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30 Counselling those troubled by anger Counsellors will inevitably at times be invited to help a person who has trouble in managing anger. Bottled-up anger can be very destructive and also very dangerous because it may break out at some time or other and the person may do injury or damage to someone else. Many counsellors, in the early People who have stages of their counselling careers, become quite frightened when a poor anger person who seeks help exhibits even moderate levels of anger. 1 his management skills can be dangerous chapter has been included to provide new counsellors with some to others including practical ideas about how to work with those people who have a counsellors problem with anger, in cases where it is not considered necessary to refer them to more experienced counsellors. People who are troubled by anger can often be helped to feel better if they are able to dissipate their anger without endangering others, and then to change some of their thinking patterns and behaviours. We will discuss two different and complementary ways of helping a person to dissipate anger. One way is to encourage them to release their anger verbally in the safety of the counselling environment, and the other is to teach relaxation (see Chapter 28). We will also consider ways to help a person to think and behave differently, so that hopefully they can deal with anger more constructively in the future. HELPING A PERSON TO RECOGNISE AND EXPRESS ANGER People who are not dangerous or violent can be allowed to recognise and express anger verbally in the counselling room. However, if an inexperienced counsellor suspects that a person seeking help might have the potential for violence, that person should be referred to a suitably qualified and experienced therapist. When, in a counselling session, a person starts to express anger you may choose to use the normal reflective counselling strategies if you wish. However, if the level of anger starts to rise then it's sensible for you, the counsellor, to take control and to ensure that the anger is directed away from you. As a counsellor, avoid allowing a person’s anger to rise significantly while they are talking directly to you, or you may end up in an unsafe situation where you feel threatened. Instead, protect yourself by using a method borrowed from Gestalt Therapy. (If you want to learn more about Gestalt ’Therapy read Clarkson and C a vicchia (2014), and if you like what you read, Counselling those troubled by anger CHAPTER 30 237you may wish to enrol in a Gestalt Therapy training course after you have completed your basic counsellor training.) The method involves the use of an empty chair. USE OF THE EMPTY CHAIR Start by asking the person, ‘Who are you most angry with?’ Next, place an empty chair facing them a metre or two away from them. Tell them to imagine that the person who is the target of their anger is sitting in the empty chair. Say to the person something like, 41 don’t want to be the recipient of your anger, so 1 don’t want you to tell me how angry you are; rather, I’d like you to talk to the imaginary person who is sitting in that empty chair, about your angry feelings towards them’. Preferably you should now stand beside the person seeking help and join them in facing the empty chair. You can then 'coach' them in their expression of anger towards the imagined person. For example, it the person starts by saying, ‘Well, actually I’m very angry with Fred, because Fred has consistently offended me with his behaviour,’ then, as counsellor, you can say yourself, Tm very angry with you, Fred, because you’ve consistently behaved badly.’ Hopefully, the person will then pick up the way in which they are expected to address the imagined person on the empty chair, instead of talking to you, and they can then be encouraged to express their anger openly and fully. This method is useful for the person as it enables them to verbalise the anger, and avoids a situation where the counsellor becomes the recipient of the anger, because the counsellor is standing beside and joining with the person. If this method appeals to you, then after completion of your basic counsellor training, you may wish to train as a Gestalt Therapist and learn other powerful techniques for enabling people to release angry feelings. WARNING! Remember that some people have great difficulty in controlling inappropriately high levels of anger. Among these are people who perpetrate violence against spouses, others, children or property. They must be referred to skilled psychotherapists and it is not appropriate for a new counsellor to Some people need attempt to help them. Moreover, rather than getting in touch with to learn to manage their anger rather and expressing their anger they need to learn ways to manage and than express it control it. If during counselling you suspect that a person has the inappropriately potential to be violent, seek assistance from an experienced counsellor or other relevant professional. HELPING A PERSON TO CHANGE THEIR THOUGHTS AND BEHAVIOURS Once counselling has been effective in enabling the person to moderate their high anger level, the next stage is to teach them how to deal with anger in the future. 238 PART 5 Dealing with particular problemsYou may find it useful to give the person seeking help a copy of the chart shown in Figure 30.1 and discuss it during a counselling session. Although the chart is fairly self-explanatory, it can be useful to work through it step by step. The first step is for the person to learn to recognise physiological cues. When we start to get angry, things happen to our bodies. What happens in your body when you are starting to get angry? We are all different: some people will notice their heart rate increase, others will breathe more rapidly, they may start to sweat, their muscles might tighten up or they might have an uncomfortable feeling in their stomach. Some people freeze on the spot and feel their hair standing on end. Because we are all different, each individual needs to identify for themselves what happens to them physiologically when they start to get angry. Once a person has learnt to recognise the physiological symptoms that occur as their anger starts to rise, they can use these as cues to indicate that action is required to take control of the anger. In fact, they have a choice: they can either let the anger take control of them and allow an angry outburst to occur or they can decide to take control of the anger, stop and respond differently. At times it may be better to allow controlled angry outbursts to occur, rather than to bottle up the emotion. Clearly, uncontrolled angry outbursts are dangerous, but letting off steam by occasionally having small controlled outbursts does enable anger to be dissipated. Unfortunately, people who continually behave angrily are certain to damage their relationships with others. THOUGHT-STOPPING An alternative to having an angry outburst is for the person to recognise the physiological cues that indicate a rise in anger, and to immediately say ‘STOP’ sharply but silently to themselves to interrupt their thoughts. The method is called thought-stopping. Once a person has interrupted the thoughts promoting anger, and stopped letting their thoughts hook them into an angry outburst, they can make the choice to step back from the situation, to move back in their imagination by 10 metres, so that they are, in effect, looking at themselves and their situation from a distant vantage point. 1 hey can then, if they choose, take a few slow, deep breaths and allow the muscles in their body to relax as they would Thought-stopping when engaged in a relaxation exercise (see Chapter 28). As the person can be very useful takes those few slow, deep breaths, each time they breathe out they for some people can say silently ‘Relax’, and allow their body to relax. Clearly, part of the process of helping a person to learn new ways of dealing with anger involves teaching relaxation (see Chapter 28). They can then use the method described above. By learning how to relax and how to recognise their patterns of behaviour, they will hopefully be able to lower the intensity of their emotional feelings in future times of crisis and then be able to deal with their anger more appropriately. TAKING TIME OUT 1 he next stage in the process of anger control involves several options, as shown on the chart (Figure 30.1). The ‘time out' block shown gives the person time to cool off Counselling those troubled by anger CHAPTER 30 239 CFigure 30.1 Anger control flow chart NOTICE PHYSIOLOGICAL CUES e,g. increased heart rate and breathing, muscle tension, stomach flutters, sweaty palms, immobility 4* STOP Step back from the situation I Take a few slow, deep breaths and relax the body I TIMEOUT Dispute irrational beliefs and use positive talk BE ASSERTIVE '1 feel. . . when . . (Make a CONCRETE statement of what I saw happening without interpretation! Listen to what the other person is saying and try to see the situation from their viewpoint Do nothing Build-up of negative feelings with emotional consequences 4* Look for a solution rather than aiming to win 4f: The possibility of a satisfactory outcome is maximised 240 PART 5 Dealing with particular problems EXAMPLES OF IRRATIONAL BELIEFS Other people should live up to my expectations! Other people should behave the way I do! Life is fair and just! I must succeed! I can't tolerate mistakes!and reduce their anger level before deciding what action, if any, to take. They may literally walk away from the situation and distance themselves physically from it. In order to do this, they may need to negotiate with some significant person in their life, so that the person concerned allows them space We need to select when they ask for it. an approach that suits the person After time out has been used to allow emotions to cool down, the emotional level may be further reduced by doing a relaxation exercise, by becoming fully absorbed in carrying out a task (such as putting full concentration into cooking a meal) or by engaging in physical exercise (like going jogging). For people who are not violent, and are not likely to become violent, another alternative is for them to dissipate their anger by beating up a beanbag, mattress or punching bag. This method can be very helpful for people who do not usually experience high levels of anger, but are angry as a result of a short-tenil life crisis. However, a word of warning: physically releasing angiy feelings in this way is not recommended for those people who are likely to become violent with either people or property. These people need to learn how to control their anger and should be referred to specialist counsellors and counselling programs. Teaching them to vent their anger by acting it out physically may be potentially dangerous because it could reinforce violent tendencies. MAKING A DECISION From this point in the anger control process the options are either to do nothing further or to move into the action described in the left-hand column on the anger control chart. Sometimes doing nothing is satisfactory. It may be that, as a result of time out followed by one of the anger-dissipating activities, the person will realise that they were overreacting and will feel OK. However, there is a danger in doing nothing at this stage as emotions may still be bottled up with a consequent increased likelihood of a future outburst. CHALLENGING SELF-DESTRUCTIVE BELIEFS If action is the preferred option, the first step involves disputing self-destructive beliefs and using positive self-talk. We all at times, when angry, give ourselves messages that are destructive because they make us feel even more unhappy and angiy. Such messages were discussed in Chapter 20 and include statements such as: 'Other people should live up to my expectations’, 'Other people should behave the way 1 do’, 'Life is fair and just’, T must win1, T must succeed’ and T can’t tolerate mistakes’. Statements like this are absurd. Why should other people live up to our expectations? Who said that other people should behave the way we do? We wouldn’t like other people to tell us how to behave and it is not rational for us to expect them to live up to our expectations. Life is patently not fair or just. Some people have lots of luck, and other people just don’t. It isn’t necessary or likely that we will always win. If we win 50 per cent of the time that would be pretty fair, and even that might not happen. So we need to remember that it is not necessary7 for us to win, it is not necessary7 for us to succeed every time and we can, if we wish, choose to tolerate Counselling those troubled by anger CHAPTER 30 241 • 4other people’s mistakes. We can, if we choose, allow other people to behave in ways that are different from the ways in which we would behave ourselves. Once we have put aside our self-destructive beliefs, we can replace them with positive thoughts, which will help us to feel better. For example, when someone fails to live up to our expectations we could say to ourselves, 'He doesn’t care enough about me to try to please me. 1 just don’t matter to him.’ That would be irrational. It is equally likely that the person concerned is just a bit careless. A more positive self­ statement would be: 'Maybe that person is naturally careless. His behaviour may have nothing to do with the way he feels about me. For all 1 know he might think I’m a great person. What’s more, it’s not important what he thinks about me, because 1 know that I’m OK.' Table 30.1 gives some specific examples of self-destructive self-statements that are likely to make a person feel angry, together with examples of alternative self­ statements that are more likely to have a positive outcome. Once a person has translated the negative messages into positive messages, they are in a situation where they can make other positive choices. They might do nothing, at least for the time being. That is a valid choice and it may be a sensible one. Sometimes it is better to let things cool off before taking action. However, it is important to be sure not to allow negative feelings to build up as a result of inaction. If negative feelings start to build up, then these will need to be dealt with. In order to do this, the person concerned might need to confront the person who they believe has done something to upset them. Where confrontation is the choice, it needs to be done in a way that is likely to lead to a positive outcome with a minimal risk of damage to the relationship. BEING ASSERTIVE Constructive confrontation requires assertive rather than aggressive behaviour. An assertive person has the goal of wanting to be heard, but not the goal of definitely getting what they want. An aggressive person is determined to win at any cost and also is intent on hurting or punishing the other person. Assertion involves communicating as an equal, it involves respecting the rights oi the other person, and demands that the other person’s point of view must be respected. Consequently, two assertive people may well come to the conclusion that they have different opinions. They will, however, respect each other’s right to have a different opinion. It is sufficient for the assertive person to be heard rather than to win an argument by convincing the other person to change their mind. Sometimes we will not be heard and it is not rational of us to expect that the other person will necessarily be capable of i. .......... X .... . hearing what we have to say. We need to come to terms with that. Being assertive One of the best ways to make assertive statements is to use '1 involves being heard and accepting feel ... when ...’ statements, as explained in Chapter 18. An that we may not get example is, ‘I feel frustrated when you interrupt me in the what we want middle of a sentence'. By using the T feel’ statement, the speaker is owning their feelings rather than blaming the other person, . j. a b a 4. a. a b ■. 4 a. a .fa 4. 4 a a .fa 4. a | + 4. a. a a fa 4. a- a a 4. 4 a a 4. a. a 242 PART 5 Dealing with particular problemsTable 30.1 Comparison of anger-producing self-destructive statements with positive self-statements SELF-DESTRUCTIVE ANGER­ PRODUCING STATEMENTEQUIVALENT POSITIVE STATEMENT If 1 don't get him to give me what 1 want, 111 be humiliated and made to look Like a loser.It's not reasonable to expect that 1 can make anyone give me what 1 want. 1 can feel proud of my ability to ask for what 1 want and accept that i may not get it. People should not let me down. When they let me down, 1 know that they don't respect me enough to want to please me.1 am a worthwhile person. It's not realistic to expect other people to live up to my expectations. When they let me down, it says more about them than me. 1 can't feel OK unless Bill agrees that I'm right.1 can't control the way Bill thinks. If he's illogical, that’s his problem, and I'm not going to make it mine. I'm OK. Marys behaviour is ruining my life. Unless she starts to do things to please me, km going to get very angry.If my happiness depends on other people's behaviour, 1 might never be happy. 1 can be happy if 1 accept other people, including Mary, the way they are and the way they behave. I've been victimised and that just isn't fair. I've got to get even.Life often isn't fair and it's unrealistic to expect that it always will be. 1 can get on with enjoying life, instead of harbouring disturbing thoughts of revenge. Note: For other examples of self-destructive beliefs, see Chapter 20. and consequently they are more likely to be heard. After the feeling statement follows a concrete statement about the behaviour that caused the feeling. As explained before, it needs to be an objective statement of behaviour, and not an interpretation of the facts. By contrast with an assertive statement, an aggressive statement would be one that began with the word ‘you\ and implied blame. For example, 4You are very mde because you deliberately try to annoy7 me by interrupting me’. Such a statement implies blame, makes an unjustified interpretation and is likely7 to lead to an argument. Another good way of making an assertive statement is to make a request that might lead to some common agreement. For example, 1 might say, 'Would you mind waiting until I’ve finished what I’m saying? If you do that, I’ll feel heard and will be more receptive to what you have to say.’ The goal of making assertive statements is to get a positive outcome. After making an assertive statement, the speaker needs to listen carefully7 to what the other person says in reply, with the intention of hearing and understanding their point of view, rather than with the intention of disputing what they say. Counseling those troubled by anger CHAPTER 30 243THE USE OF ROLE-PLAYING A good way of helping a person to practise anger control is by role-playing while using a camera to record the role-play on a DVD. By recording the role-play of a real situation that recently made the person angrxy they may be able to see how other people perceive them. Additionally, they may gain insight if they role-play both themselves and the other person, as explained in Chapter 27. They will need to continually change position and role to do this. A review of the DVD recording may enable the person to see how tempers become inflamed. The counsellor can then coach them in the anger control methods described, and in particular can teach ways to make assertive rather than aggressive statements. Remember that very angry people may be dangerous. As a new counsellor you need to be conscious of the need to consult with your supervisor and refer a person who is seeking help to another more experienced and qualified counsellor when necessary. EXTERNALISING ANGER A completely different way to deal with anger control is to externalise the anger, as explained in Chapter 21. The process of externalising separates the anger from the person so that the person perceives the anger as something that they have the power to manage or control rather than the anger being seen as a part of themselves that they are unable to influence. When using this approach for anger control, it can be useful to explore how anger influences and constrains the person’s life. Exceptions can also be explored to discover times when the person is in control so that they are able to recognise that they can, in fact, control the anger when they wish. Learning summary • • • • • Refer potentially violent people to experienced professionals. Encourage the person seeking help to direct anger to an appropriate imagined target person on an empty chair. Teach the person to use the process described by the Anger control flow chart (Figure 30.1), starting with the recognition of physiological cues. Teach the person how to replace irrational beliefs with positive self-talk, how to be assertive, how to listen to others and how to look for solutions rather than trying to win. Teach the person relaxation. References and further reading Clarkson, P. & Qavicchia, S. 2014, (iestalt Counselling in Action, 4th edn, SAGE, London. Davies, W. 2009, Overcoming Anger and Irritability, Robinson, London. Nay, R. 2012, Taking Charge of Anger: Six Steps to Asserting Yourself urithout Losing Control, 2nd edn, Guilford, New York. 244 PART S Dealing with particular problemsCounselling those troubled by depression When do you get depressed? Why do you get depressed? We all get depressed from time to time. Being depressed some of the time is a normal human condition and as counsellors we are sure to meet with people who are depressed. Depression only becomes a serious problem when it is either very deep or very7 prolonged, it is then dangerous and requires specialist treatment, so counsellors need to be aware of this and refer people for appropriate professional help when necessary. There can be many reasons for depression. Some people become depressed as a consequence of what they see as overwhelming pressure in their lives. Others are depressed as a direct result of sickness. People who are unable to meet their own expectations of themselves are usually depressed. Then there are those people whose depression is due to their inability to accept that other people do not live up to their expectations. There are people who are depressed because they are grieving as a consequence of loss, and our guess is that you can think of a range of other circumstances that are likely to produce depression. It is also important to recognise that there may be organic reasons for depression; problems with body chemistry, organic problems in the brain and other medical conditions can cause depression. USE OF THE NORMAL COUNSELLING PROCESSES For many people the normal counselling processes previously described will produce changes in emotional feelings and thought patterns so that depression lifts. So why are we writing a special chapter on depression if the normal counselling processes are usually sufficient? We are doing this because for some people who suffer from prolonged depression, a heavy7 emphasis on the reflective counselling techniques described in the early chapters of this book will not be useful, and may even have a detrimental effect. This is particularly so in cases where the depression does not seem to be related to recent or specific causes. Generally, when depression can be directly related to a person’s personal life and can be attributed to specific life events, a personal situation or an identifiable crisis, it is appropriate to use the counselling techniques previously described. While doing this, it is useful to remember that depression can often be understood in terms of blocked anger. Counselling those troubled by degression CHAPTER 31 245DEPRESSION AS BLOCKED ANGER When a person suppresses or is unable to recognise anger towards someone else, it is quite likely that they will become depressed. Can you imagine yourself being very angry with someone but being unable to express that anger? You might be unable to give vent to your anger for a variety of reasons. Maybe you care so much about the person who is the target of your anger that you do not want to hurt them by expressing anger. Perhaps you recognise that really your anger is unjustified, although real. Possibly It may be helpful for you have been taught not to blame others or not to express angry some people to learn that feelings. After all, how many times do parents say to children, ‘Don't depression can be angry7’? Sometimes parents will do this at times when it is result from appropriate for their children to be angry, and by doing so we repressed anger encourage them to block or suppress their legitimate feelings with inevitable negative consequences for themselves. How are you going to feel if you suppress angry feelings? You 're probably going to feel frustrated. If you are not able to deal with your frustration by letting that anger out, then you are likely to experience feelings of helplessness and depression. EXPLORING THE POSSIBILITY OF BLOCKED ANGER During the counselling process it is often sensible to confront a person who is suffering from depression with the possibility of anger underpinning the depression. A variety of counsellor responses can be used for raising awareness of underlying anger. Here are some examples: When you think about what has happened to you, who are you most angry with? If you weren't depressed, who would you be angry with? If instead of feeling depressed you felt angry, what would that anger be about? Sometimes, a person’s response to one of these questions will be to deny that they are angry with anyone or anything, and this may be true. However, it may be that they are unable to get in touch with their anger, if it exists, or that for some reason they don’t want to own it. If a counsellor suspects that anger is blocked then it may be useful to give the person a message that implies that it is OK to be angry in the person’s particular situation. A counsellor Inappropriately might say, ‘If I had experienced what you have experienced, 1 think expressed anger can be damaging to self that 1 would feel vew angry.' I his may enable the person to and others recognise and access anger. If it does, then dialoguing and the empty chair technique described in Chapters 27 and 30 can be used so that the nerson is given the opportunity to express anger verbally in the safety of the counselling environment. We recommend, however, that you make sure the person understands that there are appropriate and inappropriate ways of expressing anger. 246 PART 5 Dealing with particular problemsSometimes people who have learnt to disown angry feelings will tell you that they are not angry, but instead are just frustrated. There is a thin dividing line between frustration and anger. If a person is frustrated, the approach used for the expression of anger may be equally appropriate in dealing with the frustration. Often when a person who was troubled by depression expresses anger, there will be a change in their demeanour, with the lethargy caused by the depression being replaced by an energised state in which the person becomes more active and looks more in control. People suffering from depression due to the loss of a relationship are often angry with the person they have lost. Appropriate expression of that anger in the therapeutic environment may enable them to deal with it in a constructive way. However, remember that some people have the potential to be dangerous to others (see Chapter 30). These people need to learn to control their anger and should be referred for appropriate professional help for your protection and the protection of others. THOSE WHO NEED REFERRAL Counsellors need to be able to identify those people who need referral for specialist counselling or medical or psychiatric assessment and treatment. Included in this group are people who: • are so troubled by depression that they are a danger to themselves or others • are unable to function satisfactorily in their daily lives due to depression • have suffered from depression for long periods • have no clearly identifiable cause for the depression. If you are in doubt regarding referral to a suitable professional, we suggest that you talk with your Supervisor. Regardless of the need for referral in cases such as those described above, counsellors working in crisis counselling agencies will frequently become involved in counselling people who are chronically depressed. Many of them may be either unwilling to seek specialist treatment or engaged in long-term psychiatric treatment with little positive effect. We believe that it is appropriate for such people to talk to counsellors from time to time, provided that any other professionals involved are comfortable with that. Certainly, counselling by a skilled counsellor will, at the very least, enable the person to feel that someone cares enough to listen, and there may be other beneficial effects. COUNSELLING PEOPLE WHO SUFFER FROM CHRONIC DEPRESSION When counsellors are working with a person who is experiencing long-term depression, the effect of continually reflecting back depressed feelings is likely to do little more than heighten their experience of feeling depressed. Unfortunately, this may result in the person feeling that they are hopelessly and chronically depressed and beyond help. Clearly, this approach is unhelpful! When seeking to help a person Counselling those troubled by depression CHAPTER 31 247who is suffering from chronic depression we therefore need to limit our use of reflection and to use a different emphasis in our counselling. This does not mean that we should discard our ideas about the counselling relationship or forget the basic micro-skills. We need all that has previously been learnt, but with a change in emphasis. We suggest that you might like to refer to the 'Stages of the counselling process’ chart (figure 16.1 on page 135). The difference in dealing with a person who is suffering from chronic depression is that we need to move forward more quickly and decisively from the emphasis on emotions stage into the emphasis on thoughts and behaviour stages (see the right-hand side of the chart). By doing this, the emphasis is taken off emotions and replaced by an emphasis on thoughts and behaviours. Rather than accompanying the person on a journey down into depression by reflecting feelings, invite them to join you on a journey of exploration where together you will explore the influence of thoughts and behaviours on the depression, with some limited but positive goals in mind. In this process the counsellor needs to be more active and confronting than might be the case Being active and with those who do not suffer from chronic depression. caringly confronting may be helpful We suggest that when counselling chronically depressed people, the counsellor may wish to start by attending carefully to the person using active listening to allow the counselling relationship to develop. However, once the feelings of depression have been validated by reflection, then, as mentioned earlier, it is not wise to continue by reflecting feelings of depression as this will merely accentuate the depressed feelings. Instead the counsellor mayr begin to refer to the depression as something to be dealt with, rather like a piece of baggage that can be picked up or put to one side. When doing this the counsellor is using a process similar to externalising (see Chapter 21). COUNSELLING GOALS FOR PEOPLE WHO SUFFER FROM CHRONIC DEPRESSION When counselling someone who is troubled by chronic depression, it’s necessary to make a decision about what are realistic counselling goals and what are unrealistic goals. New counsellors sometimes believe that it should be possible, with skill, to help every person who is sufl'ering from chronic depression to feel better. Unfortunately this is unrealistic. However, if counsellors choose suitable goals, many people who are suffering from depression can be helped to enjoy a better quality7 of life. You might like to try to think of some realistic goals yourself before reading our suggestions: • To help the person to identify what makes them feel better and what makes them feel worse. • To help the person to recognise that they have choice regarding their current behaviour at any time. For example, they could choose to do what makes them feel better or what makes them feel worse. They could choose to sit around and do nothing, or they could choose to do something active. 248 PART 5 Dealing with particular problemsTo encourage the person to focus their mind on what they are actively doing instead of focusing on depression. • To enable the person to take action. • To enable the person to make a decision to seek appropriate specialist or psychiatric help. • To enable the person to come to a decision with regard to one of the practical problems in their life. • To help the person to challenge a self-destructive belief that is making them feel worse. • To help the person feel a sense of importance because you are listening. (Note that some people who are suffering from depression will deny that the counsellor cares because there is a limit to a counsellor’s caring. However, as a counsellor you do care enough to listen and you can say that. Be specific though. A statement such as ll care about you’ is likely to be challenged, whereas a statement such as ‘I care about you enough to want to listen to you’ can’t be sensibly challenged.) • To give the person a positive message about themselves at the end of the counselling session. For example, ‘I’m impressed by the way you were able to clearly identify what makes you feel better and what makes you feel worse’- If you decide that the goals described above might be too difficult to achieve, you could set an easier goal such as: • My goal will be to listen to this person so that for a time they are not alone but will have my company. (In this case, you are really offering company rather than counselling so you may end up chatting together rather than using counselling skills.) Even if the previous goals listed are not attainable, this last goal is definitely achievable and therefore realistic. If you decide to try to achieve one of the earlier goals mentioned, we suggest that you may wish to set one goal only, because it will be hard for someone who is suffering from a high level of depression to find the motivation required to make several choices and take action to carry’ them out. The nature of depression leads to loss of motivation and consequent The counsellor's inactivity. Unfortunately, inactivity7 reinforces depression, making it expectations need hard for the person concerned to make changes. • to be realistic USING A DIFFERENT APPROACH If, as a counsellor, you are to achieve a selected goal, once you have secured a warm and trusting relationship with the person by using active listening and problem identification, you will need to make amendments to the counselling strategies you have previously learnt. Although you will be walking alongside the person at times, at other times it will be advantageous for you to take control of the direction of counselling intervention. It may also be advantageous at times to change your counselling style so that you are more confronting, but in a friendly, caring and non-threatening way. As explained, a person who is suffering from chronic depression will find it difficult to be motivated and consequently will find it hard to change. They will find it hard to identify ways to Counselling those troubled by depression CHAPTER 31 249reduce their pain. However, by confronting with care you may enable them to explore options and take some positive action. ENCOURAGING ACTION It can be useful for a person suffering from depression to be able to recognise those behaviours and situations that make them feel less depressed. If they can discover what they need to do or where they need to go in order to feel less depressed, they may be able to escape from the intensity of the depression for a time. A good approach is to ask the person, ‘Was there ever a time when you weren't depressed?’ (see Chapter 22 regarding looking for exceptions). Most people can identify some times in their lives when they enjoyed themselves. If you can find out when those times were for the person you are seeking to help, then you may be able to help them discover some way of partially regaining some pleasant experiences. When we are suffering from depression we all tend to think negatively, so remember how difficult it will be for a person troubled by depression to try to think positively. However, if you are to help such a person, you will need to try to help them discover some positive ways of thinking and behaving. Let us consider an example: imagine that a person says, ‘1 was only happy while Judith was alive. She’s dead now and so my life is meaningless.’ In order to help this person you would need to use your ingenuity to try to discover what it was that Judith did, apart from being present, that helped the person to feel good. You might ask the question ‘What sort of things did you do when Judith was around?’ and this might lead to the answer 'We used to go for long walks in the bush’. You could then explore whether, at the present time, a long walk in the bush would be more or less depressing than not going for a walk. 1 he question ‘Would that be more or less depressing than doing what you are doing now?’ is a smart way of avoiding a 'Yes but ...’ answer. Even so, you might get the answer ‘Yes, but 1 would still be depressed? You can agree and say: 'Yes, you would still be depressed but would you be more depressed or less depressed?' Of course you might get the answer ‘I’d be just the same, miserably depressed’. In this case, seek a less ambitious goal for the session, but do not give up. Remember that this person is in pain and deserves respect and help. THE USE OF ACTIVITY Research over many years has shown that generally people who suffer from depression tend to be less depressed when they are active. This is why occupational therapy is used in psychiatric settings to help those who suffer from severe depression. Even a simple action such as going to have a shower or take a bath can be a useful activity that might temporarily ease the depressed feeling. SETTING TIME LIMITS There may be limited value in talking for lengthy periods with people who suffer from chronic depression. Generally, short interventions tend to be more useful, 250 PART S Dealing with particular problemsparticularly if they encourage the person to undertake some activity. To encourage activity, remember to reward a person with praise when they do engage in meaningful activity and when they succeed, for a time, in feeling less depressed. Because people who suffer from depression are often bored and preoccupied with negative thoughts, they may wish to talk at length Activity can often without purpose and to travel the same road in their thoughts, over be helpful in reducing depression and over again. In turn, counsellors may need to use good termination skills. A useful way to terminate a counselling session is for the counsellor to be directive in suggesting that the person go to perform a task. For example, the counsellor may say, 'I would like to finish our conversation now and suggest that you might like to go home and prepare a meal for yourself right away. Next time we meet I would like you to tell me whether you felt more or less depressed when you made and ate the meal.’ Once again, the suggestion is action-oriented and includes the goal of identifying the usefulness of activity. DEBRIEFING If counsellors join empathic ally with people who are depressed, they may pick up negative and depressed feelings themselves. It is therefore important to debrief and to look after your own needs (see Chapter 42). Learning summary • • • • • ft is normal for people to suffer from depression as a result of personal stress or as a consequence of a troubling situation. For many people who suffer from depression as a consequence of a troubling personal situation, the normal counselling processes may be sufficient. Sometimes depression results from blocked anger. Depression calls for specialist treatment when it is either very deep or prolonged. For people who suffer from chronic depression: » referral to a specialist is required (after consultation with your supervisor) » continual reflection of feelings can be counterproductive » set goals for the session and take control of the counselling process » be confronting » encourage activity » keep counselling sessions short and energised. Further reading Gilbert, P.R, 2009, Overcoming Depression: A Self-help (ini de Using Cognitive Behavioural techniques, 3rd edn, Robinson, London. Massey, A, 2005, Beat Depression and Reclaim Your Life, Virgin, London. Saunders, D. & Wills, F. 2003, Counselling for Anxiety Problems, 2nd edn, SAGE, London. Counselling those troubled by degression CHAPTER 31 251Counselling those troubled by grief and loss We have noticed that a high proportion of problems people experience are concerned with relationships. Issues related to relationships fall into four major categories. These are: 1 dysfunctional relationships 2 failure to form meaningful relationships 3 lost relationships through death and separation 4 negotiation of the normal or developmental challenges and changes in relationships. TYPES OF LOSS In each of the relationship categories listed above, issues of loss and grief may arise. In dysfunctional relationships there is a loss of expectation that these relationships will be functional and harmonious. People who are unable to form meaningful relationships may have to cope with the loss of their expectations. When couple relationships break up, both people need to adjust to the loss of a partner. In the case of married couples, there is also the loss of marital status and the loss of the expectation that marriage is for life. If children are involved, then each parent has a loss of support from their spouse in the day-to-day rearing of the children, and often one parent has a significant loss of contact with the children so their parental role is to some extent diminished. When relationships are functioning normally, new situations will arise from time to time — changes will naturally occur due to changes in roles as a consequence of the inevitable developmental stages of the relationship. There is therefore a need to confront the challenges incurred by change, and change often involves loss. Counsellors also hear about many other types of loss: for example, the loss of a limb, loss of an internal part of the body, loss of mental functioning due to ageing or brain damage, loss of a job, loss of a home or loss of self-respect. HELPING A PERSON WHO IS GRIEVING In order to be effective in helping people who are grieving over a loss, counsellors need to understand the process of grieving. There are many books on loss and grief counselling, including those listed at the end of this chapter, for those who wish to read more about the subject. 252 PART 5 Dealing with particular problemsWhen counselling somebody who has suffered a loss or who is grieving, it is important to be able to reassure them that the feelings they are experiencing are normal for a person who is grieving, and that it is normal to take time to grieve. In this regard it may be useful to self-disclose if you yourself have in the past taken time to grieve over a similar loss. RESTRICTING COUNSELLOR SELF-DISCLOSURE Although at times self-disclosure is appropriate, it should be used sparingly, and never solely to satisfy the counsellor’s needs. Before self-disclosing, we suggest that you may wish to examine what you are personally experiencing and to make a decision about whether your motive is to satisfy your own needs or is genuinely to help the person who is seeking your help. Where Self-disclosure can self-disclosure is used more than occasionally, its impact is lost, and be useful if it is used the counsellor is certainly putting their needs before those of the sparingly person seeking help. Disclosure of information about other counsellors or other people is unethical and should never occur in the counselling process. COUNSELLING SKILLS TO USE When a person is grieving, all the micro-skills previously discussed can be used as explained in Chapter 16 to allow the person to verbalise their thoughts and feelings, to experience rather than suppress their pain, and to generally explore whatever is happening within them as they experience their loss. Additionally, it is useful for a counsellor who is helping a person who has suffered a loss to have an understanding of the process of grieving. This understanding will enable the counsellor to recognise and appreciate the person’s experience more fully so that an empathic counselling relationship can be established and maintained. THE STAGES OF GRIEF People tend to go through a number of stages in the grieving process. For some people these stages follow a particular sequence, It can be helpful for but for other people the stages overlap or occur in a different order. a person who is grieving to Everyone is unique and grieves in a uniquely personal way, so understand the counsellors should avoid trying to fit a predetermined grieving commonly pattern onto a person. However, if as a counsellor you know what experienced stages the commonly experienced stages in the grieving process are, then of grieving you will be better equipped to deal with the grieving person. You may be able to explain to them that their experiences are not strange or unusual, but are normal for someone who is grieving. The stages of grief are commonly experienced in the following sequence: 1 shock 2 denial Counselling those troubled by grief and loss CHAPTER 32 253emotional, psychological and physical symptoms depression guilt anger idealisation realism acceptance readjustment personal growth. If a person is unable to work through the stages of grief, then they are likely to be stuck in a trough of hopelessness and despair. They may become neurotically obsessed by their loss, and become deeply depressed and possibly suicidal. The following paragraphs explain the stages of grief with the exception of depression. Depression was discussed in the previous chapter, Chapter 31. 3 4 5 6 7 8 9 10 11 SHOCK Often, the first stage of grief is shock. This may be particularly severe in cases of sudden loss, or where a person has not been prepared adequately for an expected loss. In this stage the person almost seems to stop functioning, is numb, is in a daze and is incapable of doing anything constructive. DENIAL Along with shock, and following on from shock, comes denial. The grieving person can’t believe that what has happened is really true. The denial process can be prolonged for people who separate from a living partner. Very often a rejected partner will deny that the relationship is over, even though the other partner is clearly saying, ‘It’s finished and Pm not ever going to come back to you.’ This is hard for a counsellor to deal with, because the grieving person needs to have time to move through the denial stage. Perhaps the most useful approach is to reflect back the person’s expectation that their partner may return, and to add to this concrete statements of fact that seem to indicate the opposite. 1 he counsellor might say, for example, 4 get the strong impression from you that you believe that your partner will come back to you. 1 also notice that she said to you that she would not do that, and that she has rejected all your approaches to her since she left. Do you think that it’s possible that she may not come back?’ This tentative statement and question may enable the person to stay in denial if they need to do that for a while longer, or to move forward. When a person is starting to accept the possibility that the loss may be permanent, it may then be useful to let them know that denial is a normal part of grieving. By doing this they can feel OK about their difficulty in not wanting to accept reality in its entirety. People who are dying often grieve in anticipation of dying and such people sometimes have real problems with denial. When a person is told that they are dying, they may try to convince themselves that what the medical practitioner is telling 254 PART 5 Dealing with particular problemsthem is not true. They may look for and try unorthodox methods to find a cure, and may start to bargain with God in an effort to get an extension to life. EMOTIONAL, PSYCHOLOGICAL AND PHYSICAL SYMPTOMS Grieving people experience feelings of depression, despair, hopelessness and worthlessness. Very often they will exhibit symptoms such as insomnia, inability to concentrate, loss of appetite and physical ill-health. This is normal. There is little that the person can do but accept that such symptoms will pass with time as the pain of grief diminishes. Naturally if such symptoms are severe or persist, the person should be encouraged to consult with a medical practitioner. GUILT Guilt often occurs in the grieving person. A counsellor will frequently hear a person say how guilty they feel because they didn’t tell the deceased how much they loved them, didn’t tell them how much they cared for them, didn’t apologise for something they had done wrong or didn’t make peace over an issue where there had been a disagreement. If, as a counsellor, a person seeking your help describes such feelings, allow them to fully explore them. ANGER Often after shock, denial, depression and guilt, anger follows. Remember though that the stages often overlap, and sometimes a person will move forward from one stage and then go back to an earlier stage. In the case of a person who is dying, anger may be directed at the medical practitioners involved. The person may feel that they haven’t had satisfactory7 medical treatment. Maybe they will believe that their illness was diagnosed too late, and consequently that it’s the doctor’s fault that death is inevitable. Similarly, a person who has lost a loved one through illness may blame the medical practitioners who treated the deceased before their death. Additionally, a bereaved person may well Feeling anger experience anger towards the person who has died. They may feel that towards a deceased loved one can be the deceased person 'had no right to die’ and has hurt them by leaving disturbing and them alone to cope in the world. This may be especially so in cases confusing where the deceased has committed suicide. Often it is hard for a person to accept that they are capable of being angry towards somebody they loved who has died. This is especially so for children who have lost a parent through death and have not had adequate counselling. They invariably feel guilty and confused by their anger and resentment towards the deceased parent. Without counselling, these feelings may endure for years. People whose partners have rejected them often become very angry’ and yet, while being angry7, desperately' want to get back into the relationship. 1 hey inevitably make it hard for themselves to do this and probably spoil their chances Counselling those troubled by grief and loss CHAPTER 32 255of reconciliation, because while saying ‘I love you and 1 want to be back in a relationship with you', they may also be experiencing anger, and are likely to express it in some way. They might give mixed messages to their partner because they are simultaneously giving ‘Please come back’ messages and angry messages. The anger, of Course, can easily be understood as part of the process of grieving. Sometimes a person who has religious beliefs and is grieving will feel angry with God, and will blame God for the loss that has occurred. For deeply religious people this may cause feelings of extreme guilt. When counselling such people, a counsellor can explain that it is normal to experience anger in grief. The counsellor might also ask the person whether they think that God is capable of accepting, forgiving and loving someone who is angry with God. When counselling people who have faith in other religions, similar issues may arise. Here it is important for the counsellor to gain sufficient understanding of the person’s beliefs to be helpful (see Chapter 39 regarding cultural issues). IDEALISATION Idealisation often follows the angry stage of grieving. It is very common for people who have suffered loss through death or separation to idealise the lost partner. The grieving person temporarily forgets any faults or negative characteristics of the deceased and remembers only an ideal person. They remember every thing positive that the deceased did and convince themselves that they loved them without reservation, and never had any negative feelings towards them. This is idealisation, and once again it is normal. It takes time for a person to move through idealisation and a counsellor needs to be careful not to try to move the person who is grieving forward too quickly, but rather to let the grieving process occur naturally. When it is appropriate, a counsellor may ask tentatively whether the lost person had any bad points, any faults, and whether they sometimes made mistakes. Slowly the realisation will dawn that, yes, there were polarities in the deceased person. The deceased was a real person, a human being with both strengths and weaknesses. ACCEPTANCE, READJUSTMENT AND PERSONAL GROWTH A person who is grieving will hopefully, in time, come to terms with their grief and start to accept the reality of their loss. They will start to be more realistic about the person they have lost, and to accept the loss as a permanent reality. 1 hey are then free to move forward and to create a new life as an individual. This may be scary, particularly for those who were heavily dependent on a relationship that has been lost. In this stage of the grieving process the person needs to be active rather than passive, to try new experiences that will lead to personal growth. New experiences, by their very nature, involve some degree of risk, and so may understandably cause the person to be apprehensive, 'faking risks can be frightening and can also be exciting. Reframing risk taking as exciting may be helpful for some people. 