Tag: Counselling

What is Motivational Interviewing?

Published on by Andrew Marshall2 Comments

Introduction

Motivational interviewing (MI) is a counselling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. Compared with non-directive counselling, it is more focused and goal-directed, and departs from traditional Rogerian client-centred therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. The examination and resolution of ambivalence is a central purpose, and the counsellor is intentionally directive in pursuing this goal. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.

Core concepts evolved from experience in the treatment of problem drinkers, and MI was first described by Miller (1983) in an article published in the journal Behavioural and Cognitive Psychotherapy. Miller and Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures.

Overview

Motivational interviewing (MI) is a person-centred strategy. It is used to elicit patient motivation to change a specific negative behaviour. MI engages clients, elicits change talk and evokes patient motivation to make positive changes. For example, change talk can be elicited by asking the patient questions such as: “How might you like things to be different?” or “How does __ interfere with things that you would like to do?”

Unlike clinical interventions and treatment, MI is the technique where the interviewer (clinician) assists the interviewee (patient) in changing a behaviour by expressing their acceptance of the interviewee without judgement. By this, MI incorporates the idea that every single patient may be in differing stages of readiness levels and may need to act accordingly to the patient’s levels and current needs. Change may occur quickly or may take considerable time, depending on the client. Knowledge alone is usually not sufficient to motivate change within a client, and challenges in maintaining change should be thought of as the rule, not the exception. The incorporation of MI can help patients resolve their uncertainties and hesitancies that may stop them from their inherent want of change in relation to a certain behaviour or habit. At the same time, it can be seen that MI ensures that the participants are viewed more as team members to solve a problem rather than a clinician and patient. Hence, this technique can be attributed to a collaboration that respects sense of self and autonomy.

To be more successful at motivational interviewing, a clinician must have a strong sense of “purpose, clear strategies and skills for such purposes”. This ensures that the clinician knows what goals they are trying to achieve prior to entering into motivational interviewing. Additionally, clinicians need to have well-rounded and established interaction skills including asking open ended questions, reflective listening, affirming and reiterating statements back to the patient. Such skills are used in a dynamic where the clinician actively listens to the patient then repackages their statements back to them while highlighting what they have done well. In this way, it can improve their self-confidence for change.

Furthermore, at the same time the clinician needs to keep in mind the following five principles when practicing MI.

Express Empathy

This means to listen and express empathy to patients through the use of reflective listening. In this step, the clinician listens and presents ideas the patient has discussed in a different way, rather than telling the patient what to do. This hopes to ensure that the patient feels respected and that there are no judgments given when they express their thoughts, feelings and experiences but instead, shows the patient that the clinician is genuinely interested about the patient and their circumstances. This aims to strengthen the relationship between the two parties and ensures it is a collaboration, and allows the patient to feel that the clinician is supportive and therefore will be more willing to be open about their real thoughts.

Develop Discrepancy

This means to assist patients in developing discrepancies between the current self and what they want to be like in the future after a change has taken place. The main goal of this principle is to increase the patient’s awareness that there are consequences to their current behaviours. This allows the patient to realize the negatives aspects and issues the particular behaviour that MI is trying to change can cause. This realisation can help and encourage the patient towards a dedication to change as they can see the discrepancy between their current behaviour and desired behaviour. It is important that the patient be the one making the arguments for change and realise their discrepancies themselves. An effective way to do this is for the clinician to participate in active reflective listening and repacking what the patient has told them and delivering it back to them.

Avoid Arguments

During the course of MI the clinician may be inclined to argue with a patient, especially when they are ambivalent about their change and this is especially true when “resistance” is met from the patient. If the clinician tries to enforce a change, it could exacerbate the patient to become more withdrawn and can cause degeneration of what progress had been made thus far and decrease rapport with the patient. Arguments can cause the patient to become defensive and draw away from the clinician which is counterproductive and diminishes any progress that may have been made. When patients become a little defensive and argumentative, it usually is a sign to change the plan of attack. The biggest progress made towards behaviour change is when the patient makes their own arguments instead of the clinician presenting it to them.

Roll with Resistance

“Rolling with resistance” is now an outdated concept in MI; in the third edition of Miller & Rollnick’s textbook Motivational Interviewing: Helping People Change, the authors indicated that they had completely abandoned the word “resistance” as well as the term “rolling with resistance”, due to the term’s tendency to blame the client for problems in the therapy process and obscure different aspects of ambivalence. “Resistance”, as the idea was previously conceptualised before it was abandoned in MI, can come in many forms such as arguing, interrupting, denying and ignoring. Part of successful MI is to approach the “resistance” with professionalism, in a way that is non-judgmental and allows the patient to once again affirm and know that they have their autonomy and that it is their choice when it comes to their change.

Support Self-Efficacy

Strong self-efficacy can be a significant predictor of success in behaviour change. In many patients there is an issue of the lack of self-efficacy. They may have tried multiple times on their own to create a change in their behaviour (e.g. trying to cease smoking, losing weight, sleep earlier) and because they have failed it causes them to lose their confidence and hence lowers their self-efficacy. Therefore, it is clear to see how important it is for the patient to believe that they are self-efficient and it is the clinician’s role to support them by means of good MI practice and reflective listening. By reflecting on what the patient had told them, the clinician can accentuate the patient’s strengths and what they have been successful in (e.g. commending a patient who had stopped smoking for a week instead of straining on the fact they failed). By highlighting and suggesting to the patient areas in which they have been successful, this can be incorporated into future attempts and can improve their confidence and efficacy to believe that they are capable of change.

While there are as many differences in technique, the underlying spirit of the method remains the same and can be characterized in a few key points:

  • Motivation to change is elicited from the client, and is not imposed from outside forces.
  • It is the client’s task, not the counsellor’s, to articulate and resolve the client’s ambivalence.
  • Direct persuasion is not an effective method for resolving ambivalence.
  • The counselling style is generally quiet and elicits information from the client.
  • The counsellor is directive, in that they help the client to examine and resolve ambivalence.
  • Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction.
  • The therapeutic relationship resembles a partnership or companionship.

Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.

