Models of counselling

Specific models of counselling are usually differentiated by their theoretical base or traditions. The most relevant models for psychiatry are information-giving, reflective or client-centred, problem-solving, cognitive-behavioural, interpersonal, and psychodynamic counselling. Each of these will be described in turn.

Information-giving

Giving information is an important part of contemporary psychiatric practice. This reflects a more open and collaborative approach to treating patients, and the ethical requirement to provide patients and their carers with the material necessary for informed decision-making. For example, for patients with schizophrenia or alcohol misuse, the provision of information about the diagnosis, causes, and potential consequences of their condition is essential for mobilizing their motivation and compliance with treatment. Indeed information-giving is always crucial when communicating a diagnosis. Information-giving is also fundamental to counselling for risk, as in genetic counselling, and to any intervention in which the patient is helped to make decisions, for example crisis intervention.

Psychoeducative methods have a place in most models of counselling and psychotherapy, but have specific importance in problem-solving and cognitive-behavioural counselling. However, information-giving involves more than just giving information. Wherever possible the patient's curiosity and enquiry about their condition is promoted, encouraging them to ask questions and, when appropriate, to find their own answers. The technique of guided learning is central to cognitive therapy and counselling, as will be described below. Sometimes the practitioner assists by providing information, but not so much in a didactic fashion as in response to the patient's questions, for patient and therapist are engaged in collaborative enquiry.

There are many forms of information in psychiatry, for example, information about the genetic or neurochemical basis of an illness, or the actions and potential side-effects of a prescribed medication. A psychologist or counsellor may present a psychological model of a specific condition, such as the cognitive model of panic. Whatever the information imparted, good practice requires that the practitioner checks whether the patient has understood the information given and that its meaning is comprehended, for otherwise it will not be utilized. Information-giving is rarely the endpoint of an intervention, serving instead as the basis for decision-making or continuing therapeutic work.

Client-centred counselling

Reflective or client-centred counselling originates from the work of Carl Rogers, whose emphasis on the recognition and empowerment of the help-seeker challenged the perceived authoritarianism of both the medical model and psychoanalysis. This model highlights respect for the person, and adopts the optimistic assumptions that each person has an inner potential for healthy development and achievement, or 'self-actualization'. Rogers (!5) highlighted the importance of the 'core conditions' of empathy, warmth, unconditional positive regard, and genuineness in human relationships, including the counselling relationship. Research has repeatedly confirmed that these non-specific factors are indeed fundamental to the change process in counselling and psychotherapy. (4!8» Rogers' model of counselling is non-directive. The counsellor's task is to create the core relationship conditions in which the client's inner resources and potentials will be unlocked, leading to the spontaneous resolution of problems and developmental growth.

The central features of client-centred counselling can be incorporated into other models with advantage, especially respect for the client and the other core conditions. While a non-directive and reflective approach has value, and may be useful for initial data-gathering and supportive work, caution must be applied to the use of Rogerian counselling in psychiatry. Severe resource constraints require practitioners to impose time limits on counselling, which therefore must be more focused and 'active'. Furthermore, very disturbed or dysfunctional patients may be unable to access an inner potential for spontaneous change and growth, implicit within the client-centred model. There are some patients for whom a reflective non-directive approach may be harmful, for this may promote an overwhelming upsurge of avoided or forgotten recollections of traumatic experiences without providing methods for coping with them. As will be described below, victims of childhood sexual abuse or other destructive experiences may be retraumatized by unstructured reflective counselling.

Problem-solving counselling

Although problem-solving is integral to cognitive-behavioural therapy or counselling, (!9) it is considered separately here because it has been utilized and empirically validated as a specific treatment model, particularly for depression. The basic tenets of problem-solving have also been extended into the interpersonal domain, specifically with the development of 'Interpersonal cognitive problem-solving therapy'. (29 Egan,(2!) whose models have been influential in counselling training and practice, described his three-stage counselling approach as a problem-management model. Like Rogers, he assumes that people are essentially responsible and capable, and that they can resolve their problems if they obtain the necessary 'working knowledge'. The counsellor helps the client by establishing a collaborative relationship in which problem-solving is promoted in three stages: (i) problem clarification; (ii) setting goals; (iii) facilitating action.

Problem-solving therapy was first described as a form of behavioural modification by D'Zurilla and Goldfried. (22> Problem-solving therapy or counselling has developed into a collaborative and focused method, which involves several stages:

• identification and formulation of the patient's problem(s)

• setting clear and achievable goals

• generation of alternatives for coping

• selection and operationalization of a preferred solution

• evaluation of progress, with further problem-solving as necessary.