256 PART 5 Dealing with particular problemsALLOWING THE GRIEVING PROCESS TO OCCUR Finally, as a counsellor, do not try to calm or soothe the grieving person. Do not try to cheer them up or help them to contain their sadness and fears. Instead, help them to express emotions freely, to cry if they wish, and to grieve fully. It is only when grief endures for an excessively long period that it becomes maladaptive. In such cases, professional help from an experienced counsellor, psychologist or psychiatrist is required. Know the limits of your own competence, and when appropriate, after consultation with your supervisor, refer the person who seeks your help to others who are more qualified and experienced than you are. Learning summary • • • People grieve for lost expectations, relationships, bodily functions, jobs and losses of all kinds. Normal stages of grief include shock, denial psychological and somatic symptoms, depression, guilt, anger, idealisation, realism, acceptance, readjustment and personal growth. It’s usually a mistake to try to calm or soothe a grieving person. Encouraging free expression of emotions tends to be more therapeutic. Further reading Freeman, S.J. 2005, Grief and Loss: Understanding the Journey, Brooks/Cole ('engage Learning, Belmont. Humphrey, G.M. 2008, Counselling for Grief and Bereavement, 2nd edn, SAGE, London. Mallon, B. 2008, Dying, Death and GrieJ: Working with Adult Bereavement, SAGE, London. Counselling those troubled by grief and loss CHAPTER 32Crisis intervention What comes into your thoughts when von think about the word 'crisis’? We suggest that you might like to stop and think for a moment to explore your own ideas about crisis. Our guess is that your thoughts might have included remembering a disaster that affected other people or you might have remembered a time when you were confronted by a traumatic experience of your own. Here are some of the feelings and thoughts that many people associate with the word ‘crisis’: • panic • fear • horror • help • 1 can’t cope with this • 1 don’t know what to do • 1 need to do something in a hurry • if I don’t act quickly there will be a bigger disaster; and • more panic! DIFFERING VIEWS OF CRISIS Crisis situations are situations of high risk. In a crisis, something is happening or has happened to abruptly change the participant’s perception of a safe and ordered world. It is as though the bottom brick in a column of bricks is being pulled away so that the whole column will collapse. However, there is another and very different perspective on the appraisal of a crisis which we will consider later under the heading ‘The dangers and value of a crisis’. Can you think what it might be? Firstly, however, let’s think about the various types of crises that people typically experience. TYPES OF CRISES There are several very different types of crisis. Although they are different, they also have similarities. They all raise the stress level of the person or people involved and call for a quick response in order to minimise practical, emotional and psychological damage. You may wish to stop reading for a moment or two to see whether you can identify for yourself the different types of crises that people experience. 258 PART 5 Dealing with particular problemsWe are all familiar with crises which fall into the following categories: • natural disaster • accidental • medical • emotional • relationship • developmental. These categories are not mutually exclusive or independent of each other, but are useful in helping us to think about the similarities and differences of various types of crisis. We will now consider each of the categories listed. NATURAL DISASTER TV news has made us all very familiar with the practical type of crisis with physical and emotional consequences that occur when a volcano erupts, there is a bushfire, a flood or an earthquake, or when lightning strikes. Sometimes the effects of natural disasters are long-lasting. A drought can cause famine, and the effects may last for years unless there is an effective and timely response. Unfortunately, as with most crises, natural disasters usually occur with little or no warning. ACCIDENTAL CRISES lhese crises inevitably occur from time to time. Examples are when a building catches fire, when two cars collide or when a child falls down some stairs. In the worst accidental crises there is a loss of life. Obviously, these crises occur without warning, with the consequence that those involved are not properly prepared and are often not able to make the most appropriate response. MEDICAL CRISES Some medical crises fall into the 4accidental’ category’. However, many do not. Medical crises occur when people have strokes, heart attacks, seizures, asthma attacks or any of the many medical conditions that afflict the human race. Similarly, medical crises occur when people are incapacitated by illness. A migraine headache, for example, may prevent a person from doing those things necessary for their own wellbeing and the wellbeing of others. Other examples of medical crises are when a woman delivers a baby unexpectedly and there is no one around to help, or when there are complications with a birth. Similarly, a crisis occurs when a baby becomes sick or when there are problems with feeding a baby. Medical crises are often very frightening because of high personal involvement at a physical, emotional and psychological level. As with accidental crises, in the most severe cases there can be loss of life. Crisis intervention CHAPTER 33 259EMOTIONAL CRISES An important and valuable human characteristic is our capacity to be emotional. If we were deprived of our emotions we would be automatons — mere machines. Unfortunately, at times the emotions we experience are painfully destructive and prevent us from functioning normally. Rage, sadness, depression and despair can all lead to states of crisis where the individual may be at risk. RELATIONSHIP CRISES Anyone who has worked for a telephone crisis-counselling service will tell you that relationships are a common factor underlying many crisis calls. Dysfunctional relationships, broken or lost relationships, and the absence of relationships are probably the most common causes of emotional crisis. However, we are separating relationship crises from other more general emotional crises because this is such an important sub category’. l ime and again people experience crisis when relationships are strained, break up or are lost through death or unavoidable separation. Often, spouses feel devastated and as though their whole world has collapsed when they discover that their partner is having an extramarital affair. Similarly, those involved in having an affair usually experience a high degree of emotional pain. Sometimes people experience profound disappointment due to the behaviour of those who are in close relationships With them. Parents are particularly vulnerable to such feelings. I line and again, parents have told us how disappointed and sometimes devastated they were when they learnt that their child had been caught stealing or behaving in some other way contrary to their own expectations. Unfortunately, too often in our present society relationship crises involve physical violence, usually with women and children as the victims. Counsellors are continually hearing about emotional, sexual and physical abuse occurring within families, which should provide a safe and secure environment. DEVELOPMENTAL CRISES There are some crises that none of us escape. These are the developmental crises that occur naturally and inevitably as we pass through the various developmental stages of our lives. Tor most people the first developmental crisis is probably at the time of birth. However, for some there could well be earlier ones when, for example, sudden changes occur within a mother’s body. From birth onwards the list of developmental crisis times is endless. Here are a few examples: • when a child takes a first step • the first day in child care • starting school • the onset of puberty • starting work 260 PART 5 Dealing with particular problemsleaving home living with a partner getting married having a child death in the family separation mid-life crisis divorce starting again with a new partner retiring growing old dying. At each of these stages there is risk involved, a raised stress and anxiety level is inevitable, and there will probably be other emotional responses. Often, there is a need for appropriate decisions to be made with consequent action. t here is an inevitability about many developmental crises, t hey are often a natural and necessary part of growing up and getting older. However, each crisis can be threatening, calls for a response, and marks the beginning of a new stage in life. • • • • • • • • • • • • THE DANGERS AND VALUE OF A CRISIS Most crises spell danger. They are fraught with risk, t hey shake us up and interrupt the comfort of our lives. They call for responsive action and usually this needs to happen without delay. However, crises are not necessarily bad. Although they usually do have emotional consequences, there is another way of looking at crises. A time of crisis may also be a time of opportunity. I he impact of a crisis often produces an opportunity for change. A crisis can be the catalyst for the development of something new. It can be a time when we let go of what has been and start afresh. Surprisingly, even from the most terrible tragedies something of value may emerge. Saying this in no way diminishes the sadness and horror of tragedy, but it is worth remembering that, given an appropriate response, something new and worthwhile may grow out of a tragedy. A person may grow stronger psychologically or spiritually, relationships may change for the better, or something in A time of crisis may poor condition and of limited use may be replaced with something also be a time of more useful. Unfortunately, though, many people are permanently opportunity scarred by the crises that they have experienced. A good metaphor for a crisis, which can sometimes be used when counselling, is to describe the crisis experience as rather like going through a doorway from one room into another. If you imagine yourself moving through a doorway between two rooms, you may recognise that you are leaving behind many of the things in the room you are departing, although you may be taking some things with you. In the new room there will be some unknowns. Consequently, you may experience sadness at losing the things you are leaving behind. Also, you may experience apprehension as you wonder about what lies ahead in the new room. If you wish, you can focus on feelings of apprehension and ■ l 4 4 I t 4. 4 1 st .1 i F + 4S& a. x 4 a i. 4. dasaoB. 4 a t. a j a r - 4 Crisis intervention CHAPTER 33 261this may be threatening. Alternatively, you may be able to give yourself some positive messages about the future so that you feel challenged and consequently energised. In using this metaphor we need to remember that it is usually not appropriate to tell someone in crisis that something good might emerge! To do such a thing would usually be inappropriate and would not address the person’s pain. However, as the person is starting to move out of a crisis, it may be appropriate to use the metaphor. At this stage positive opportunities may present themselves, so that at the appropriate time these may be fully explored with the person seeking help. It is also useful to remember that in some instances it may be premature and inadvisable for a person to make far-reaching decisions before they have had time to work through the trauma of a crisis. However, the converse can also be true. Sometimes, a crisis provides the opportunity and impetus for sensible and important decisions to be made. THE COUNSELLOR'S PERSONAL RESPONSE David remembers the time when he used to work as a crisis-line telephone counsellor. This is what he has to say about that time: Sometimes, with a suicidal caller, or when a woman with children was trapped in domestic violence, I would feel my hair standing on end. My body would tense, my palms would be sweaty, and I would realise that I was gripping the phone as tightly as I could. It was then that I would recognise my panic. Panic induces the 'frightened rabbit' syndrome. The rabbit freezes. It can't move and is consequently unable to protect itself or its offspring. Are you a frightened rabbit at times? I am! Rabbits can also run, and use their brains to avoid danger by changing direction. The first step in dealing with panic is to recognise the physical symptoms that indicate the onset of panic. I would usually notice that my whole body was tense. How do you recognise your panic? The way to do this is to Learn to recognise the messages your body gives you. Then you can easily recognise your frightened rabbit mode and consequently be able to deal with it. Once you have recognised your panic, you are in a position to do something about it. The first thing ! do is to say to myself, Tm panicking, and my panic is not helpful'. Next, 1 consciously relax my body. I loosen the tight grip I have on the phone (if !'m working on the phone). I move my body into a more comfortable position, take a few deep breaths and at the same time let my body relax a little as I breathe out. I follow this by discarding those internal messages and self-destructive beliefs that contribute to panic, and replacing them with internal messages such as: I don't have a magic wand. Nobody else has a magic wand. There are limits to what I can do. If I stay calm I will be more likely to think sensibly. 262 PART 5 Dealing with particular problemsThe person who is seeking help is more likely to know the solution than I am. Can I help the person to feel calmer and to have some degree of control so that they can use their resources most effectively? What are the person's options? What are my options? What are the limits to what I am able to do? Hopefully, 1 am then able to attend to the person seeking help in an effective and caring way using appropriate counselling interventions. APPROPRIATE COUNSELLING INTERVENTIONS What’s appropriate at a counselling level will clearly depend very much on the nature of the crisis, and whether the counselling is face-to-face or by phone. For example, if a house is on fire and the person doesn’t know what to do, then it will not be appropriate to spend time reflecting feelings. Practical advice is urgently required! Give it. Yes, we counsellors generally try to avoid giving advice and instead encourage those who seek our help to make their own decisions. However, as with most rules, common sense is needed regarding when to apply the rule and when to do the opposite. Sometimes when quick action is needed, we have to be very direct in order to prevent a major disaster from occurring. Quick action does not mean acting in panic but means being carefully decisive and giving clear instructions. If as a counsellor you find yourself panicking, once you become aware of this, take action to deal with the panic. T hen sensible decisions can be made with regard to the most satisfactory’ approach. Similarly, if a person seeking help is panicking they will be unlikely to respond effectively and act sensibly. The counsellor’s first job in this situation may be to help the person to deal with the panic. A possible counselling response in this situation could be: I'm catching the panic of this situation. Let's stop and think. Have you any idea what you could do right now? What do you think of this response? It joins with the person, may enable them to recognise and deal with the panic and addresses the need for action. It could be an appropriate response, depending on the situation. Can you suggest some other suitable responses? T hroughout a crisis intervention, try to maintain as much calmness as you can so that the person seeking help is reassured. If you are able to do this they will feel more secure and will be more likely to believe that a satisfactory outcome will be achieved. They might then be able to match some of your calmness. As a crisis intervention proceeds, the full range of counselling skills are often required. If you stay with the person, using the normal process of a counselling session as outlined in Chapter 1 6, then they will feel supported and empowered to cope. They will be enabled to experience their feelings in the safety’ of the Crisis intervention CHAPTER 33 263counselling relationship and should reach some sense of completeness by the end of the process. Yes, you may leave them feeling intensely sad, drained and possibly even devastated, but hopefully you will have managed to create a relationship of trust so that they felt supported through the crisis. If you did, then the person is likely to feel comfortable in coming back to talk with you, or with another counsellor, in the following few days or weeks. It is during this time that they may well need counselling help as they cope with the emotional, psychological and practical after­ effects of the crisis. Although all the micro-skills are needed, it is worth remembering that the micro- skill called 'normalising’ (see Chapter 17) is particularly useful when dealing with developmental crises. People often feel relieved to know that what is happening to them is inevitable and normal, even if distressing and painful. Sensibly, the counselling interventions used must take account of any practical options available to the person concerned and the counsellor, so we will now consider practical responses to a crisis. PRACTICAL RESPONSES TO A CRISIS It is essential that counsellors involved in crisis intervention are clear about the range of practical responses available to them. Because crises usually come without warning, counsellors need to be prepared. As a counsellor you need to know what options you may have when confronted with a person who is in a crisis situation. You need to have a clear idea of the boundaries within which you work so that you know what you can and can’t do. The options available to you and the boundaries that constrain you will depend on the policies and practices of the agency where you are working. You, the counsellor, will need to know the answer to a number of questions including the following so that you can be of help to a person in an emergency situation: • If a person phones you in a crisis, are you able to go out to visit them or not? If not, is there someone else on your counselling team who is able to go? If so, what limitations do they have to their ability to intervene practically? • Are you permitted, within the guidelines of your employing agency, to ask a person in a crisis to come in to see you, or to see another counsellor? Under what circumstances can this be done? • Can you supply or arrange for transport, accommodation, financial or material assistance or any other service for the person seeking help? • Does your agency’s policy allow you to accompany the person seeking help to give them practical assistance? • Do you have a comprehensive list of resources available, so that if you can’t provide the required help yourself, you can let the person seeking help know who might be able to help? • Are you permitted to call the police, an ambulance, the fire brigade or any other service? If so, do you need to have the person’s permission in all cases or are there exceptions? 