Four Processes

There are four steps used in motivational interviewing. These help to build trust and connection between the patient and the clinician, focus on areas that may need to be changed and find out the reasons the patient may have for changing or holding onto a behaviour. This helps the clinician to support and assist the patient in their decision to change their behaviour and plan steps to reach this behavioural change. These steps do not always happen in this order.

Engaging

In this step, the clinician gets to know the patient and understands what is going on in the patient’s life. The patient needs to feel comfortable, listened to and fully understood from their own point of view. This helps to build trust with the patient and builds a relationship where they will work together to achieve a shared goal. The clinician must listen and show empathy without trying to fix the problem or make a judgement. This allows the patient to open up about their reasons for change, hopes, expectations as well as the barriers and fears that are stopping the patient from changing. The clinician must ask open ended questions which helps the patient to give more information about their situation, so they feel in control and that they are participating in the decision-making process and the decisions are not being made for them. This creates an environment that is comfortable for the patient to talk about change. The more trust the patient has towards the clinician, the more likely it is reduce resistance, defensiveness, embarrassment or anger the patient may feel when talking about a behavioural issue. Overall, the patient is more likely to come back to follow up appointments, follow an agreed plan and get the benefit of the treatment.

Focusing

This is where the clinician helps the patient find and focus on an area that is important to them, where they are unsure or are struggling to make a change. This step is also known as the “WHAT?” of change. The goal is for the clinician to understand what is important to the patient without pushing their own ideas on the patient. The clinician needs to ask questions to understand the reasons if and why the patient would be motivated to change and choose a goal to reach together. The patient must feel that they share the control with the clinician about the direction and agree on a goal. The clinician will then aim to help the patient order the importance of their goals and point out the current behaviours that get in the way of achieving their new goal or “develop discrepancy” between their current and desired behaviours. The focus or goal can come from the patient, situation or the clinician. There are three styles of focusing; directing, where the clinician can direct the patient towards a particular area for change; following, where the clinician let the patient decide the goal and be led by the patient’s priorities, and; guiding, where the clinician leads the patient to uncover an area of importance.

Evoking

In this step the clinician asks questions to get the patient to open up about their reasons for change. This step is also known as the “WHY?” of change. Often when a patient puts this into words it reinforces their reasons to change and they find out they have more reasons to change rather than to stay the same. Usually, there is one reason that is stronger than the others to motivate the patient to change their behaviour. The clinician needs to listen and recognise “change talk”, where the patient is uncovering how they would go about change and are coming up with their own solutions to their problems. The clinician should support and encourage the patient when they talk about ways and strategies to change, as the patient is more likely to follow a plan they set for themselves. When the patient is negative or is resisting change the clinician should “roll with resistance” where they do not affirm or encourage the negative points but highlight the ways and reasons the person has come up with to change. The clinician must resist arguing or the “righting reflex” where they want to fix the problem or challenge the patient’s negative thoughts. This comes across as they are not working together and causes the patient to resist change even more. The clinician’s role is to ask questions that guide the patient to come up with their own solution to change. The best time to give advice is if the patient asks for it, if the patient is stuck with coming up with ideas, the clinician can ask permission to give advice and then give details, but only after the patient has come up with their own ideas first. If the clinician focuses more on their own reasons they believe the patient should change this would not come across as genuine to the patient and this would reduce the bond they made in the engaging process.

Planning

In this step the clinician helps the patient in planning how to change their behaviour and encourages their commitment to change. This step is also known as the “HOW?” of change. The clinician asks questions to judge how ready the patient is to change and helps to guide the patient in coming up with their own step by step action plan. They can help to strengthen the patient’s commitment to changing, by supporting and encouraging when the patient uses “commitment talk” or words that show their commitment to change. In this step the clinician can listen and recognise areas that may need more work to get to the core motivation to change or help the patient to overcome uneasiness that is still blocking their behavioural change. In doing this, they help to strengthen the patients motivation and support that they are capable of achieving this goal on their own. The clinician should help the patient to come up with SMART goals which are; Specific, Measurable, Achievable, Relevant and Time bound. This helps to set benchmarks and measure how their behaviour has changed towards their new goal.

Adaptations

Motivational Enhancement Therapy

Motivational enhancement therapy is a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers’ Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback.

Motivational interviewing is supported by over 200 randomised controlled trials across a range of target populations and behaviours including substance abuse, health-promotion behaviours, medical adherence, and mental health issues.

Motivational Interviewing Groups

MI groups are highly interactive, focused on positive change, and harness group processes for evoking and supporting positive change. They are delivered in four phases:

  1. Engaging the group.
  2. Evoking member perspectives.
  3. Broadening perspectives and building momentum for change.
  4. Moving into action.

Behaviour Change Counselling

Behaviour change counselling (BCC) is an adaptation of MI which focuses on promoting behaviour change in a healthcare setting using brief consultations. BCC’s main goal is to understand the patient’s point of view, how they’re feeling and their idea of change. It was created with a “more modest goal in mind”, as it simply aims to “help the person talk through the why and how of change” and encourage behaviour change. It focuses on patient-centred care and is based on several overlapping principles of MI, such as respect for patient choice, asking open-ended questions, empathetic listening and summarizing. Multiple behaviour change counselling tools were developed to assess and scale the effectiveness of behaviour change counselling in promoting behaviour change such as the Behaviour Change Counselling Index (BECCI) and the Behaviour Change Counselling Scale (BCCS).

Behaviour Change Counselling Scale


The Behaviour Change Counselling Scale (BCCS) is a tool used to assess lifestyle counselling using BCC, focusing on feedback on the skill achieved. “Items of BCCS were scored on 1-7 Likert scales and items were tallied into 4 sub-scales, reflecting the 3 skill-sets: MI and readiness assessment, behaviour modification, and emotion management”.

The data obtained is then presented on: item characteristics, sub-scale characteristics, interrater reliability, test-retest reliability and construct validity.

Based on a study conducted by Vallis, the results suggest that BCCS is a potentially useful tool in assessing BCC and aid to training practitioners as well as assessing training outcomes.