From a problem-solving perspective, depression results from the interaction between negative life events, current problems, and deficient problem-solving activities or coping. This model of depression is supported by empirical evidence. Furthermore, problem-solving therapy has been shown to be an effective treatment for depression/23)

Research in the United Kingdom has demonstrated the effectiveness of brief problem-solving therapy or counselling as a treatment for emotional disorder and depression in the primary care setting. Catalan et aA,(24> in a randomized study of poor-prognosis emotional disorder, compared four sessions of problem-solving conducted by a psychiatrist with 'treatment as usual' (pharmacological and/or psychological) given by the primary care physician. The patients selected had recent-onset depression, anxiety, or related symptoms, and were still unwell without treatment 4 weeks after presentation. Patients in the problem-solving group showed a significantly greater reduction in symptoms than those in the control group. This difference was maintained after !6 weeks, during which time the control-group patients had a significantly higher rate of consultation with their general practitioners. No patients dropped out of the index group, confirming that problem-solving was an acceptable treatment.

A second study in the primary care setting showed that problem-solving therapy was an effective and feasible treatment for major depression. (25> Depressed patients were randomly allocated to problem-solving therapy, amitriptyline plus standard clinical management, or drug placebo and standard clinical management. Each treatment was delivered in six sessions over !2 weeks, by either a psychiatrist or a general practitioner. At the end of treatment significantly more patients in the problem-solving group had recovered than in the placebo group, but amitriptyline was not superior to placebo. However, there was no significant difference in recovery rates between the problem-solving and amitriptyline groups. Patients were satisfied with problem-solving therapy, and there was no difference in outcome between patients treated by the psychiatrist or the general practitioner.

These studies confirm that problem-solving therapy or counselling is a feasible, acceptable, and effective treatment in the primary care setting for depression and other emotional disorders. It can be learned by general practitioners, but can also be offered by other trained professionals including counsellors.

Cognitive-behavioural approaches

The cognitive models of counselling propose, in brief, that the sense we make of the world depends on how we structure and perceive our experience; our feelings are related to our thoughts and behaviours; and therapy is aimed at changing the thought, belief, and behaviour elements of functioning. Cognitive approaches are highly structured, looking at specific problems and aiming to enable the client to learn skills to help them deal with present and future problems.

Rational-emotive behaviour therapy, developed by Ellis, (262Z) has traditionally been one of the most influential of the cognitive approaches in the counselling world. It is based on the view that our problems stem not from events themselves but from our irrational thinking about events. If the client holds strong convictions that life should be fair, comfortable, or painless, when it is not, then suffering can only result. The client will then be locked into responding in a dysfunctional manner to adverse life events. Rational-emotive behaviour therapy involves disputing such 'irrational' thoughts and conducting experiments to discover new ways of behaving. (28>

The cognitive approaches to counselling have been introduced relatively recently to the counselling world, for a number of reasons as outlined by Wills and Sanders/29' The highly structured approach, focusing on techniques, rested uncomfortably with counsellors trained in client-centred approaches, and many reacted to its overtly behavioural roots. Furthermore, cognitive therapy was felt to pay insufficient attention to the therapeutic relationship and to the influence of past events on current problems. However, the last few years have seen a major change in the way cognitive therapy is being adopted within counselling, and a large proportion of counsellors integrate at least some of the approaches into their work. (The model and its application are described in Chapter6.3,.2.1 and Chapter.6.3.2.2.)

The basic tenets of the cognitive-behavioural approach are the development of a collaborative relationship in which client and counsellor work together to understand and resolve problems. The counselling revolves around the development of a cognitive conceptualization or formulation of the problems, which determines the approaches and techniques used in counselling. The method is structured, generally but not always short term, and uses a variety of techniques developed in cognitive and other disciplines. The attraction of cognitive therapy to counsellors is increasing, with more overt focus placed on the therapeutic relationship, long-term approaches, and schema-focused work inherent in newer models. There is enormous scope for counsellors to adopt cognitive therapy in a more systematic and rigorous manner, particularly in light of the empirical evidence supporting its effectiveness and increasing demand for briefer interventions. Further details of cognitive approaches to counselling are given by Wills and Sanders (2E> and Bedell and Lennox.3,'

Interpersonal counselling

Interpersonal counselling is a modified version of interpersonal therapy, which has its own origins in the interpersonal psychology of Meyer and Stack-Sullivan, as described by Klerman et al.(31) (see Chapt§L6.3:3). This perspective reasons that much human behaviour is influenced by the basic need for fulfilling mutual relationships. Abnormal mental functioning and behaviour is often associated with disturbances in relationships; therefore the major focus in interpersonal therapy is on the patient's current interpersonal relationships. Interpersonal therapy has been shown in successive research studies to be an effective treatment for depression, dysthymia, and bulimia nervosa/32» It is a collaborative, focused, and time-limited therapy usually involving between 10 and 20 sessions.