264 PART 5 Dealing with particular problemsCan you arrange for women and children subject to domestic violence to be accommodated in refuges, or in other temporary accommodation if refuge accommodation is not available? If so, who will supply the transport? Will someone from your agency or another agency be available to accompany the perspn/s or not? Clearly, these are just some of the questions you may need to answer and there are countless more. Unfortunately, you probably won’t think of some of them until a specific situation arises that is new to you. In training, it’s useful to brainstorm and to try to think of every’ imaginable crisis so that you know exactly what is available, and exactly what you are, and are not, permitted and able to do. • EXPECTATIONS OF THE PERSON SEEKING HELP People seeking help sometimes have unrealistic expectations of counselling services. This is particularly so in the case of crisis telephone counselling services, where some callers may expect that counsellors are at all times available to visit those who would like such a visit. From the outset it can be advantageous to be clear with the person seeking help about the limits of your service so that false or unrealistic expectations do not develop. Can you say ‘No’? It’s hard to say ‘No’, isn’t it? For example, you may need to say to someone who is seeking help, Tm sorry, but there is no one available to see you right now, but you are welcome to talk with me on the phone if you would like to do that.’ PRACTICAL INTERVENTION At an appropriate stage in the counselling process you, the counsellor, may need to assess whether there is a need for practical intervention. For example, it might be advisable to call an ambulance, the police, the fire biigade, a medical practitioner or some other helper. Alternatively, for example, in a case of threatened suicide, it may be necessary to arrange for a crisis worker to meet urgently with the person who is making this threat. In many agencies, counsellors work under direct supervision. If you work in such an agency, then you may need to inform or get permission from your supervisor before being able to set in train an appropriate practical intervention. While doing this it is important to stay in touch with the person seeking help as much as is possible. A person who phones in a crisis situation is likely to feel anxious if left on hold for even a short time. Be careful to maintain as much continuity of contact with them as possible and to keep them fully informed of your actions. In particular, if you are putting a caller on hold tell the caller why you are doing that and let them know how long your absence is likely to be. If you take longer than expected, interrupt what you are doing, go back quickly to the phone and reassure the caller. Be cautious when considering whether it is necessary7 or not to intervene at a practical level. It is often tempting for a counsellor to take over responsibility from a person when this is not really necessary; sometimes intervention by a counsellor is very appropriate but at other times it is not. Consider an example where a person needs an ambulance. In some cases, it may be advantageous for the person, and not the counsellor, to call the ambulance. By doing this the ambulance personnel get a direct message from the person involved rather Crisis intervention CHAPTER 33 265than a message that might have been inadvertently altered in transmission. Also, it is empowering for a person to take action rather than to be left feeling that they are incapable of doing so. On the other hand, in some cases there may be uncertainty about the ability of the person concerned to perform the task satisfactorily, or they may be particularly vulnerable and in need of support. In such cases, the counsellor may sensibly decide, with the person's permission, to call the ambulance on their behalf Clearly, sensitive judgement is needed by counsellors in deciding when to intervene and when to encourage a person to take responsibility themselves for any necessary action. There can be no hard and fast rule. GIVING SPECIFIC INSTRUCTIONS At a time of crisis intervention a counsellor may need to be very directive and very direct in order to avoid an escalation of the crisis. This is particularly so in cases where the counsellor has professional knowledge that will be useful to the person involved. If we use childbirth as an example, a nursing sister, medical practitioner, paramedic or other trained person may be able to provide crucial information that can be essential for the wellbeing of the mother and child. Such a person needs to be clear, concise, concrete and specific in giving directions to the person seeking help or helpers. Even so, it is imperative that the counsellor retains the full use of listening and joining skills. It is at times like these that the person undergoing the crisis may have important information to give that could be overlooked unless full attention is given to their verbal and non-verbal communication. As in counselling generally, it’s desirable to stay in tune with the feelings of the person seeking help, so that any intervention initiated is acceptable to them. Exceptions to this are situations where the counsellor needs to intervene in order to fulfil their duty of care to the person seeking help or to other people involved. Clearly, counsellors have a duty of care in cases where a person is out of control of their own behaviour due to psychosis or drugs, or in cases where the safety of another person is at risk. POST-TRAUMATIC STRESS Unfortunately, a counsellor’s work does not necessarily finish when a crisis is over. It is now well documented that people often suffer from emotional and psychological after-effects as a result of a severe crisis. These after-effects are generally referred to as post-traumatic stress. Post-traumatic stress can occur in persons who directly experience a crisis, and in people who act as helpers at a time of crisis, such as emergency services personnel, police, ambulance personnel, medical and nursing staff, counsellors and social workers. Relatives and friends may also suffer post-traumatic effects. Usually the first evidence of emotional trauma becomes apparent immediately after the crisis, or within a few days. Some people try to shrug off these post-traumatic effects, believing that time will heal all. Unfortunately, time often doesn’t heal all, and 266 PART 5 Dealing with particular problemsit is common tor those who have been personally involved in a crisis, and those who have in some way helped them, to be seriously affected emotionally and psychologically some weeks or months after the event. Post-trauma tic stress can best be minimised by those involved undergoing counselling ata time of their own choosing — some people who have experienced a crisis will prefer to engage in counselling shortly after the crisis event, wrhereas others will prefer to defer counselling until later. Because of the possibility of post-traumatic stress, it is sensible to follow up on people who have been through a severe crisis. During the days and weeks following a crisis it can he advantageous if the people involved are offered counselling help. Without this offer, the risk of undesirable psychological effects showing up later may be increased. As stated previously, counsellors may be affected themselves when they work with people who are experiencing a crisis. As a counsellor, don’t forget your own needs. After counselling someone in a crisis, talk to your supervisor or another counsellor about your owil experience of the counselling process and the emotional feelings generated within you. Such talking through, or debriefing, as it is called, needs to be accepted as necessary and normal after any crisis intervention work. It certainly is not a sign of weakness to engage in such debriefing. On the contrary7, it is a sign of maturity, good sense and personal strength. Learning summary • • • • • • • Crisis spells danger and opportunity. Crises occur naturally accidentally, medically, developmentally, as a result of emotional and relationship problems, and in other ways. In crisis intervention, counsellors need to deal with panic, be calm, use the full range of counselling skills and sometimes give specific directions to the person seeking help. Counsellors need to know the limits of their ability to intervene practically. _hey need to be clear in communicating these Limits to those who seek their help. Counsellors need to be prepared for crisis and to have ready access to information about available resources for practical help. There are times when it is appropriate to intervene practically on a person's behalf, and times when it is not. Appropriate action is required to deal with the possibility of post-traumatic stress in both the person involved and the counsellor. Further reading James, R.K. & Gilliland, B.E. 2013, Crisis Intervention Strategies, 7th edn, Brooks/Cole, Belmont, GA. Kanel, K. 2012, A Guide to Crisis Intervention, 4th edn, Brooks/Cole, Belmont, CA. Kobe its, A.K. 2005, Crisis Intervention Handbook: Assessment, Treatment and Research, 3rd edn, Oxford University Press, New York.. Crisis intervention CHAPTER 33Responding to suicidal intentions Crisis telephone counselling services frequently get calls from people who are contemplating suicide and sometimes callers have already overdosed on prescribed medication before ringing for help. Also face-to-face counsellors will inevitably be confronted at times by people who have suicidal thoughts or tendencies. Most, it not all, counsellors are anxious when counselling such people, and working with them is inevitably stressful. ETHICAL ISSUES 1 here are ethical issues involved when dealing with a pei’son who is contemplating suicide, and before choosing strategies that are acceptable to you, as a counsellor, you may need to clarify your own values with regard to suicide. As counsellors, it is desirable that, if possible, we do not impose our own values on the people who seek help. However, we do need to be congruent and genuine, so each of us needs to do whatever is necessary’ to satisfy7 our own conscience. In addition, we need to be aware of any legal obligations and the legal implications of our Counsellors have a actions. We must remember that we owe a duty of care to every7 person who seeks our help and that we need to respect the policies duty of care to those who seek of the agency for which we work. If there are internal conflicts for their help us when dealing with a pei’son who is contemplating suicide, then we need to resolve these for both our own wellbeing and theirs. Does a person have the right to take their own life if they choose to do so? Your answer to this question may differ from Olli’s, and our answers may differ from those of a pei’son who seeks our help. We suggest that you discuss this question in depth with your training group if you are in one, or with your supervisor, so that you have a clear idea of your own attitudes and beliefs regarding suicide and of your supervisor’s expectations. You will then be better equipped to help a person who has suicidal thoughts. We recognise that some counsellors believe that a person has the right to kill themselves if, after careful consideration, they choose to do so. However, most counsellors strongly oppose this view and believe that firm intervention is justifiable and necessary7 to prevent suicide from occurring. Many counsellors believe that a person who is contemplating suicide may be temporarily emotionally disturbed and not capable of making a rational decision at that time. This belief is reinforced by experiences with people who were suicidal and then later have thanked the counsellor, 268 PART 5 Dealing with particular problemsbecause they have found new meaning and satisfaction in their lives. Consequently, most counsellors believe that a counsellor s duty of care justifies the need for firm intervention, involuntary hospitalisation and subsequent psychiatric treatment where other options fail. Clearly, there are duty of care issues involved because suicide involves a one-way journey, and people who have suicidal thoughts need to be taken seriously. Remember that people who repeatedly make suicide attempts often succeed in killing themselves eventually. Their cry for help needs to be heard before it is too late. REASONS FOR CONTEMPLATING SUICIDE People who are considering suicide broadly fall into four categories, although three of these overlap to some extent. The first category comprises people whose quality of life is terrible, and who see little or no possibility7 for improvement. Included in this category are people who are chronically ill, in chronic pain, seriously disabled and/or in extreme poverty’ with little possibility7 of changing their situations. Such people are often severely depressed and are seriously at risk of ending their lives because they can see little reason for living. This is particularly so if they are alone and do not have adequate social support. The second category7 includes people who have experienced a recent trauma. These people are very much at risk around their time of crisis. Included in this category are people who have suffered losses such as those described in Chapter 32. fhe third category comprises people who use suicidal talk or suicidal behaviour as a last resort in an attempt to get others to hear or respond to their pain. Sometimes their goal is to manipulate the behaviour of others. They are still genuinely at risk, but their motivation is different. They often have considerable The first step in ambivalence towards dying and may not really want to die. Some people helping is to try to understand the in this categoiy are openly manipulative and, for example, might say to a person s current spouse who has left them, ‘Come back to me or 1 will kill myself. thinking I he fourth categoiy includes people who are having a psychotic episode and may be hearing voices that tell them to kill themselves. Clearly, these people need urgent psychiatric help. We have drawn up a list of possible reasons why a person might contemplate or talk about the possibility of suicide. As you read the list you may wish to think about whether there might be other reasons which have not been included. Possible reasons include: • because they despair of their situation and are unable to see an alternative solution to their problems, which seem to them to be unsolvable, intolerable and inescapable • because they are emotionally disturbed, are afraid that they may commit suicide and want to be stopped • to make a statement • as a way of hurting others; an ultimate expression of anger • to make a last-ditch effort to draw attention to a seemingly impossible situation, when other methods have failed

• T9lfr + 4lfr + Responding to suicidal intentions CHAPTER 34 269• • • • • to manipulate someone else because they have positively decided to commit suicide, want to do it and want other people to understand the reasons for the proposed action to be in contact with another human being prior to, or while, dying to say 'Goodbye’, as preparation for death because they are having a psychotic episode and are hearing voices telling them to kill themselves. ASSESSMENT OF RISK OF SUICIDE Anyone who says that life is not worth living may be at some level of risk. However, many people who have no intention of killing When assessing the level of risk it can themselves experience times when they despair and start to question be helpful to die value of their lives. A difficulty for counsellors is to determine consult with your the level of risk for a particular person. It is here that experience can supervisor be helpful in estimating level of risk, in deciding whether action needs to be taken or not, and in choosing the action to take, if action is needed. Consequently, new counsellors need to consult with their supervisors. There are some factors that are commonly considered in the relevant literature to be useful in determining level of risk (see the further reading suggested at the end of this chapter). A number of risk factors will now be discussed. GENDER AND ETHNICITY Although women attempt suicide more often than men, males are associated with higher risk. This is because males are more often successful in completing suicide than females. In particular, in Australia, Aboriginal males are associated with high risk. AGE Suicide is more likely to occur in the young and the old, with the risk being higher in people up to the age of 18 years and above 45. INTENSE OR FREQUENT THOUGHTS OF SUICIDE Whenever a person thinks of suicide it is wise to assume that there is some level of risk. However, if the thoughts are persistent or strong with little ambivalence, risk is increased. WARNING SIGNALS People who commit suicide have often given out warning signals over a period of time. Unfortunately, sometimes these are disregarded because they may have been given many times and been seen incorrectly as threats that will not be carried out. 270 PART 5 Dealing with particular problemsHAVING A SUICIDE PLAN If a realistic plan for committing suicide has been developed, then clearly the person has moved beyond vague thoughts that life is not worth living and there is a real risk that the plan may be carried out. CHOICE OF A LETHAL METHOD Some methods of committing suicide are more likely to reach completion than Others because they are quick or provide little opportunity for withdrawal if the person concerned has a change of mind as death approaches. Examples are when a person uses a gun or jumps off a high building. AVAILABILITY OF METHOD Risk is higher if the person already has the means to carry out the plan. For example, if a person has a loaded gun, or enough pills to cause death, then the plan may be carried out. DIFFICULTY OF RESCUE Risk is increased in cases where it would be difficult for others to intervene and prevent the suicide attempt. Examples are where a person is in an isolated place, when the location is unknown or when someone has climbed a structure, making it difficult for others to follow. BEING ALONE AND HAVING LACK OF SUPPORT People who are alone, single or separated, and believe that no one cares for them, are vulnerable to depression and suicidal thoughts and action. It may also be easier for them to cany out a suicidal plan without interference. PREVIOUS ATTEMPTS Previous attempts are an indication of increased risk. This is particularly so if the attempts have been frequent, are recent and have been serious. A FRIEND OR FAMILY MEMBER HAS DIED OR COMPLETED SUICIDE Risk of suicide is increased where