Behaviour Change Counselling Index

The Behaviour Change Counselling Index (BECCI) is a BCC tool that assesses general practitioner behaviour and incites behaviour change through talking about change, encouraging the patient to think about change and respecting the patient’s choices in regards to behaviour change. BECCI was developed to assess a practitioner’s competence in the use of Behaviour Change Counselling (BCC) methods to elicit behaviour change. Used primarily for the use of learning practitioners in a simulated environment to practice and learn the skills of BCC. It “provides valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention”. Rather than the result and response from the patient, the tool emphasizes and measures the practitioner’s behaviours, skills and attitude. Results from the study show that after receiving training in BCC, practitioners show great improvement based on BECCI. However, as BECCI has only been used in a simulated clinical environment, more study is required to assess its reliability in a real patient environment. Furthermore, it focuses heavily on practitioner behaviour rather than patient behaviour. Therefore, BECCI may be useful for trainers to assess the reliability and effectiveness of BCC skills but further research and use is required, especially in a real consultation environment.

Technology Assisted Motivational Interview

Technology Assisted Motivational Interview (TAMI) is “used to define adaptations of MI delivered via technology and various types of media”. This may include technological devices and creations such as computers, mobile phones, telephones, videos and animations. A review of multiple studies shows the potential effectiveness of the use of technology in delivering motivational interviewing consultations to encourage behaviour change. However, some limitations include: the lack of empathy that may be expressed through the use of technology and the lack of face-to-face interaction may either produce a positive or negative effect on the patient. Further studies are required to determine whether face-to-face consultations to deliver MI is more effective in comparison to those delivered via technology.

Limitations

Underlying Mental Health Conditions

Patients with an underlying mental illness present one such limitation to motivational interviewing. In a case where the patient suffers from an underlying mental illness such as depression, anxiety, bipolar disease, schizophrenia or other psychosis, more intensive therapy may be required to induce a change. In these instances, the use of motivational interviewing as a technique to treat outward-facing symptoms, such as not brushing teeth, may be ineffective where the root cause of the problem stems from the mental illness. When working with these patients, it is important to recognise that only so much can be done at certain levels. The treating therapists should, therefore, ensure the patient is referred to the correct medical professional to treat the cause of the behaviour, and not simply one of the symptoms.

Pre-Contemplation

Patients in the pre-contemplation stage of the stages of change present a further limitation to the model. If the patient is in this stage, they will not consider they have a problem and therefore are unlikely to be receptive to motivational interviewing techniques. It is important that motivational interviewers are well trained in the approach to be taken when handling these patients. Well intended messages can have the opposite effect of pushing the patient away or causing them to actively rebel. In these instances discussing how the issue may be affecting the patient must be handled very delicately and introduced carefully. Suggesting less harmful ways of dealing with the client’s issue and helping them recognize danger signs may be a better approach to plant the seed aiding their progression to the contemplation stage.

Motivation

Professionals attempting to encourage people to make a behavioural change often underestimate the effect of motivation. Simply advising clients how detrimental their current behaviour is and providing advice on how to change their behaviour will not work if the client lacks motivation. Many people have full knowledge of how dangerous smoking is yet they continue the practice. Research has shown that a client’s motivation to alter behaviour is largely influenced by the way the therapist relates to them.

Therapist/Client Trust

Clients who do not like or trust their health care professionals are likely to become extremely resistant to change. In order to prevent this, the therapist must take time to foster an environment of trust. Even when the therapist can clearly identify the issues at hand it is important to have the patient feels the session is collaborative and that they are not being lectured to. Confrontational approaches by well-meaning therapists will inhibit the process.

Time Limitations

Time limits placed on therapists during consultations also have the potential to impact significantly on the quality of motivational interviewing. Appointments may be limited to a brief or single visit with a patient; for example, a client may attend the dentist with a toothache due to a cavity. The oral health practitioner or dentist may be able to broach the subject of a behaviour change, such as flossing or diet modification but the session duration may not be sufficient when coupled with other responsibilities the health practitioner has to the health and wellbeing of the patient. For many clients, changing habits may involve reinforcement and encouragement which is not possible in a single visit. Some patients, once treated, may not return for a number of years or may even change practitioners or practices, meaning the motivational interview is unlikely to have sufficient effect.

Training Deficiencies

While psychologists, mental health counsellors, and social workers are generally well trained and practiced in delivering motivational interviewing, other health-care professionals are generally provided with only a few hours of basic training. Although perhaps able to apply the underpinning principles of motivational interviewing, these professionals generally lack the training and applied skills to truly master the art of dealing with the patient’s resistant statements in a collaborative manner. It is important that therapists know their own limitations and are prepared to refer clients to other professionals when required.

Group Treatment

Although studies are somewhat limited, it appears that delivering motivational interviewing, in a group may be less effective than when delivered one-on-one. Research continues into this area however what is clear is that groups change the dynamics of a situation and the therapist needs to ensure that group control is maintained and input from group members does not derail the process for some clients.

Applications

Motivational interviewing was initially developed for the treatment of substance abuse, but MI is continuously being applied across health fields and beyond that. The following fields have used the technique of MI.

Brief Intervention

Brief intervention and MI are both techniques used to empower behavioural change within individuals. Behavioral interventions “generally refer to opportunistic interventions by non-specialists (e.g. GPs) offered to patients who may be attending for some unrelated condition”. Due to speculation in the health industry the use of brief intervention has been deemed to be used too loosely and the implementation of MI is increasing rapidly.

Classroom Management

Motivational interviewing has been incorporated into managing a classroom. Due to the nature of MI where it elicits and evokes behavioural change within an individual it has shown to be effective in a classroom especially when provoking behaviour change within an individual. In association with MI, the classroom check-up method is incorporated which is a consultation model that addresses the need for classroom level support.

Coaching

Motivational interviewing has been implemented in coaching, specifically health-based coaching to aid in a better lifestyle for individuals. A study titled “Motivational interviewing-based health coaching as a chronic care intervention” was conducted to evaluate if MI had an impact on individuals health who were assessed as chronically ill. The study’s results showed that the group that MI was applied to had “improved their self-efficacy, patient activation, lifestyle change and perceived health status”.

