure the counselling room is a comfortable, quiet calm room at the just the right temperature, free from interruption (Julie, 2006). If the client’s privacy is invaded through unwarranted interruptions, it may leave the client feeling unvalued and emotionally and physically unsafe. The chairs should be comfortable and arranged so as to help the client/counsellor relax and not feel tense. Neither occupant should be in a domineering position, adding emotional security. The counsellor should be mindful about where they position themselves in terms of their own physical safety e.g. close to the door.

    2. Be able to conduct a counselling session with a client in an ethical, effective, and safe way
    2.2 Open the session, explaining the working agreement

    I commence the session by familiarising myself with the client, ensuring I am engaging with the clients on some of her terms through use of the name she is most comfortable with. I explain that my particular engagement framework is the person centred approach, and although I avoid detail I do suggest it’s a listening methodology. I am quite explicit on limits around confidentiality and its exclusions. However I am amiss, and this can be detrimental to the therapeutic relationship, in mentioning that I would include (if appropriate) the client in proceedings should she make a disclosure. I am clear about the time boundaries explaining the time span of each session, frequency and number of sessions being offered. In a formal setting this would be formalised through a signed working agreement, professionalising the relationship and contracting boundaries. I make clear I am bound by a code of professional ethics, the BACP’s ethical
    framework (2002), explaining what this body is, who it represents. I go on to suggest the client may choose to read up on the professional standards document but fail to expand upon the boundaries – such as appropriate and professional conduct between the two of us. I feel this can become laborious and ‘over-emphasise’ professionalism, negating the rapport and relationship I hope to establish. These things should be included in a formal contract, but as this was not on offer in this instance, key elements should have been mentioned, most notably my professional boundaries to allay fears of exploitation in what is usually a vulnerable state.

    2.3 Develop the session using the following skills and interventions appropriate for the session and the model used Attentiveness and Rapport
    Rogers (1957) wrote, ‘significant personality change does not occur except in a relationship’ (p.96). In order for psychological contact to take place, both counsellor and client must want to be there and be prepared to engage one another (Casemore, 2006). As the counsellor I try to give all of my physical attention to the client in order to be fully present for her, so that, as Bolton (1979) infers, my attentiveness conveys to the client that I am interested in what she has to say, and so she may experience me as supportive (Egan, 2000). I try hard to be prepared, calm and with my own issues and problems emotionally put to one side, for the duration of the session. I record specific events and important names on my notes and revise these before each session so the client experiences me as someone who values her and the issues she brings.

    Active Listening, minimal encouragements and managing the silence. Active listening demonstrates to the client that I am involved and engaged in what she is saying. Through ‘attending’- orientating myself physically to the client, she is aware she has my full, undivided attention and I care. To do this I adopt the SOLER position: sitting squarely, open posture, leaning forward ever so slightly, maintaining eye contact and being relaxed (Bayliss, 2003). I used conversational seating positions to avoid being perceived as confrontational or threatening and was aware of my own behaviours and the impact this could have on the client e.g. fidgeting, interrupting. Rogers would let the client know he was present and was
    listening in an accepting manner (Farber et al, 1996). Most often he accomplished this with a simple paraverbal, “M-hm, m-hm (ibid. p.16). Throughout the session I make use of such minimal encouragements, and also employ nodding, a calm tone, and eye contact to reassure her I am paying attention. ‘Clients often work very hard during silences…they need space and time to feel things and let them develop’ (Merry, 1999, p.98). Sometimes clients will need silences to process what has been said and can help them find their own solution to their problems. During this particular session there are only a couple of moments where the client is contemplative, thinking through issues and arriving at a position undirected. For example where she talks of the power dynamic in the home and admits to enjoying the feeling of power over her spouse and children.

    Empathic Listening
    Being empathic is to enter as deeply as possible into the perceptual world of the client, perceive her experiences (most likely different to my own) and then communicate that perception back to ‘amplify and clarify her own experience and meaning’ (Drab, undated, p.2). This creates the sense of a ‘safe space’ for her deeper internal explorations. In working through her issues I try to reflect back some of her feelings and emotions that I have sensed, for example where I reflect the clients fear of harm but overwhelming sense of responsibility. In doing so she comes to the conclusion she fears a loss of power within her familial environments.