a family member, close friend, colleague or peer has completed suicide. Additionally there may be risk where a loved one or pet has died. LISTENING TO SONGS ABOUT DEATH Some people, particularly the younger members of society, tend to listen obsessively to songs about death, dying and suicide. This increases risk. Responding to suicidal intentions CHAPTER 34 271DEPRESSION People who are depressed, feel hopeless, helpless or in despair are at risk. Phis is particularly so with severe depression where there may be symptoms such as loss of sleep or an eating disturbance. PSYCHIATRIC HISTORY Psychiatric illness or history is another indication of increased risk. LOSS OF RATIONAL THINKING Loss of rational thinking can occur for a variety of reasons. People who have been traumatised, are under the influence of alcohol or drugs, are suffering from dementia or have a psychiatric disorder may not be capable of thinking rationally. They therefore present increased risk and there are clear duties of care for the counsellor. UNEXPLAINED IMPROVEMENT Someone who has been exhibiting severely depressed feelings with suicidal thoughts and then suddenly changes to display a calmness and sense of satisfaction for no recognisable reason may be at Very high risk. The person may have completed preparations for suicide and have a sense of relief at the thought of their planned escape from acute emotional pain. By convincing the counsellor that everything is now OK, they may effectively mislead the counsellor so that preventative action is not taken. GIVING AWAY POSSESSIONS AND FINALISING AFFAIRS Behaviours such as giving away personal possessions, making a new will or terminating a lease may be an indication that the person is preparing for suicide and at high risk. MEDICAL PROBLEMS Medical problems that severely interfere with quality of life, are painful or are life­ threatening increase the risk of suicide. Chronic illness with little perceived hope of a cure or respite may increase a person s desire to terminate life. Here, there are both values and duty of care issues, as some people firmly believe that voluntary7 euthanasia is morally justifiable while others strongly disagree. SUBSTANCE ABUSE Excessive use of alcohol or drugs, both illegal and legally prescribed, raises the suicide risk. Certainly, alcohol or other substance abuse is associated with completed suicides. RELATIONSHIP PROBLEMS People who believe that they are locked in to highly dysfunctional relationships and cannot leave are at increased risk. Similarly, there may be risks for people whose 272 PART 5 Dealing with particular problemsrelationships are breaking up, who are separating or separated, and for those who are going through the process of divorce. When relationships change through, for example, remarriage, moving into a new stepfamily, having a new child in the family or children leaving the family, there may be an increased risk. CHANGES IN LIFESTYLE OR ROUTINE Many people find it difficult to adjust to changes in their lifestyle or routine, so times of change can precipitate suicidal thoughts and increased risk. Examples are when a person changes job, school or their place of residence. This may be particularly relevant when a person moves to a new locality and may lose access to long-term friends. FINANCIAL PROBLEMS Issues involving poverty, unemployment and financial difficulties, where the person concerned is depressed and feeling helpless to change the situation, lead to an increased risk. Important examples are bankruptcy and cases where a person loses a business or home. TRAUMA AND ABUSE Traumatic events and the experience of abuse or perceived abuse, in both the past and the present, may contribute to suicide risk. I his includes emotional, physical, sexual and social abuse. LOSS All losses of importance contribute to suicide risk. Examples include loss of a significant relationship, job, employment opportunities, business, home, possessions, self-esteem and loss of role. People who experience failure either at work or academically, or believe that they have failed others, are likely to suffer loss of self-esteem. The risk factors that have been discussed are included in Figure 34.1. 1 his may be photocopied for personal use and used as an aid in identifying risk factors when counselling people with suicidal thoughts or tendencies. However, it must be remembered that there is no precise formula for assessing risk, because we human beings are each unique, possessing our own individual qualities. All talk of suicide needs to be taken seriously and appropriate help sought where necessary. COUNSELLING STRATEGIES Perhaps the biggest problem for a new counsellor when seeking to help a person troubled by suicidal thoughts is the counsellor’s own anxiety. Sometimes new counsellors will tty to deflect a person away from suicidal talk rather than encouraging them to bring their self-destructive thoughts out into the open and deal with them appropriately. Unfortunately, such avoidance of the issue may increase the likelihood of a suicide attempt. Responding to suicidal intentions CHAPTER 34 273Figure 34.1 Assessment of suicide risk Risk factors - tick boxes where risk is indicated □ Gender □ Age □ Ethnic background□ Medical problems □ intense and/or frequent thoughts of suicide □ Warning signals given out over a period of time □ Has a suicide plan □ Choice of a lethal method □ Availability of method □ Difficulty of rescue □ Is isolated or alone □ Lack of support□ Significant life-changing events □ Change in lifestyle and/or routine □ Change in job, school or house locality □ Previous suicide attempts □ A friend, peer, colleague or family member has completed suicide □ Listening obsessively to songs about death, dying or suicide □ Death of loved one, friend or pet □ Depression □ Psychiatric illness or history □ Loss of rational thinking □ Unexplained improvement □ Giving away possessions □ F inalising affairs □ Relationship highly dysfunctional □ Relationship break up, separation or divorce □ Relationship changes - remarriage, new stepfamily, addition of new child, children leaving family □ Relationship worries -■ fear of losing a family member or partner or that someone is not coping 274 PART 5 Dealing with particular problems □ Alcohol and/or drug abuse □ Financial problems □ Socioeconomic situation □ Trauma □ Abuse or perceived abuse — emotional, physical, sexual or social abuse in the past or the present □ Loss of employment or employment opportunities □ Loss of business, home or possessions □ Loss of self-esteem — feeling a failure at work or academically — or belief that others have been let down □ Loss of role □ Other factors not listedBRING SUICIDAL THOUGHTS INTO THE OPEN Whenever counselling a depressed or anxious person, counsellors need to look for the smallest clues that might suggest that the person may be contemplating suicide. People are often reluctant to say "I would like to kill myself. They tend instead to be less specific and to make statements such as ' 1 don’t enjoy life anymore’ or ‘I’m fed up with living.' When a person makes a statement such as this, it is sensible for the counsellor to be direct, and ask them, ‘Are you It can be thinking of killing yourself?' In this way, suicidal thoughts are brought advantageous to be direct when out into the open and can be dealt with appropriately. We need to exploring suicidal remember that a significant proportion of people are at some times in thoughts their lives ambivalent about wanting to live and that many consider the possibility of committing suicide before rejecting it. r + >ra fe + 4 ■ f> + + 4
• •' ■«• + + *■ * + DEAL WITH YOUR OWN FEELINGS You will be a very’ unusual person indeed if you don't become emotionally tense when a person tells you that they are thinking of killing themselves. As a counsellor, allow yourself to experience your feelings and then you will be able to decide what to do about them. It is likely that these feelings may result from you giving yourself unhelpful messages such as those listed in Table 34.1. If so, you can give yourself new messages, after discarding the self-destructive messages that may be contributing to your tension. Table 34.1 presents some typical self-destructive and alternative helpful self­ statements for the situation. Challenge your self-destructive thoughts, and if your feelings of tension don’t subside, consult your supervisor. COUNSELLING SKILLS I he micro-skills that have been learnt previously, together with an appropriate counselling relationship, are the basic tools for helping a person who is contemplating suicide. We suggest that initially it is important to concentrate on building a relationship with the person, so that when trust has been established they can talk openly about their feelings and intentions. The counsellor might invite them to do this by saying, ‘I am concerned for your safety and The counselling wellbeing, and it is important for me to understand fully how and relationship can be a valuable resource why you feel the way you do.' By taking this approach the person is when confronting likely to recognise that the counsellor is joining with them in the suicidal thoughts exploration of their feelings, thoughts and options, rather than working in opposition to them. FOCUS ON THE PERSON'S AMBIVALENCE We recognise that each individual counsellor needs to make a decision for themselves about how to counsel a suicidal person. Some counsellors prefer a direct Responding to suicidal intentions CHAPTER 34 275Table 34.1 Comparison between self-destructive and helpful self-statements for counsellors seeking to help people with suicidal thoughts SELF-DESTRUCTIVE STATEMENTHELPFUL SELF-STATEMENT 1 am personally responsible if this person completed suicide.Sadly in the long term, no one can stop this person from killing themselves if they firmly decide to do that. Ultimately it will be their choice. 1 should stay with the person until they no longer have suicidal thoughts.It's impossible for me to watch over the person 2.4 hours a day. In the long term they have to be responsible for themselves. However, if 1 wish, and am able, 1 can take steps to arrange appropriate psychiatric supervision. 1 have the power to change this persons mind if 1 am skilful enough. OR 1 must persuade this person not to suicide.1 don't have the power to change someone else's mind, ThW most 1 can do is to help them explore the issues involved, and then take any other action available to me. I'm not as well qualified as other counsellors.1 am me, with my skills and limitations. If 1 am able to refer this person on to someone more qualified 1 will, and in the meantime I II do my best. If 1 am incompetent 1 will be to blame for this person's death.It's unrealistic for me to expect to be a perfect counsellor in such a stressful situation. 1 cannot take responsibility for their decision. 1 can only do what 1 am capable of doing. 1 must Live up to the person's expectations.1 do not need to live up to the person's expectations. 1 can't cope.1 can cope provided that i set realistic expectations for myself. approach where they will try to convince the person that they should not kill themselves, and for some people this may be the best approach. However, in our view this is not always the best approach because it puts the counsellor in opposition to the person. We think that usually it is more useful to focus on building a relationship with the person and then exploring their ambivalence — 'Should I kill myself or not?1 Most, if not all, people with suicidal thoughts have some degree of ambivalence towards dying. If a person was 100 per cent convinced that they wanted to kill themselves, they probably wouldn't be talking to a counsellor; they would just 276 PART 5 Dealing with particular problemsgo ahead with their suicide plan. We have found that focusing on the person-to- person counselling relationship while exploring the person's ambivalence is often the key to the successful counselling of those who are contemplating suicide. EXPLORING THE PERSON'S OPTIONS As explained in Chapter 25, when a person chooses between two alternatives they lose one of the options and may also have to pay a price for the chosen option. By choosing suicide, a person loses life, contact with others and the opportunity to communicate with others about their pain. In addition they lose hope, if they had any, for a better future. The cost of dying is likely to include fear of the unknown and for some religious people fear of being punished for killing themselves. We think that in many situations it can be advantageous to make a person who is contemplating suicide aware of their ambivalence, and to help them to look at the consequences, costs and pay-offs of dying and of living. Although at some stage we may decide that duty of care requires the use of firm A person needs to intervention, in the first instance we try to avoid directly pressuring fully explore their self-destructive the person to stay alive and instead help in the exploration of their thoughts in order to options. In this way the person is likely to feel understood, has the be able to change opportunity'’ to work through their pain and may feel sufficiently them valued to enable them to reconsider their decision. By joining with the person, they are free to explore both the 41 want to die1 part of self and the opposite polarity, with the counsellor walking alongside during the exploration. THE DIRECT APPROACH The direct approach is to try to persuade the person who is contemplating suicide that living is the best option. This approach is not usually our first preference because it sets up a struggle between the person who is saying ‘I want to die’ and the counsellor who is saying ‘I want you to live’. There is then heavy pressure on the counsellor to convince the person of the rightness of living, and this may be difficult as the counsellor and the person are in opposition rather than joining together. Even so, this approach can be successful with some people. There is no universal 'right way’ to go. Every’ person is unique and so is every’ counsellor. Each counsellor needs to choose an approach that seems right for them and for the person who is seeking their help. If a counsellor concentrates on establishing and maintaining a sound person-to-person counselling relationship, then they optimise the chances of success. Where this approach is not successful, duty of care requires the counsellor to take action, in consultation with their supervisor, to ensure the person’s safety and wellbeing. Responding to suicidal intentions CHAPTER 34 277DEALING WITH DEPRESSION AND ANGER People who are contemplating suicide are usually in deep depression, and depression, as explained in Chapter 31, is often due to repressed anger. Sometimes a person who is contemplating suicide may be turning anger, which could be appropriately directed at others, inward and towards themselves. It may be useful to ask the question 'Who are you angry with?’ If the person replies by saying 'Myself, you can agree that that is obvious and consistent with wanting to suicide. You might say, ‘You are so angry with yourself that you want to punish yourself by killing yourself.’ 1 his reframe of suicide as self-punishment rather than escape may be useful in some cases in helping to produce change. You could then ask, ‘After yourself, who are you most angry with?’ If by doing this you can help the person to verbalise their anger and direct it away from themselves and onto some other person or persons, their depression and suicidal thoughts may moderate. However, it is important to remember that as a counsellor it is important to do your best to ensure that the person who seeks your help is not a danger to others. LOOKING FOR THE TRIGGER Another way of entering a person’s world is to find out what triggered off the suicidal thoughts today. Very often a single event is the trigger and this trigger can sometimes give important clues about the person’s intentions. For example, is the person’s intention pa illy to punish someone who has angered or hurt them? If so, it might be useful to explore the issues involved. CONTRACTING After working through the relevant issues with a person who has been troubled by suicidal thoughts, many counsellors encourage the person to sign a contract to agree that if strong suicidal thoughts return they will not kill themselves before coming back for counselling. Although we ourselves do not use written contracts, we do negotiate with such people to obtain a verbal agreement about what action they will take if strong suicidal thoughts recur. We explore alternatives with them regarding the help they might seek if they start to feel tempted again to commit suicide. We ask them who is the first person they would try to contact, and if that person wasn’t available who else could they contact, or where would they go for help, in seeking a verbal agreement we rely on the strength of the counselling relationship, making it clear that the person is important to us and that we believe that we can trust them to honour the agreement. RECOGNISE YOUR LIMITATIONS Don’t forget that it is unrealistic, unfortunately, to expect that a person will necessarily decide to stay alive. Although you may be able, if you choose, to take measures to ensure that the person stays alive in the short term, in the long term, if they are 278 PART 5 Dealing with particular problemsdetermined to kill themselves, they are likely to succeed. However, as counselling progresses you will need to decide, in consultation with your supervisor, whether direct action to prevent suicide is warranted and necessary. This decision is a heavy one and is certain to be influenced by your own values and those of the agency that employs you. There are some cases where the decision to In some cases our intervene is clear. It would, for example, be unethical and irresponsible duty of care demands firm direct to allow someone who was psychologically disturbed due to a action temporary psychiatric condition or a sudden trauma to kill themselves without determined and positive action being taken to stop them. A person who is seriously contemplating suicide is likely to need ongoing psychotherapy from a skilled professional, so be prepared to refer appropriately. 