Environmental Sustainability

Initially motivational interviewing was implemented and formulated to elicit behavioural change in individuals suffering from substance abuse. However, MI has been reformed and has multiple uses. One of these uses include of stabilising the surrounding environment of an individual. This is completed by allowing the individual to evoke behavioural change within themselves and elicit motivation to change certain habits, for example substance abuse. By motivating the individual, it allows them to maintain the environment surrounding them to eliminate factors of temptation. However, if relapse occurs it is normal and is bound to happen.

Mental Disorders

Motivational interviewing was originally developed by William R. Miller and Stephen Rollnick in the 1980s in order to aid people with substance abuse disorders. However, it has also been implemented to help aid in established models with mental disorders such as anxiety and depression. Currently an established model known as cognitive behavioural therapy (CBT) is being implemented to aid in these issues. Research suggests that with collaborating motivational interviewing and CBT has proved to be effective as they have both shown to be effective. A study was conducted as a randomised cluster trial that suggests that when MI was implemented it “associated with improved depressive symptoms and remission rate”. There is currently insufficient research papers to prove the effect of MI in mental disorders. However, it is increasingly being applied and more research is going into it.

Dual Diagnosis

Dual diagnosis can be defined as a “term that is used to describe when a person is experiencing both mental health problems and substance misuse”. Motivational interviewing is used as a preventative measure for individuals suffering from both a mental health issue and substance misuse due to the nature of MI eliciting behavioural change in individuals.

Problem Gambling

Gambling issues are on the rise and it is becoming a struggle for therapists to maintain it. Research suggests that many individuals “even those who actively seek and start gambling treatment, do not receive the full recommended course of therapy”. Motivational interviewing has been widely used and adapted by therapists to overcome gambling issues, it is used in collaboration with cognitive behavioural therapy and self-directed treatments. The goal of using MI in an individual who is having issues with gambling is to recognize and overcome those barriers and “increase overall investment in therapy by supporting an individual’s commitment to changing problem behaviours”.

Parenting

Motivational interviewing is implemented to evoke behavioural change in an individual. Provoking behavioural change includes the recognising of the issue from an individual. A research was conducted by utilising motivational interviewing to help promote oral regime and hygiene within children under the supervision of a parent. In this research the experimental group which was parents who received MI education in the form of a “pamphlet, watched a videotape, as well as received an MI counselling session and six follow-up telephone calls”. The mothers who had received the MI counselling session showed that “children in the MI group exhibited significantly less new caries (decayed or filled surfaces)” in contrast to the children in the control group. This suggests that the application of MI with parenting can significantly impact outcomes regarding the children of the parent.

Substance Dependence

Motivational interviewing was initially developed in order to aid people with substance abuse, specifically alcohol. Due to the results it displayed MI can be implemented into any substance abuse or dependence treatment. Research that was conducted utilised MI with a cocaine-detoxification programme. This research had found that out of the 105 randomly assigned patients, the randomly assigned group that underwent MI treatment indicated that “completers who received MI increased use of behavioural coping strategies and had fewer cocaine-positive urine samples on beginning the primary treatment”. This evidence suggests that the application of MI in substance dependent individuals has a positive impact in aiding the individual to overcome this issue.

A 2016 Cochrane review focused on alcohol misuse in young adults in 84 trials found no substantive, meaningful benefits for MI for preventing alcohol misuse or alcohol-related problems.

What is Counselling Psychology?

Published on by Andrew Marshall6 Comments

Introduction

Counselling psychology is a psychological specialty that encompasses research and applied work in several broad domains: counselling process and outcome; supervision and training; career development and counselling; and prevention and health. Some unifying themes among counselling psychologists include a focus on assets and strengths, person-environment interactions, educational and career development, brief interactions, and a focus on intact personalities.

Brief History

The term “counselling” is of American origin, coined by Carl Rogers, who, lacking a medical qualification was prevented from calling his work psychotherapy. In the US, counselling psychology, like many modern psychology specialties, started as a result of World War II. During the war, the US military had a strong need for vocational placement and training. In the 1940s and 1950s, the Veterans Administration created a specialty called “counselling psychology”, and Division 17 (now known as the Society for Counselling Psychology) of the APA was formed. The Society of Counselling Psychology unites psychologists, students and professionals who are dedicated to promote education and training, practice, scientific investigation, diversity and public interest in the field of professional psychology. This fostered interest in counsellor training, and the creation of the first few counselling psychology PhD programmes. The first counselling psychology PhD programmes were at the University of Minnesota; Ohio State University; University of Maryland, College Park; University of Missouri; Teachers College, Columbia University; and University of Texas at Austin.

In recent decades, counselling psychology as a profession has expanded and is now represented in numerous countries around the world. Books describing the present international state of the field include the Handbook of Counselling and Psychotherapy in an International Context; the International Handbook of Cross-Cultural Counselling; and Counselling Around the World: An International Handbook. Taken together these volumes trace the global history of the field, explore divergent philosophical assumptions, counselling theories, processes, and trends in different countries, and review a variety of global counsellor education programmes. Moreover, traditional and indigenous treatment and healing methods that may predate modern counselling methods by hundreds of years remain of significance in many non-Western and Western countries.

Employment and Salary

Counselling psychologists are employed in a variety of settings depending on the services they provide and the client populations they serve. Some are employed in colleges and universities as teachers, supervisors, researchers, and service providers. Others are employed in independent practice providing counselling, psychotherapy, assessment, and consultation services to individuals, couples/families, groups, and organisations. Additional settings in which counselling psychologists practice include community mental health centres, Veterans Administration medical centres and other facilities, family services, health maintenance organisations, rehabilitation agencies, business and industrial organisations and consulting within firms.

The amount of training required for psychologists differs based on the country in which they are practicing. Typically, a psychologist completes an Undergraduate Degree followed by 5-6 years of further study and/or training, leading to the Ph.D. While both psychologists and psychiatrists offer counselling, psychiatrists must possess a medical degree and thus are able to prescribe medication where psychologists are not.