    Effective questioning
    Rogers wrote in 1986, “I am trying to determine if my understanding of the clients inner world is correct – whether I am seeing it as he or she is experiencing it at this moment (p.376, quoted in Farber et al, 1996). Rogers called this ‘testing understandings’ or ‘checking perceptions’. Questions during the counselling session can help to open up new areas for discussion by pinpointing an issue. They can also assist to clarify information that at first may seem ambiguous to me. Questions that invite clients to think or recall information can aid in a client’s journey of self-exploration (Counselling Micro-skills, 2009). On a number of occasions I asked exploratory questions to help the client explore or clarify something for my
    understanding. It is my implicit hope that in doing so the client reflects further on what they feel. For example, after telling the client that nothing is ‘stupid’ I avoid the momentary awkwardness by asking, immediately, if this is causing tension for her. The entire session is dedicated to her answer.

    Paraphrasing and summarising
    Rogers had a remarkable ability to match his responses to the clients inner meaning-feeling state – however confused these clients words may have been (Farber et al, 1996, p. 17) These skill involves communicating the clients emotions back to them, rewording what they may have shared from my understanding of it to help her express what she feels or believes more clearly. Where my summary is not a true reflection of her inner state she can correct my interpretation. Hearing what I have perceived, correctly or incorrectly, may help her understand herself better, triggering a clearer understanding. I did this on a number of occasions through this session: after a long period of the client speaking I paraphrase her sentiments and reflected them back to her when I spoke of her fear of sharing power and responsibility.

    Focusing and challenging
    It is important for me as the counsellor to keep communication focused on the facts and feelings of relevant concern. I use questions to help the client clarify terms, feelings and goals. During the session I ask my client to focus on her definition of power and what its loss would mean for her. Although more comfortable providing reassurances, Rogers would, occasionally, confront them (clients) when they appeared to be avoiding a painful issue (Farber et al, 1996). To do this successfully the counsellor should avoid taking tangents, generalisations or anything abstract. Clearly I failed in this regard by detracting from what was ‘current’ by referencing previous sessions and losing the ‘here and now’ which could have helped the client elucidate further on what the issues are. Reflecting on the counselling skills process and immediacy

    Immediacy is the ability of the counsellor to use the immediate situation to
    invite the client to look at what is going on between them in the relationship; using the existing feelings/senses/hunches within the client and within me as part of the process of establishing a relationship (Merry, 1999). Present ‘here and now’ feelings are not denied or avoided, but talked about openly and appropriately (ibid.). It also helps when there is a blockage between me and the client by inviting them to explore what is going on between us. I used this skill in a limited capacity when I asked the client why she felt sharing her emotions might be ‘stupid’. This enabled us both to address what was the central tenet of her issues.

    Awareness of boundaries including referrals
    Boundaries help distinguish the professional nature of the relationship, ensuring clients are fully aware of what is and isn’t acceptable behaviour. Without boundaries a client may feel psychologically unsafe during therapy; that there is no proper structure and purpose to the therapy (Kent, 2010). I stipulated the boundaries in my opening and alerted the client to the fact that she can contact the BACP, an external professional body to whom I am accountable, should she feel these have been in any way breached.

    The client makes reference to speaking to a female counsellor. If she was adamant that it was essential to her understanding herself, her growth and her autonomy I would of course facilitate this as working beyond our limits runs the risk of negligence and bringing the profession into disrepute. In doing so I am aware that making referrals is a principled, skilled and ethically driven activity (Williams, 1993). I would discuss potential alternatives with the client in advance and ensure her consent is obtained (BACP, 2002). All referral notes would be kept in accordance with Data Protection Act (1998) requirements.