1 he eventual wellbeing of such a person depends on them being able to make significant changes to their thinking and way of living, and this is unlikely to be achieved in one counselling session. Learning summary • • • • People who make repeated suicide attempts often succeed m killing themselves. Suicidal people include those who are locked into miserable lives, those who have recently experienced trauma, and those who want to manipulate others. When counselling a suicidal person, it is important to deal with your own feelings as a counsellor and to challenge any irrational beliefs you may have. When counselling a person who is contemplating suicide, focus on the counselling relationship using the normal counselling micro-skills: » find out what triggered the suicidal thoughts » bring the persons anger into focus » hook into the person's ambivalence if that can be useful » explore the person's options and particularly the costs of dying » use a more direct confrontational approach if you think that it is more likely to be effective » decide what direct action is warranted and necessary to prevent suicide » whenever possible, refer to suitably qualified professionals. Further reading Duffy, D. & Ryan, T. (eds) 2004, Xew Approaches to Preventing Suicide: A Manual for Practitioners, Jessica Kingsley, London. Henden, J. 2008, Preventing Suicide: The Solution Focused Approach, Wiley, Chichester. Reeves, A. 2010, Counselling Suicidal Clients, SAGE. London. Responding to suicidal intentions CHAPTER 34 279TRAINING GROUP EXERCISES RELATING TO PART 5: DEALING WITH PARTICULAR PROBLEMS Chapter 29: Counselling those troubled by addiction 1 Ambivalence exercise Invite the training group to form triads. Ask each person in the triad to sit quietly for a minute or two and to think of something they feel ambivalent about (for example, someone may feel ambivalent about whether or not to continue in a course of study; another may be ambivalent about continuing to engage in an exercise program). Instruct the trainees to briefly share with the others in their triad what it is that they feel ambivalent about and to clearly state what the two alternatives are (e.g. continue to study versus stop studying). Next the members of the triad are to decide whose ambivalence' the other two participants will work with (that is, who will be the ambivalent one'). Once the triad members have decided on an ambivalent one' the other two group members can volunteer to argue with each other, in a polite and friendly way, with one arguing for one of the alternatives and the other arguing for the other alternative. This exercise will work best if the two arguers are willing to take extreme positions, even though in reality they may not personally agree with these positions (for example, if the 'ambivalent one' is in two minds about continuing to gamble, then one of the persuaders needs to take a strong position in favour of gambling even if they don't personally agree with it). However, if a trainee is not comfortable in doing this, their position must be respected and if they wish they may choose to withdraw from the exercise. It is important to tell the trainees that the exercise is meant to be exaggerated, fun and above all friendly. The exercise can be allowed to go for a few minutes and then the person who was ambivalent is to be given an opportunity to comment on the experience and any effect it has had with regard to them making a decision. Next, the trainees can discuss what they've learnt from the experience in the whole training group. 2 Identifying positives and negatives Work in pairs with one person acting as the 'person seeking help' and the other as the counsellor'. The person seeking help is to talk about a behaviour of theirs that they feel ambivalent about (e.g. diet or exercise). _he counsellor is to assist the person seeking help to draw a table similar to that shown in Table 29.1 but related to the issue that the person seeking help is ambivalent about. The form is to be completed by filling in the positives and negatives relating to each side. The person seeking help is then invited to rate each positive and negative comment on a score from 1 to 10 (10 is most important, 1 is least important). The scores can then be totalled in each column and the totals compared. Discussion can then follow with regard to the experience of participating in this exercise. 280 PART 5 Dealing with particular problems3 Discussion on stages of change In the whole training group discuss how you would determine the stage that a person had reached with regard to their motivation to change. Try to use practical anecdotal examples to illustrate the discussion. Chapter 30: Counselling those troubled by anger Personal responses to anger Working individually, write down your current feelings and thoughts with regard to counselling an angry person. In doing this, take account of your responses to the questions: a Is it OK to be angry? b Are there different ways to express anger? c When does anger become a problem? d How would you know if a person might become violent? Write down any skills you think might be useful when in the presence of someone who is expressing anger. When you have completed the above exercise, discuss any issues you have identified with your training group. In particular, make reference to the issue of personal safety and explore ways that counsellor safety can be promoted. Chapter 31: Counselling those troubled by depression 1 Counselling a person with negative attitudes Work in pairs with one person acting as the person seeking help and the other as counsellor. The person seeking help is to role-play being consistently negative and depressed throughout the conversation with regard to every topic that is discussed. 2 Reflecting on the counselling experience On completion of the conversation and in the whole group discuss the counsellors experience of the conversation and how this experience might impact on the counselling relationship, in particular with regard to the emotional feelings experienced by the counsellor. Chapter 32: Counselling those troubled by grief and loss 1 Exploring a range of losses Working individually, write down a list of as many situations as you can think of where a person might experience loss. Rank these in order of severity. Next, discuss your list and rankings with your training group. Notice differences of opinion in your group and discuss these differences with regard to how they might impact on your relationship with the people you are trying to help and their perceptions of their loss. 2 Personal experiences of loss Working individually, if you feel comfortable in doing so, write down a list of personal losses that you have suffered and put these in order of severity with regard to the effect they had on you personally. Decide whether you are willing to share any of these experiences with your training group, if while doing this exercise you recognise training group exercises PART 5 281that you are becoming troubled by remembering a loss, taLk with your group facilitator or take other positive action, such as seeking counselling help to address your grief. Next, if you think it appropriate and believe that it would be helpful for the other members of the group, discuss one of your experiences of Loss and explain how you were able to deal with this loss and become more resilient as a consequence. Chapter 34: Responding to suicidal intentions 1 Values discussion In your training group, discuss and share your beliefs and values with regard to suicide and how these beliefs and values might influence your work with a suicidal person. 2 Discussion of suitable counselling strategies when working with a person who has suicidal intentions In your training group, discuss what strategies you would use to cope with your own feelings when seeking to help a person who has suicidal intentions. Next, in your training group discuss how you might initiate a conversation with a suicidal person with regard to: a their ambivalence b your duty of care. 282 PART 5 Dealing with particular problemsPART 6 TECHNOLOGY AND COUNSELLING Technology forms a significant part of our lives today. Therefore, exploring ways in which technology can be effectively used within a counselling context is increasingly important. In this section we consider both telephone and internet counselling.Telephone counselling We would like to ask you, the reader, a question: 'Do you think that it would be harder to be a telephone counsellor or a face-to-face counsellor?' We feel certain that you will have to think hard about this question because the two types of counselling are in some ways similar but in other ways very different. Before reading on, you may wish to think about what the major differences are. One major difference is that the nature of the contact between the counsellor and the person seeking help is obviously quite different in telephone counselling compared with face-to-face counselling, and this is sure to have an impact on the counselling process. ADVANTAGES OF HAVING VISUAL CONTACT X d A telephone counsellor (TC) has much less information about the person seeking help than a face-to-face counsellor. Because the TC can t see the caller, they are consequently denied a wealth of information. In contrast, a face-to-face counsellor can directly observe the person. From this visual contact they may be able to make tentative judgements about the person’s emotional state, coping ability, age, social status, cultural background and temperament; They are also able to gauge more easily the person’s willingness to share, and their comfort with the counselling relationship. From visual observation the face-to-tace counsellor has the benefit of many subtle clues that are not available to the TC. Most importantly, the c messages. This is much more difficult to do by phone. Have you ever TCs only have tried to smile down a telephone line? It’s not the easiest thing to do, is non-visual clues to their caller's it? Have you ever wondered whether the person talking to you by reactions phone was crying or not? In the face-to-face situation those telltale tears would leave you in no doubt. TIME TO BUILD A RELATIONSHIP Another significant difference between the two types of counselling concerns the counsellor’s ability to build a relationship with the person seeking help. The face-to- face counsellor has more time in which to build a relationship by using both verbal and non-verbal cues. Rarely does a person walk out of a counselling session during the 284 PART 6 Technology and counsellingfirst minute or two. But tor the TC the situation is quite different. If some level of trust isn’t established early on in the call, the caller might well hang up, thereby terminating the counselling process! In many ways, then, telephone counselling is more difficult than It is easy for a caller face-to-face counselling. The TC has to have good 'fishing’ skills, to hang up t hey need to be able to engage their caller through a gradual process that is active but non-threatening, so that the caller feels safe enough in the relationship to begin and to continue talking. BEING PREPARED FOR A CALL To be effective, it is important for a TC (Figure 35.1) to be ready to make the most of the first few moments of a call to engage the caller; the first minute or two of the call are often critical. A distressed caller in a highly emotional state will easily be frightened away, and is likely to hang up unless some immediate warmth and responsiveness comes through from the counsellor. INFLUENCE OF THE COUNSELLOR'S OWN PROBLEMS We counsellors are people with our own needs. If we are preoccupied by our own emotional problems and if our own unfinished business with other people needs attention, then we are very unlikely to be ready to engage with a caller over the phone when it rings. It takes time to put aside our own stuff, and unless we have done that, it will intrude. Sometimes when a person seeking help is coming to a second or subsequent face- to-face counselling session it’s possible for a counsellor to let go of their own preoccupations by owning them openly and saying to the person something like:

• Figure 35.1 The counsellor attending to the call Telephone counselling CHAPTER 35 285: 1 have just had a difficult few minutes and haven’t yet distanced myself from that experience. I’m letting you know this so that 1 can put that experience to one side and give you my full attention without being distracted by intruding thoughts/ Sharing information like this can be useful in two ways. Firstly, it addresses the process occurring for the counsellor and will probably enable the counsellor to focus on the person without the problem of intruding thoughts. Secondly, the counsellor models an appropriate way of displacing, or putting to one side, troubling thoughts. Unfortunately, this technique can’t be used in telephone counselling unless the caller is well-known to the counsellor. The TC—caller relationship is usually too fragile for such a disclosure at the start of a call. PREPARING YOURSELF FOR A CALL to pay full attention to the caller and to the counselling process. 1 he TC therefore needs to prepare adequately before the phone rings. .... t.......................................... If they are troubled by Worrying or disturbing thoughts, then they We need to be need to deal with these in some appropriate way. We are all different ready when the phone rings and the way in which we prepare ourselves may not work for other people. 1 here are four common ways of preparing for a telephone counselling session. They are: 1 Talking through your own problems with your supervisor. 2 Owning your intruding thoughts by telling a colleague that they exist. 3 Using relaxation, meditation or prayer, depending on your spiritual orientation. 4 Engaging in physical exercise. TALKING THROUGH YOUR OWN PROBLEMS WITH A SUPERVISOR Owning the problems that are troubling you and talking them through with your supervisor or another counsellor is certainly a good approach. By doing this the problems are not just put to one side but are worked through. This is particularly useful, because if you just put your own problems to one side without working them through then they are sure to re-emerge if the problems of the person seeking help are in some way similar. Working through them first is clearly the ideal. SHARING YOUR PROBLEMS WITH A COLLEAGUE Unfortunately, in practice it is not always possible to talk through one’s own problems prior to a telephone counselling session. It may, however, be possible to use a similar method to that described previously for face-to-face counsellors, but instead of telling the caller that you need to put aside some troubling thoughts, you could tell a colleague. It might be sufficient to say to another TC: ‘1 realise that I have brought with me some troubling thoughts about my family. 1 don’t want to unburden them on 286 PART 6 Technology and counsellingto you because you may have needs of your own at this time, but I will talk them through with my supervisor later. Telling you that these thoughts exist helps me to put them to one side for the time being, so that i feel better prepared to answer the phone.’ USE OF RELAXATION, MEDITATION OR PRAYER The use of relaxation, meditation or prayer can be effective in helping a counsellor to feel more prepared for a telephone counselling session. We are all unique individuals and so what suits one person will not be appropriate for another. While some counsellors find the use of structured relaxation exercises helpful, others have learnt techniques for meditating. People who have religious beliefs often find it useful to pray to ask for help in preparing them to receive calls. USE OF EXERCISE Engaging in physical exercise before a telephone counselling session can be helpful. People who enjoy exercising often find that they are able to feel good and to let go of troubling thoughts in this way. The alternatives are many and include jogging, playing golf, squash, tennis and swimming. THE CALLER'S PERSPECTIVE Having dealt with the need for appropriate preparation by the counsellor, it is time to consider the caller’s position (figure 35.2). Callers are often anxious and uncertain about what to expect. The act of picking up a phone and dialling a stranger can be worrying for some people. Some callers, being anxious, may have made a few false starts before finally dialling your number and waiting for you to respond. Consequently, the first few words and the way in which you, the telephone counsellor, speak to them are crucial. Figure 35.2 The person calling for help Telephone counselling CHAPTER 35 287THE INITIAL CONTACT Most human beings tend to approach strangel's with caution. We are wary and tentative in establishing relationships. Consequently, if a TC were to pick up the phone at its first ring and to talk quickly, the caller may feel threatened and be frightened away. We human beings approach The way the phone each other warily and in our natural caution we draw back when is answered is certain to have an someone tries to meet us at a faster pace than we find comfortable. immediate influence We wonder if you have ever felt taken aback when you have called on the caller someone and they have answered the phone before you have heard it ring? We need to be careful to meet the caller at an appropriate pace, so remember to be calm and relaxed so that the process of joining occurs naturally. We find that picking up the phone after two or three rings and answering caringlv in a way that is warm and non-threatening is useful. At Lifeline centres, TCs often start by saying: ‘Hello, this is Lifeline. Can I help you?7 1 he words are important and so is the tone and pace. The voice quality needs to be calming and inviting without being gushy. RESPONDING TO 'PRANK' CALLERS Some callers, particularly children, may initially behave in a way that suggests that the call is a prank call (see later in this chapter regarding nuisance calls). However, we need to be careful not to respond inappropriately to such callers, because their behaviour may be their way of attempting to access the counselling service and to test the counsellor’s acceptance of them. It is important that all callers are treated with respect. By doing this it is sometimes possible to achieve useful counselling conversations in calls that initially appear to be pranks. CONTINUING WITH THE CALL After the initial contact, the process of building a trusting relationship gets seriously under way. Inappropriate responses or inappropriate timing may result in the caller hanging up rather than continuing to talk. The counsellor needs to be tentative, and to recognise and make allowance for the caller’s hesitancy. Lhey need to explore cautiously what is safe for the caller and what is not. l hey have to listen intently and to use all their skills and judgement in an effort to build a comfortable non-threatening relationship, so that the caller is empowered to talk freely. ’The counsellor has to maintain such a level of empathic understanding and warmth that the caller will become more at ease rather than be scared away. With some callers this is no problem, but with others, as explained before, the simple act of picking up the phone has in itself been a difficult step. Too much talking by the counselloris sure to push the caller away, as is too much silence. Yes, telephone counselling is difficult! It involves knowing when to be verbally active, and when to draw back and to listen in silence. Judging the needs of the caller and responding empathically without intruding are what is required. 