Process and Outcome

Counselling psychologists are interested in answering a variety of research questions about counselling process and outcome. Counselling process refers to how or why counselling happens and progresses. Counselling outcome addresses whether or not counselling is effective, under what conditions it is effective, and what outcomes are considered effective – such as symptom reduction, behaviour change, or quality of life improvement. Topics commonly explored in the study of counselling process and outcome include therapist variables, client variables, the counselling or therapeutic relationship, cultural variables, process and outcome measurement, mechanisms of change, and process and outcome research methods. Classic approaches appeared early in the US in the field of humanistic psychology by Carl Rogers who identified the mission of counselling interview as “to permit deeper expression that the client would ordinarily allow himself”

Therapist Variables

Therapist variables include characteristics of a counsellor or psychotherapist, as well as therapist technique, behaviour, theoretical orientation and training. In terms of therapist behaviour, technique and theoretical orientation, research on adherence to therapy models has found that adherence to a particular model of therapy can be helpful, detrimental, or neutral in terms of impact on outcome.

A recent meta-analysis of research on training and experience suggests that experience level is only slightly related to accuracy in clinical judgement, Higher therapist experience has been found to be related to less anxiety, but also less focus. This suggests that there is still work to be done in terms of training clinicians and measuring successful training.

Client Variables

Client characteristics such as help-seeking attitudes and attachment style have been found to be related to client use of counselling, as well as expectations and outcome. Stigma against mental illness can keep people from acknowledging problems and seeking help. Public stigma has been found to be related to self-stigma, attitudes towards counselling, and willingness to seek help.

In terms of attachment style, clients with avoidance styles have been found to perceive greater risks and fewer benefits to counselling, and are less likely to seek professional help, than securely attached clients. Those with anxious attachment styles perceive greater benefits as well as risks to counselling. Educating clients about expectations of counselling can improve client satisfaction, treatment duration and outcomes, and is an efficient and cost-effective intervention.

Counselling Relationship

The relationship between a counsellor and client is the feelings and attitudes that a client and therapist have towards one another, and the manner in which those feelings and attitudes are expressed. Some theorists have suggested that the relationship may be thought of in three parts: transference and countertransference, working alliance, and the real – or personal – relationship. Other theorists argue that the concepts of transference and countertransference are outdated and inadequate.

Transference can be described as the client’s distorted perceptions of the therapist. This can have a great effect on the therapeutic relationship. For instance, the therapist may have a facial feature that reminds the client of their parent. Because of this association, if the client has significant negative or positive feelings toward their parent, they may project these feelings onto the therapist. This can affect the therapeutic relationship in a few ways. For example, if the client has a very strong bond with their parent, they may see the therapist as a father or mother figure and have a strong connection with the therapist. This can be problematic because as a therapist, it is not ethical to have a more than “professional” relationship with a client. It can also be a good thing, because the client may open up greatly to the therapist. In another way, if the client has a very negative relationship with their parent, the client may feel negative feelings toward the therapist. This can then affect the therapeutic relationship as well. For example, the client may have trouble opening up to the therapist because they lack trust in their parent (projecting these feelings of distrust onto the therapist).

Another theory about the function of the counselling relationship is known as the secure-base hypothesis, which is related to attachment theory. This hypothesis proposes that the counsellor acts as a secure base from which clients can explore and then check in with. Secure attachment to one’s counsellor and secure attachment in general have been found to be related to client exploration. Insecure attachment styles have been found to be related to less session depth than securely attached clients.

Cultural Variables

Counselling psychologists are interested in how culture relates to help-seeking and counselling process and outcome. Standard surveys exploring the nature of counselling across cultures and various ethnic groups include Counselling Across Cultures by Paul B. Pedersen, Juris G. Draguns, Walter J. Lonner and Joseph E. Trimble, Handbook of Multicultural Counseling by Joseph G. Ponterotto, J. Manueal Casas, Lisa A. Suzuki and Charlene M. Alexander and Handbook of Culture, Therapy, and Healing by Uwe P. Gielen, Jefferson M. Fish and Juris G. Draguns. Janet E. Helms’ racial identity model can be useful for understanding how the relationship and counselling process might be affected by the client’s and counsellor’s racial identity. Recent research suggests that clients who are Black are at risk for experiencing racial micro-aggression from counsellors who are White.

Efficacy for working with clients who are lesbians, gay men, or bisexual might be related to therapist demographics, gender, sexual identity development, sexual orientation, and professional experience. Clients who have multiple oppressed identities might be especially at-risk for experiencing unhelpful situations with counsellors, so counsellors might need help with gaining expertise for working with clients who are transgender, lesbian, gay, bisexual, or transgender people of colour, and other oppressed populations.

Gender role socialisation can also present issues for clients and counsellors. Implications for practice include being aware of stereotypes and biases about male and female identity, roles and behaviour such as emotional expression. The APA guidelines for multicultural competence outline expectations for taking culture into account in practice and research.

Counselling Ethics and Regulation

Perceptions on ethical behaviours vary depending upon geographical location, but ethical mandates are similar throughout the global community. Ethical standards are created to help practitioners, clients and the community avoid any possible harm or potential for harm. The standard ethical behaviours are centred on “doing no harm” and preventing harm.

Counsellors cannot share any confidential information that is obtained through the counselling process without specific written consent by the client or legal guardian except to prevent clear, imminent danger to the client or others, or when required to do so by a court order. Insurance companies or government programmes will also be notified of certain information about your diagnosis and treatment to determine if your care is covered. Those companies and government programmes are bound by HIPAA to keep that information strictly confidential.

Counsellors are held to a higher standard than most professionals because of the intimacy of their therapeutic delivery. Counsellors are not only to avoid fraternising with their clients. They should avoid dual relationships, and never engage in sexual relationships.

Counsellors are to avoid receiving gifts, favours, or trade for therapy. In some communities, it may be avoidable given the economic standing of that community. In cases of children, children and the mentally handicapped, they may feel personally rejected if an offering is something such as a “cookie”. As counsellors, a judgement call must be made, but in a majority of cases, avoiding gifts, favours, and trade can be maintained.