    Working at an appropriateness pace
    Throughout the session I make use of para-verbals and allow the momentary silences in order that the client should dictate the pace of the session. This also avoids ‘expertism’: in the technological age there is a high premium placed on the ability to identify problems quickly and apply known effective techniques for their speedy solution (Merry, 199, p.12). Instead I
    try to listen and respond empathically to the clients experiencing process as it is lived in our therapeutic half hour, without goals (ibid.) meaning the client controls the pace and I follow. Checking understanding with the client

    Rogers often checked explicitly whether he was correctly getting his clients meaning (Farber et al, 1996, p.16) At several points during the conversation I check to make sure I understand the client’s perspective correctly. This occurs when the client discusses feeling disempowered through being, as she describes it, ‘reduced’ to just a housewife. I avoid sharing my opinions through verbal or facial expressions and try to demonstrate acceptance through my checking understanding. It demonstrates a non-judgemental attitude and hopefully communicated respect, empathy and a genuineness from me that I am here for her, in my entirety. I have made her world my own. Working with diversity as it impacts on the session

    My client states early on that she feels stupid speaking about her pregnancy with a man. According to Merry (1999), there is limit to the extent I can change my behaviour to accommodate the client without compromising my theoretical basis. To counter this he recommends knowledge of the clients cultural and sub-group (female; Polish; economic migrant; working class; mother; Catholic etc) so that her concerns can be appreciated in terms of her cultural norms and values. Could I manage this as man? I would say no. I tried to understand some of her concerns by reflecting on my own partner who belongs to some of the same sub-groups. But did I manage this in the half hour session. On reflection I would say no. Instead I utilise the now established therapeutic relationship to convince her I am here to listen and that nothing is stupid. The client then goes into detail about the events around her pregnancy. I rely instead on her trust in me, to lay a foundation for growth and healing to occur.

    2.4 End a session appropriately, using the following where applicable The session ends within the agreed time boundaries, ending ever so slightly short of the planned 30 minutes. In my summation I attempt to demonstrate I have listened to the client; I paraphrase the key themes of the session; I
    empathise with her emotions and reflect back, paraphrasing, what she has been feeling. There is no work set to be done outside of the session as it is not something that comes up naturally through the discourse. Although a referral isn’t necessary, suggesting a Union or and Employment lawyer did come across my mind. But I was aware that this was leading and prevented the client experiencing genuine growth through finding and making use of these options of her volition. There was no requirement to renegotiate or renew working agreements but I do make mention of the next appointment by recommending a course of action should the client be unable to make the session.

    3. Be able to reflect on the counselling session
    3.1 Evaluate the effectiveness of the opening of the session My opening covered all components required: I make the client aware of my status and my compliance within a formal ethical framework. I encourage the client to take the time, should she so choose, to read the document. In hindsight an overview of the values and principles may have been useful but within the confines of a time limited session this could be detracting from the client. I make clear the methodology I employ but fail to explain the key principles of Person-Centred therapy. I ensure time boundaries are emphasised in this verbal contracting stage – a written contract however is far more ethical as it holds both parties to a set of signed principles, and provides the client with a set of agreed standards by which she, as a ‘consumer’ entering the counselling ‘market-space’, can hold the counsellor to. Housekeeping is covered, including health and safety requirements with regards emergencies. I detail confidentiality but omit the Data Protection Act and the clients rights to access their information/how and what we store. With this aspect of counselling governed by legal statutes I think it is vital that such information is covered. I explain the complaints process including reference to the BACP – this is a double edged sword however. The client must feel psychologically safe during therapy (Kent, 2010) but raising it could draw disquiet from the client; it may add to the feeling of being psychologically unsafe knowing that there is the potential for exploitation or other harms (issues which may be the cause of their requiring support). This may impact negatively on the therapeutic relationship. I try to put her at ease by
    encouraging her to get comfortable and handing power and ‘expertism’ to her by making clear this is her time and we will begin whenever she’s ready. 3.2 Justify the use of the skills used during the session