In interpersonal counselling, the therapeutic focus is on the patient's current interpersonal relationships rather than the presenting symptoms. During the assessment phase links are established to a disturbance in one or more interpersonal domains: grief; interpersonal disputes; interpersonal role transitions; and interpersonal deficits. Particular attention is given to recent changes in the patient's domestic, work, and social relationships. Interpersonal counselling assumes that such events provide the interpersonal context in which the emotional and somatic problems associated with anxiety, distress, and depression occur. The patient's interpersonal problems are explored, including their expectations of specific relationships. In a problem-solving manner, alternative interpersonal strategies are identified, rehearsed between treatment sessions, and modified as necessary.

Interpersonal counselling was developed in primary health care as a brief, and therefore feasible, psychosocial treatment to be undertaken by nurse practitioners for patients presenting with stress and distress, in whom there was no formal psychiatric disorder. It involved a maximum of six sessions, of half an hour or less. In a randomized controlled study, interpersonal counselling was shown to produce significantly greater symptom relief than a 'usual care' control condition, particularly in terms of more rapid reduction in symptoms, improved mood, and improved psychosocial functioning.(33) Interestingly, interpersonal counselling led to the increased use of mental health facilities, but this was seen as a positive and adaptive outcome.(34)

Psychodynamic counselling

Psychodynamic counselling draws from the theoretical traditions of psychoanalysis, but has limited resemblance to it in practice. Psychodynamic approaches accord significance to past experience, the continuing influence of which may be mediated by unconscious processes, and particularly to adverse experiences in relationships during early life. This is seen to influence attachment patterns, psychosocial development, and later psychological functioning. Unconscious processes derived from early experiences contribute to the generation and maintenance of abnormal psychological states. In psychodynamic counselling and psychotherapy, these unconscious processes may be identified through examination of transference and countertransference developments in the therapeutic relationship.

The historical emphasis in psychoanalysis of unconscious conflict still has relevance for current practice, but psychodynamic counselling and psychotherapy has been greatly influenced by the contemporary perspectives of object relations and attachment theories (see Chapter 3.3.2). Both theories give prominence to the lasting interpersonal influence of earlier relationship experiences, as internal sources both of security or self-reliance and of repeating destructive relationship patterns. These theoretical positions fit readily with the interpersonal and person-centred traditions of counselling.

Psychodynamic theory also emphasizes a developmental perspective, recognizing the successive tasks of psychosocial development associated both with individuation and the family life cycle. This perspective is highly relevant for mental health counselling, since psychiatric problems (most obviously adjustment disorders) often emerge at points of transition in individual or family development.

The search for the personal meaning of the patient's problem or symptoms is central to psychodynamic counselling. The counsellor encourages patients to talk about their difficulties, but also to reflect on their spontaneous associations and their attitudes towards the counsellor as potential sources of information about the presenting problems. For example, the anxious patient who becomes irritable towards the counsellor may be giving expression to unacknowledged angry feelings that conflict uncomfortably with her view of herself as gentle and tolerant. The patient may then be helped to recognize how her submissive and placatory traits originated in childhood in response to her mother's hostile and rejecting behaviour, as if to avoid her mother's anger while maintaining closeness to her. This interpersonal pattern, which is characteristic of anxious-insecure attachments, may have been evident in the patient's other relationships, as with the counsellor. Through discussion with the counsellor, the patient may come to see her anxiety as a product of the tension between her unacknowledged resentment of her mother and her self-protective compliance, and that this defensive strategy is now outdated and self-defeating. The relationship with the counsellor is potentially the source of a 'corrective emotional experience', particularly if the counsellor's attentiveness to, and non-judgemental acceptance of, the client offsets an earlier formative experience of humiliation and rejection.