The National Board for Certified Counsellors states that counsellors “shall discuss important considerations to avoid exploitation before entering into a non-counselling relationship with a former client. Important considerations to be discussed include amount of time since counselling service termination, duration of counselling, nature and circumstances of client’s counselling, the likelihood that the client will want to resume counselling at some time in the future; circumstances of service termination and possible negative effects or outcomes.”

Outcome Measurement

Counselling outcome measures might look at a general overview of symptoms, symptoms of specific disorders, or positive outcomes, such as subjective well-being or quality of life. The Outcome Questionnaire-45 is a 45-item self-report measure of psychological distress. An example of disorder-specific measure is the Beck Depression Inventory. The Quality of Life Inventory is a 17-item self-report life satisfaction measure.

Process and Outcome Research Methods

Research about the counselling process and outcome uses a variety of research methodologies to answer questions about if, how, and why counselling works. Quantitative methods include randomly controlled clinical trials, correlation studies over the course of counselling, or laboratory studies about specific counselling process and outcome variables. Qualitative research methods can involve conducting, transcribing and coding interviews; transcribing and/or coding therapy sessions; or fine-grain analysis of single counselling sessions or counselling cases.

Training and Supervision

Professional Training Process

Counselling psychologists are trained in graduate programmes. Almost all programmes grant a PhD, but a few grant a Psy.D. or Ed.D. Most doctoral programmes take 5-6 years to complete. Graduate work in counselling psychology includes coursework in general psychology and statistics, counselling practice, and research. Students must complete an original dissertation at the end of their graduate training. Students must also complete a one-year full-time internship at an accredited site before earning their doctorate. In order to be licensed to practice, counselling psychologists must gain clinical experience under supervision, and pass a standardised exam.

Australia

In Australia, counselling psychology programmes are accredited by the Australian Psychology Accreditation Council (APAC). To become registered as a counselling psychologist, one must meet the criteria for the area of practice endorsement. This includes an undergraduate degree in the science of psychology, an Honours degree or Postgraduate Diploma in Psychology, and a Master’s or Doctorate degree in counselling psychology. Graduates must then complete a registrar programme to obtain an area of practice endorsement and use the title counselling psychologist. A substantial component of this master’s degree is dedicated to individual psychotherapy, family and couples therapy, group therapy, developmental theory and psychopathology.

Training Models and Research

Counselling psychology includes the study and practice of counsellor training and counsellor supervision. As researchers, counselling psychologists may investigate what makes training and supervision effective. As practitioners, counselling psychologists may supervise and train a variety of clinicians. Counsellor training tends to occur in formal classes and training programmes. Part of counsellor training may involve counselling clients under the supervision of a licensed clinician. Supervision can also occur between licensed clinicians, as a way to improve clinicians’ quality of work and competence with various types of counselling clients.

As the field of counselling psychology formed in the mid-20th century, initial training models included Robert Carkuff’s human relations training model, Norman Kagan’s Interpersonal Process Recall, and Allen Ivey’s micro-counselling skills. Modern training models include Gerard Egan’s skilled helper model, and Clara E. Hill’s three-stage model (exploration, insight, and action). A recent analysis of studies on counsellor training found that modelling, instruction, and feedback are common to most training models, and seem to have medium to large effects on trainees.

Supervision Models and Research

Like the models of how clients and therapists interact, there are also models of the interactions between therapists and their supervisors. Edward S. Bordin proposed a model of supervision working alliance similar to his model of therapeutic working alliance. The Integrated Development Model considers the level of a client’s motivation/anxiety, autonomy, and self and other awareness. The Systems Approach to Supervision views the relationship between supervisor and supervised as most important, in addition to characteristics of the supervisor’s personal characteristics, counselling clients, training setting, as well as the tasks and functions of supervision. The Critical Events in Supervision model focuses on important moments that occur between the supervisor and supervised.

Problems can arise in supervision and training. First, supervisors are liable for malpractice. Also, questions have arisen as far as a supervisor’s need for formal training to be a competent supervisor. Recent research suggests that conflicting, multiple relationships can occur between supervisors and clients, such as that of the client, instructor, and clinical supervisor. The occurrence of racial micro-aggression against Black clients suggests potential problems with racial bias in supervision. In general, conflicts between a counsellor and his or her own supervisor can arise when supervisors demonstrate disrespect, lack of support, and blaming.

Vocational Development and Career Counselling

Vocational Theories

There are several types of theories of vocational choice and development. These types include trait and factor theories, social cognitive theories, and developmental theories. Two examples of trait and factor theories, also known as person-environment fit, are Holland’s theory and the Theory of Work Adjustment.

John Holland hypothesized six vocational personality/interest types and six work environment types:

  • Realistic;
  • Investigative;
  • Artistic;
  • Social;
  • Enterprising; and
  • Conventional.

When a person’s vocational interests match his or her work environment types, this is considered congruence. Congruence has been found to predict occupation and college major.

The Theory of Work Adjustment (TWA), as developed by René Dawis and Lloyd Lofquist, hypothesizes that the correspondence between a worker’s needs and the reinforced systems predicts job satisfaction, and that the correspondence between a worker’s skills and a job’s skill requirements predicts job satisfaction. Job satisfaction and personal satisfaction together should determine how long one remains at a job. When there is a discrepancy between a worker’s needs or skills and the job’s needs or skills, then change needs to occur either in the worker or the job environment.

Social Cognitive Career Theory (SCCT) has been proposed by Robert D. Lent, Steven D. Brown and Gail Hackett. The theory takes Albert Bandura’s work on self-efficacy and expands it to interest development, choice making, and performance. Person variables in SCCT include self-efficacy beliefs, outcome expectations and personal goals. The model also includes demographics, ability, values, and environment. Efficacy and outcome expectations are theorised to interrelate and influence interest development, which in turn influences choice of goals, and then actions. Environmental supports and barriers also affect goals and actions. Actions lead to performance and choice stability over time.

Career development theories propose vocational models that include changes throughout the lifespan. Donald Super’s model proposes a lifelong five-stage career development process. The stages are growth, exploration, establishment, maintenance, and disengagement. Throughout life, people have many roles that may differ in terms of importance and meaning. Super also theorised that career development is an implementation of self-concept. Gottfredson also proposed a cognitive career decision-making process that develops through the lifespan. The initial stage of career development is hypothesized to be the development of self-image in childhood, as the range of possible roles narrows using criteria such as sex-type, social class, and prestige. During and after adolescence, people take abstract concepts into consideration, such as interests.