    I make use of immediacy early on as the client appears uncomfortable discussing her particular issue with a male counsellor. Making clear I am here to listen, I encourage the client to think of counselling as androgynous and be at ease talking about anything. This works as she opens up about the issue. This also demonstrates some ability to engage with diversity as it impacts the session. I paraphrase and reflect the most poignant aspects of what the client shares. By attempting to capture the essence of her feeling I allow her to confirm my understanding. By bouncing her thoughts back I attempt to trigger a deeper critical reflection on her feelings, enhancing the therapeutic relationship and bringing her closer to the organism. This proves effective as she begins to dissect her conditions of worth. I make use of using non-verbal communication (Bayliss, 2003): body language, facial expressions and content by way of my tone to convey genuineness and unconditional positive regard. By conveying warmth, acceptance and respect I was trying to communicate to the client my sincere belief that she has the inherent strength and capacity to achieve self-actualisation. When the client said she found it difficult discussing this issue with a man, I showed no surprise but rather empathy in my reply and demeanour. I avoided being ‘brutally honest’ in a confrontational or rude way, opting instead to gently challenge some of the clients unhealthy beliefs and behaviours, when the time was right. I referred to earlier sessions as demonstrations of contradictions in her thought. I used focusing and challenging to get the client to reflect deeper on the main issue at stake – her health. This was effective as it made her go into more detail about the potential consequences of her actions. I utilised silence wherever possible to give the client time to reflect on the discussion. This led to the client realising the issue was not as serious as first feared as she has weathered a similar storm previously. The client was able to control the pace of the session. I am aware that too many questions sends a message to the client that I am in control and could create a situation in which she feels I have all the answers. I empathised with the client and try to access
    her frame of reference through effective questioning. This safe space for her deeper internal exploration leads her to recognise what she fears most but also how the loss of power may affect her. My questions early on tended to be closed. For example, “So you feel she’s putting you in harms way?” I followed this with an open question, ‘What’s that doing to you?’ It could be argued that in my first question I was paraphrasing and that my tone was exploratory. When asking questions I tended to use ‘why’ – ‘Why do you feel that was stupid?’ ‘Why’ could provoke feelings of defensiveness in clients and may encourage them to feel as though they need to justify themselves in some way. I go on to use questioning based on how I perceive the client, ‘I am sensing that you feel some sort of responsibility?’ In hindsight I now see this question as directive – I took the client away from the ‘moment’ towards an tangential topic that wasn’t significant at that juncture. I summarise the session at its conclusion, drawing out the key themes to demonstrate caring for the client and a real understanding of her plight. I offer the word ‘risk’ as a paraphrase – albeit somewhat leading – of the issues highlighted and the response from the client is “good” – perhaps suggesting I have established a therapeutic relationship and have helped her funnel her concerns to something understandable and manageable.

    3.3 Explain why other skills were not used during the session There was no call for skills such as making referrals. The client clearly needed to be made aware of her Union rights under Employment Law. Whilst not an orthodox referral, the need for such an intervention was evident. But I feared being directive and denying her the opportunity for growth. 3.4 Evaluate the effectiveness of the closing of the session The session, with hindsight, ends somewhat abruptly. I feel this shows a little insensitivity to the clients needs and feelings as she is expressing through her amusement, her frustration with her antagonist. In my summary I choose to attempt Rogers method of ‘interpretation’, an extrapolation beyond the data (Farber et al, 1996). I mention the word risk. Whilst leading questions are the antithesis of Humanistic counselling I would argue that in this instance the client was tendering for the term that best described her situation in the English language – not her mother tongue. Rogers interpretations seem designed to further his understanding of the clients world (ibid. p.21). It felt natural
    in the moment to ‘interpret’ and proffer the word ‘risk’ as an attempt to draw a reaction from the client affirming or dismissing my interpretation. Perhaps this is presumptuous of me to make this offering as I do not perceive the client as a fluent speaker of the English language. In other ways the closing was effective in that it highlighted empathy, listening and a genuine concern for the client. Overall it covered the key issues from her frame of reference and took on board her fears and concerns. The weakness however is a dogmatic one and may have been improved by eliminating use of ‘interpretation’. 14

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