The generation of insight, as illustrated in the above example, may be sufficient to enable patients spontaneously to bring about the required changes in their lives. Psychodynamic counselling may also incorporate an element of problem-solving and behavioural experimentation to assist with the identification and rehearsal of new and more adaptive interpersonal strategies. The use of different strategies may not be possible if counselling is very brief, but may not be necessary if the patient has the psychological-mindedness and motivation to experiment independently with new strategies. Detailed accounts of psychodynamic counselling are given by Wiener and Sher(14) and Jacobs.(35>

Crisis counselling

Crisis counselling is an eclectic treatment approach for patients presenting in psychological crisis. It is a short active intervention that draws on a range of different treatment models, including problem-solving, with the aim of mobilizing the patients own coping resources. (3.6)

In psychological terms, crisis is the response of an individual, family, or other group to challenges (stressors) that threaten or overwhelm usual coping resources. Crisis embodies both danger and opportunity, for successful resolution of crises promotes coping resources and psychological growth. Thus the successful resolution of crises may be both important in developmental terms and also in the prevention of psychiatric disorders. The inability to cope with critical challenges, however, may lead to adjustment disorder or other stress-induced psychiatric states. Post-traumatic disorders, for example, result from exposure to certain extremely stressful (traumatizing) experiences.

The stressors that generate crisis may be divided into developmental or accidental. The former are associated with those transitional phases of psychosocial development characterizing the lifecycle, such as adolescence, leaving home, childbirth, and retirement. 'Accidental' stressors are those associated with unexpected or non-developmental life events such as injury, bereavement, relationship breakdown, or redundancy. The coincidence of accidental and developmental stressors is a particularly potent trigger for crisis. All crises involve actual or threatened loss. Certain factors may render people vulnerable to such stressors, including previous unresolved loss, social isolation, and cultural alienation. Conversely, secure early attachment, family and social support, and previous success in coping with adversity, confers some protection against the challenge of crisis.

Crisis is not a pathological state, though its outcome might be. Psychiatric illness may be precipitated in those who are predisposed by constitution, previous adversity, or social isolation. Crisis might present in one person, or in a family, group (e.g. a social group or work team), or even a community (e.g. following a murder). Crisis represents challenge, but it also presents an opportunity for resolving old maladaptive coping patterns and for psychological growth in the individual, family, or social network.

Crisis counselling is an active, focused, and short-term intervention, usually involving no more than a few sessions in the days and weeks after the onset of crisis. It is indicated for those who, though in danger of decompensating, have identifiable coping resources (ego strengths), family or other social support, and a history of adaptive functioning. Early intervention is important in order to avert the psychiatric symptoms and maladaptive patterns of coping (e.g. excessive alcohol consumption, self-harm) that are characteristic of adjustment disorders, or frank psychiatric breakdown. It may be practised as an adjunct to physical methods of treatment. Crisis intervention embraces a spectrum of approaches, from emergency inpatient psychiatric treatment to crisis counselling in the patient's own home.

The task in crisis counselling is to help the patient redefine the challenge and to mobilize resources for its resolution. The therapeutic relationship offers security for this task, particularly for patients who are isolated. The help of family and friends is enlisted whenever possible. Psychodynamic exploration may be helpful in assessing the nature of the crisis, but the techniques of cognitive appraisal and problem-solving are more relevant for overcoming it.

The first step in crisis counselling is assessment, and wherever possible this will involve the patient's family or other social network, including friends or neighbours. Ideally, in keeping with the collaborative principles of crisis counselling, the patient and the social network participate actively in the assessment process. This addresses the nature of the stressor, the nature and severity of the patient's initial response, an assessment of risk, and his or her available coping resources including external supports. Relevant historical data are taken into account, to elucidate both previous coping resources and specific vulnerability factors. Psychodynamic processes may be highlighted, for example when maladaptive reactions to earlier crises obstruct resolution of the current problem.

A shared formulation of the crisis is then agreed, forming the basis for a redefinition of the problem. Patient and counsellor work together to identify the aims of counselling, who from within the social network will participate in it, and the methods by which resolution may be achieved. Problem-solving, cognitive, and interpersonal methods may be employed in an eclectic fashion within an individualized programme. Appropriate emotional expression is encouraged, but maladaptive responses are gently discouraged. Active cognitive appraisal of the crisis permits mobilization of the personal and social resources necessary for its resolution. The counsellor encourages rehearsal of new coping strategies, first within the security of the counselling relationship where possible, then in the patient's real-life context. Except in the briefest crisis counselling, attention is paid to the significance for the patient of ending. This permits examination of those issues of loss inherent to most crises.

Crisis counselling is an important component of community mental health provision. It may be provided at self-referral counselling centres, operated by psychiatric services or voluntary agencies. Its relevance has again been recognized as resource constraints have led to increased pressure for alternatives to hospital admission.

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