Career Counselling

Career counselling may include provision of occupational information, modelling skills, written exercises, and exploration of career goals and plans. Career counselling can also involve the use of personality or career interest assessments, such as the Myers-Briggs Type Indicator, which is based on Carl Jung’s theory of psychological type, or the Strong Interest Inventory, which makes use of Holland’s theory. Assessments of skills, abilities, and values are also commonly assessed in career counselling.

Professional Journals

In the United States, the premier scholarly journals of the profession are the Journal of Counselling Psychology and The Counselling Psychologist.

In Australia, counselling psychology articles are published in the counselling psychology section of the Australian Psychologist.

In Europe, the scholarly journals of the profession include the European Journal of Counselling Psychology (under the auspices of the European Association of Counselling Psychology) and the Counselling Psychology Review (under the auspices of the British Psychological Society). Counselling Psychology Quarterly is an international interdisciplinary publication of Routledge (part of the Taylor & Francis Group).

On This Day … 09 November

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People (Births)

  • 1939 – Paul Cameron, American psychologist and academic.

People (Deaths)

  • 2002 – William Schutz, American psychologist and academic (b. 1925).

Paul Cameron

Paul Drummond Cameron (born 09 November, 1939) is an American psychologist. Cameron has been designated by the Southern Poverty Law Centre as an anti-gay extremist.

While employed at various institutions, including the University of Nebraska, he conducted research on passive smoking, but he is best known today for his claims about homosexuality. After a successful 1982 campaign against a gay rights proposal in Lincoln, Nebraska, he established the Institute for the Scientific Investigation of Sexuality (ISIS), now known as the Family Research Institute (FRI). As FRI’s chairman, Cameron has written contentious papers asserting associations between homosexuality and the perpetration of child sexual abuse and reduced life expectancy. These have been heavily criticised by others in the field.

In 1983, the American Psychological Association expelled Cameron for non-cooperation with an ethics investigation. Position statements issued by the American Sociological Association, Canadian Psychological Association, and the Nebraska Psychological Association accuse Cameron of misrepresenting social science research.

William Schutz

William Schutz (19 December 1925 to 09 November 2002) was an American psychologist.

Schutz was born in Chicago, Illinois. He practiced at the Esalen Institute in the 1960s. He later became the president of BConWSA International. He received his PhD from UCLA. In the 1950s, he was part of the peer-group at the University of Chicago’s Counselling Centre that included Carl Rogers, Thomas Gordon, Abraham Maslow and Elias Porter. He taught at Tufts University, Harvard University, University of California, Berkeley and the Albert Einstein College of Medicine, and was chairman of the holistic studies department at Antioch University until 1983.

In 1958, Schutz introduced a theory of interpersonal relations he called Fundamental Interpersonal Relations Orientation (FIRO). According to the theory three dimensions of interpersonal relations were deemed to be necessary and sufficient to explain most human interaction: Inclusion, Control and Affection. These dimensions have been used to assess group dynamics.

Schutz also created FIRO-B, a measurement instrument with scales that assess the behavioural aspects of the three dimensions. His advancement of FIRO Theory beyond the FIRO-B tool was most obvious in the change of the “Affection” scale to the “Openness” scale in the “FIRO Element-B”. This change highlighted his newer theory that behaviour comes from feelings (“FIRO Element-F”) and the self-concept (“FIRO Element-S”). “Underlying the behaviour of openness is the feeling of being likable or unlikeable, lovable or unlovable. I find you likable if I like myself in your presence, if you create an atmosphere within which I like myself.”

W. Schutz authored more than ten books and many articles. His work was influenced by Alexander Lowen, Ida Pauline Rolf and Moshe Feldenkrais. As a body therapist he led encounter group workshops focussing on the underlying causes of illnesses and developing alternative body-centred cures. His books, “Profound Simplicity” and “The Truth Option,” address this theme. He brought new approaches to body therapy that integrated truth, choice (freedom), (self) responsibility, self-esteem, self-regard and honesty into his approach.

In his books one encounters the concept of energy cycles (e.g. Schutz 1979) which a person goes through or call for completion. The single steps of the energy cycles are: motivation – prepare – act – feel.

Schutz died at his home in Muir Beach, California in 2002.

Book: Anti-Discriminatory Practice in Counselling & Psychotherapy

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Book Title:

Anti-Discriminatory Practice in Counselling & Psychotherapy.

Author(s): Colin Lago and Barbara Smith (Editors).

Year: 2010.

Edition: First (1st).

Publisher: SAGE Publications Ltd.

Type(s): Paperback and EPUB.

Synopsis:

Anti-Discriminatory Practice in Counselling and Psychotherapy is a groundbreaking text which identifies the ease with which individuals can be disadvantaged merely on the basis of their gender, race, culture, age, sexuality or ability. Examining these and other areas of discrimination, leading experts highlight how vital it is for counsellors, psychotherapists – and others in the helping professions – to be aware of and engage with their own social, political and cultural attitudes, and how they must develop their skills as culturally sensitive, reflective practitioners if counselling is to be truly accessible to all members of society.

This substantially revised and updated second edition now also includes chapters on working within an anti-discriminatory approach with:

  • Refugees;
  • People with mental health difficulties; and
  • People with disfigurement or visible differences.

While each thought-provoking chapter now:

  • Links theory to practice by providing case studies and extracts from therapeutic dialogues;
  • Assesses the most recent research findings;
  • Provides exercises for enhancing awareness and skills within each different domain or care setting; and
  • Presents references for further recommended reading.

Clearly written and accessible, Anti-discriminatory Practice in Counselling and Psychotherapy is an indispensable addition to the toolkit of everyone either training to be or practising in the counselling and psychotherapeutic professions.

Book: Brief Counselling: A Practical Integrative Approach

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Book Title:

Brief Counselling: A Practical Integrative Approach.

Author(s): Colin Feltham and Wendy Dryden.

Year: 2006.

Edition: Second (2ed).

Publisher: Open University Press.

Type(s): Paperback and Kindle.

Synopsis:

Almost two thirds of counsellors and psychotherapists work with clients in up to twenty sessions each: this book reflects that reality and the challenges involved.

The bestselling first edition of this book, by two of the UK’s leading counsellor trainers and academics, was praised by trainers and tutors for its accessibility, comprehensiveness and practicality. It was also a leading contribution to the movement towards time-conscious counselling and to an understanding of the therapeutic alliance across time.

The second edition has been thoroughly updated to include significant recent professional developments and new thinking in the counselling field. Additions include more detailed discussion of:

  • Assessment.
  • Contracting.
  • Very brief counselling.
  • Clinical reasoning.
  • Clients’ modalities.
  • Technical repertoire.
  • Depression and realism.
  • Supervision of brief counselling.

In the rapidly maturing profession of counselling, this book’s sensitivity to time as a precious resource, clients’ perceptions, evidence-based guidelines and integration of some of the best thinking from several counselling models make it an ideal core text for beginners and reflective practitioners. Thoughtful and busy practitioners in primary care, employee counselling, educational, voluntary and private practice settings will find many immediately helpful ideas and examples in this classic text.

Book: Working with Sexual Issues in Psychotherapy

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Book Title:

Working with Sexual Issues in Psychotherapy: A Practical Guide Using a Systemic Social Constructionist Framework (Basic Texts in Counselling and Psychotherapy).

Author(s): Desa Markovic.

Year: 2017.

Edition: First (1st).

Publisher: Red Globe Press.

Type(s): Paperback and Kindle.

Synopsis:

Whilst many psychotherapists work skilfully and creatively with the subject of sex, the lack of professional support systems such as training and supervision mean that the topic is often still treated as taboo in the psychotherapy room.

This secretive treatment may increase clients feelings of shame and embarrassment, thus mirroring the confusing views on sexuality in society and leading to the onset and development of sexual dysfunctions.

Bringing the medical perspective of sexology together with systemic psychotherapy informed by social constructionism, this timely book seeks to fill the gap in psychotherapy literature, research and training by providing a theoretical framework, as well as practical guidance, for effective therapeutic interventions in working with sex and sexual relationships in clinical practice.

Exploring topics such as sexual prejudice, the significance of sexual diversity and the assessment and treatment of sexual dysfunctions, enriched with a wealth of engaging case studies, Working with Sexual Issues in Psychotherapy is a fascinating and important read both for students new to this complex topic, and for practitioners looking for a comprehensive source of reference.

Book: Introducing Counselling: A Practical Guide

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Book Title:

Introducing Counselling: A Practical Guide.

Author(s): Alastair Ross.

Year: 2013.

Edition: First (1st), UK Edition.

Publisher: Icon Books Ltd.

Type(s): Paperback and Kindle.

Synopsis:

Introducing Counselling: A Practical Guide is an accessible and practical route into counselling techniques. What is it? How does it work? And how can it change your life?

With expert advice on everything from the ethics of counselling to identifying steps forward, this book offers an invaluable guide to anyone who is interested in counselling others, or in having counselling themselves. Introducing Practical Guides bring you the world’s greatest theories and research to improve your life, your skills and your well-being.

Packed full of straightforward, realistic advice that has immediate results, Practical Guides are engineered by experts in their fields to help you achieve your goals.

Book: Becoming an Addictions Counselor

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300300

Book Title:

Becoming an Addictions Counselor: A Comprehensive Text.

Author(s): Peter L. Myers and Norman R. Salt.

Year: 2018.

Edition: Fourth (4th).

Publisher: Jones & Bartlett Learning.

Type(s): Paperback and Kindle.

Synopsis:

Becoming an Addictions Counselor, Fourth Edition provides evidence-based findings, cutting-edge treatment techniques, and a focus on critical thinking to show future counsellors how to respond to clients’ needs rather than impose “cookie-cutter” routines.

The Challenges & Opportunities for Counselling & Psychotherapy in the Aftermath of COIV-19.

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Research Paper Title

Counselling and psychotherapy post-COVID-19.

Background

The researchers consider how the prolonged, complex and uncertain aftermath of the COVID-19 crisis will present challenges and opportunities for counselling and psychotherapy.

Increased mental strain on populations, individuals and professionals is likely to be compounded by further constraints in therapeutic resources.

Nevertheless, emerging needs and priorities will offer ground for systems thinking in linking the application of a range of therapeutic frameworks, theories to address global challenges, integration of counselling and psychotherapy into new sectors, service models for the most vulnerable, use of digital approaches, support mechanisms for professionals and interdisciplinary research.

Reference

Vostanis, P & Bell, C.A. (2020) Counselling and psychotherapy post-COVID-19. Counselling and Psychotherapy Research. doi: 10.1002/capr.12325. Online ahead of print.

Book: Substance Abuse – Assessment & Diagnosis

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Book Title:

Substance Abuse – Assessment & Diagnosis.

Author(s): Gerald A. Juhnke.

Year: 2002.

Edition: 1ed.

Publisher: Routledge.

Type(s): Hardcover, Paperback and Kindle.

Synopsis:

Substance abuse counselling has gone beyond being viewed as optional training; instead it is fast becoming an essential part of the education of helping professionals. In this book, Dr. Gerald Juhnke presents an innovative, practical model to be used in the assessment and diagnosing of substance abuse and related co-morbid disorders.

Substance Abuse Assessment and Diagnosis includes practical “nuts and bolts” direction on how to facilitate a thorough, multi-tiered substance abuse assessment. This book uniquely incorporates detailed examples of how to use individual and significant other clinical interviews, including the CAGE, SUBSTANCE -Q, etc, standardised specialty instruments, drug detection types, and personality instruments to accomplish this feat. This is the only book of its kind that provides practical detail on how to use and score these varied assessment instruments-including the newest “cornerstone instruments,” the MMPI-2, the SASSI-3 and the recently released SASSI-A2.

Students and practitioners alike will benefit from this comprehensive volume on the assessment and diagnosis of substance abuse.