288 PART 6 Technology and counsellingHANG-UPS One of the advantages of seeking telephone counselling rather than face-to-face counselling is that a caller can easily opt out at any time without embarrassment. Inevitably, some callers who are not used to calling TCs are likely to hang up prematurely in their first attempts to engage in such a counselling process. Don’t despair when a caller hangs up, because it is inevitable that this will happen from time to time. Even so, every’ experienced TC knows how demoralising it can be to lose a call. When it does happen, remind yourself that the caller may have achieved a minor goal by learning that they can cope with picking up the phone, dialling the number and starting to talk. Elaving made what ALL TCs experience for them may have been a big step, they may then be able to phone hang-ups - so don't back later to talk for longer, if you are becoming worried by callers take this personally! hanging up, we suggest that you talk through the issue with your supervisor. STAYING FOCUSED Telephone counselling often requires a high level of concentration with intense listening. Frequently, distressed callers will talk quietly and consequently be difficult to hear. Tor new counsellors, there may seem to be too many things to attend to at the same time. The counsellor needs to listen to the spoken words, identify the emotions underlying them, understand or picture the caller’s situation, attend to the process of the call and make suitable responses. Telephone counselling certainly is Very demanding for a counsellor, but it can also be very satisfying for counsellors who sensibly and properly attend to their own personal needs (see Chapter 42). SKILLS NEEDED 1 he counselling micro-skills described earlier are all needed in telephone counselling just as they are in face-to-face counselling. On the macro scale, the process of a telephone counselling call will be very similar to the process of a face-to-face counselling session, as described in Chapter 15. However, there are some differences at both the micro and macro level. Let us look at each of these in turn. USE OF MICRO-SKILLS In telephone counselling, all the micro-skills described previously are required. However, in using these skills special attention is required to compensate for the lack of visual and other non-verbal information. The caller can’t see your face, your facial expression or your body posture. In our day-to-day communication, the words we say are moderated, amplified or changed in other ways as a consequence of the non­ verbal behaviour that accompanies the words. For example, a counsellor may add emphasis to what they are saying by leaning forward as they say it. A caring Telephone counselling CHAPTER 3S 289expression may reassure the person that what the counsellor is saying isn’t meant to be hurtfill to them although it may be confronting. TCs need to compensate for the lack of non-verbal cues by adding tone and expression to their voices over and above what The caller only has would ordinarily be required in face-to-face contact. Additionally, your verbal cues to let them know you whereas a face-to-face counsellor can listen in silence at times, it is are still Listening important that in telephone counselling the counsellor should regularly give verbal cues that listening is still occurring. Obviously this shouldn’t be overdone, but it is reassuring for a caller to hear minimal responses such as ‘ah-ha’, 'yes’, 'mm’ coming in response to their own statements. At times during personal telephone calls to friends or family, have you ever had to ask 'Are you still there?’ because the other person has been listening silently? Most people find it disconcerting when they get little or no response while talking to someone on the phone. Certainly, in the counselling situation it is important for the caller to know that the counsellor is still there, and listening intently. Similarly, the TC can’t see the caller and will sensibly need to check out with the caller information that would, in a face-to-face session, be obvious from the appearance of the person. In a prolonged silence it may be appropriate to ask, 'What is happening for you right now?’ If you suspect that your caller is crying but are unsure, it may be worth waiting for a while and then saying in a quiet, caring tone of voice, : You sounded very sad as you spoke and 1 am wondering whether you are starting to cry.’ A MACRO VIEW: THE OVERALL PROCESS T he process of a telephone counselling call can often be described by the flow chart shown in Figure 16.1 (see page 135). Clearly each call is different, but it can be helpful to recognise, and if necessary influence, the stages through which the call progresses. For example, it can be advantageous to recognise when it is sensible to move from the active-listening stage into the later stages. When doing this a counsellor needs to trust their gut feelings, to be sensitive to the caller, and to be able to recognise whether the overall process of the call seems to be meeting the caller’s needs. It is there that experience and supervision are useful. INFLUENCING THE PROCESS OF A CALL While you are attending to the caller, take time to recognise where the call is heading and, if appropriate, make decisions with regard to the process. For example, it is not going to help a chronically depressed caller if you continue active listening for too long, particularly if you are reflecting feelings and negative thoughts. In fact you may well succeed in helping the caller to move further down into a trough of despair! Recognise the time to move on and to start using skills which address thoughts and behaviours (see Chapter 31). It is important, as described in the earlier part of this book, to follow the direction the caller chooses and generally to meet the caller’s agenda in preference to your own. However, these guidelines are not inflexible rilles and need to be seen in the 290 PART 6 Technology and counsellingcontext of the whole call, the caller’s situation, the policies of the counselling agency and the counsellor s own goals for the counselling process. In our view a caller is more likely to feel helped if some progress is made in the call towards an increased awareness such that there is a likelihood of adaptive change occurring for the caller. To achieve this, the TC may at times have to influence the direction and process of the call. Don’t forget, however, that change usually occurs through increased awareness rather than through the counsellor pushing for change (see Chapter 26 on facilitating action). If a caller is repeatedly going through the same material, then it is appropriate to raise their awareness of that process by directly confronting it (see Chapter 19). It will often be useful to tell the caller what you notice is happening in a call. For example, a counsellor might say to a caller who suffers from chronic depression, 4 notice that you seem to be becoming overwhelmed by depression’. Once the process has been identified, then the TC has the opportunity to move the call into a new stage. For example, the counsellor might move into the stages where the emphasis is on thoughts (see Figures 16.1 and 16.2) and might use an exception-oriented question from Solution-Focused Counselling as described in Chapter 22. The counsellor might ask, ‘Was there ever a time when depression didn’t overwhelm you?’ 1 his question might be followed by asking, ‘What was different then?’, or 'So there was a time when you knew how to beat your depression?’, and 'Is there anything that you could do now that would be similar to what you did before when you had some control over depression?’ We have used the example of depression because most telephone counselling centres receive a significant number of calls from those people who are troubled by chronic depression. Such people often need to have medical or psychiatric help and it is important to raise this as an option if it is not occurring (for further information on counselling people who are troubled by depression see Chapter 31). You may be surprised that we are implying that TCs may need to pay more attention to control of the process of the counselling session than face-to-face counsellors. We think this is true because telephone callers often do not feel constrained by time, and when they become comfortable with a counsellor some callers are content to chat rather than focus their thoughts in order to use the interaction constructively. Also, FCs frequently only have a single interaction with a particular caller, so there may be no possibility of ongoing work, which more often occurs m face-to-face counselling. ADDRESSING EACH CALLER'S PERSONAL NEEDS If we refer back to Figures 16.1 and 16.2 (see pages 135 and 136), it is clear that for some callers it may be sufficient to move directly through the process as described in the figures. For other callers, particular stages need to be emphasised if the caller is to be helped. As each call progresses, a picture of the caller and their situation will emerge and you will need to make decisions about how best to help this caller. You may decide that it is sufficient for the call to stay mostly in the active-listening and emphasis-on-emotions stages, with consequent cathartic release for the caller. Telephone counselling CHAPTER 35 291However, for other calls it may be desirable to gently encourage the caller to move forward into subsequent stages that will enable fuller clarification of the problem, or may facilitate changes in thinking or behaviour. To be a fully effective and responsible TC you need to be able to assess what is most appropriate for each caller. Unlike face-to-face counselling, you may not get another opportunity to have a counselling conversation with a particular person, so you will need to make the most of your opportunity. However, do not think that you have to achieve life-changing results in one call. If the caller finds it useful talking to you, then they are likely to use a telephone counselling service again. Each call can be seen as one step in an upward flight of stairs where the caller is moving one step at a time. SOLVING THE CALLER'S PROBLEM A FAIRY STORY Once upon a time in the land of Great Tragedy and Despair there lived a wonderful person who became known as Super-TC. Super-TC was better than most TCs because his calls lasted only a few minutes. He was always able to give good advice and his callers usually politely thanked him for that. His approach was to identify the caller's problem swiftly and then to suggest a solution. Sometimes, when Super-TC couldn't think of a solution himself, although that wasn't very often, he would refer the caller to someone else who might have a solution. Occasionally callers would make it clear that they wanted a longer counselling interaction. In these instances, Super-TC would say to the caller, 'Its clear to me that you have a quite serious psychological condition. You need to make an appointment immediately to see either a face-to-face counsellor or, better still, a psychiatrist.' At times, particularly when tired, it is easy for a TC to inadvertently start behaving in some ways like Super-TC. No one is perfect. It is always tempting to provide a quick solution rather than to suffer the emotional pain of listening to someone else who is suffering. Of course, there are times when it is appropriate and responsible to refer a caller to others. Generally, however, before doing that, it is preferable to allow the caller to deal with their emotional issues in the ‘here and now’. Often when this is done a referral will not be necessary. Some TCs, who have trained specifically for working on the phone, believe that face-to-face counsellors are necessarily more competent than they are, with the consequence that they will refer to face-to-face counselling before helping the caller fully by using the normal counselling skills and processes. Unfortunately, we professional face-to-face counsellors, social workers, psychologists and psychiatrists vary in our competence. Yes, it is appropriate to refer on when you are out of your depth, and it is unethical and irresponsible not to do so. However, give your callers the opportunity to explore their pain fully with you on the phone if that is what they would like to do, in J 292 PART 6 Technology and counsellingaddition to giving them an onward referral if necessary. If you are unsure about what you are doing, we suggest that you might like to talk to your supervisor. Unfortunately, Super-'PCs are likely to disempower their callers. When in doubt, By finding solutions for them, Super- fCs may confirm callers’ worst consult your fears by the implied message: ‘You are not capable of running your supervisor own life and making your own decisions. You need someone else to tell you what to do.' There are times in our lives when we do need someone to tell us what to do, but usually human beings of normal intelligence prefer to make their own decisions, and can feel good about themselves if they are empowered through the counselling process to do so. If counselling has been really effective, an empowered person who has talked with a counsellor might think: ‘Counselling wasn’t much help, the counsellor didn’t tell me what to do, instead 1 made my own decision. 1 am an OK person and can run my own life.’ It is clear that finding solutions for other people is usually not helpful. However, it can be very’ useful indeed to help people to find solutions for themselves. In this regard readers might wish to use the solution-focused skills described in Chapter 22. MAKING NOTES DURING THE CALL It is not easy to give a caller your full attention and at the same time to pay attention to the process of the call so that you can facilitate appropriate changes in
• Figure 35.3 Genogram x. 2 years 10 years 5 years x z ■X Si Key Female

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Male Sex unknown Married ~~ Separated —//— Divorced Yxf Deceased Boundary around people who all live together Note: BiLL was married to Sandra and they had two children, Nicholas and Monique. Sandra and Bill divorced. Later, Bill met Maureen and they have a 2-year-old child. telephone counselling CHAPTER 35 293that process if necessary’. A high degree of concentration is required and it is easy to become distracted and to forget important information. To avoid losing information, and to help in more fully understanding a caller’s situation so that you can see their picture more clearly, it can be useful to make notes during a call. Some TCs add sketches as the call proceeds and find that this helps them to focus on the caller more intently. If a caller is talking about family problems, then it can be useful for a TC to draw the family tree in the form of a genogram. Figure 35.3 is a simple example of a genogram. G eno grams can be useful in helping the counsellor to more fully understand the caller’s background. USING YOUR IMAGINATION As a TC you can’t see the caller, but you can, if you choose, imagine them. While they are talking, you can construct a visual picture and imagine yourself in the caller’s position and situation. If you do this you may be able to experience more fully what it is like to be the caller and consequently he able to respond with noil-judge mental empathy. ADVANTAGES OF TELEPHONE COUNSELLING We have made the point previously that in our opinion telephone Telephone counselling is more difficult than face-to-face counselling. It is, counselling can however, an extremely valuable form of counselling. Some people help people who who would never come to a face-to-face counselling interview will might not be willing use the phone. From the caller’s perspective, telephone counselling to come to face-to- offers the following advantages: face counselling • It is safer for the caller because they can if they wish protect their anonymity. This may help them to feel less concerned about the consequences of sharing private thoughts and emotions with a stranger. • The caller knows that if they are feeling too threatened, they can hang up. This is far easier than walking out of a counselling room. • Telephone counselling is easily and immediately accessible (unless the line is engaged) with no waiting list. The caller just has to pick up a phone and dial. • Generally, telephone counselling is of low cost to the caller. SETTING BOUNDARIES Because telephone Counselling provides a safe environment in which a caller can share their deepest secrets, it also has some hazards. Some people who phone in are alone and have no close friends who can listen to them. Such people can be very vulnerable and may wish they had an understanding friend. Good counsellors are accepting, warm, empathic and non-judgemental. Consequently, lonely callers may build a very’ skewed picture of the person they are sharing with, perceiving the 294 PART 6 Technology and counsellingcounsellor very positively. It is essential, therefore, to set clear boundaries so that the caller understands that the relationship is a phone relationship and cannot be extended beyond that. To do otherwise is to set up an expectation in the caller that, maybe, there could be the beginnings of a personal relationship. Remember that lonely, unhappy people are often needy and vulnerable. It is totally unethical to take advantage of them. Further, it is unrealistic to think that you could help them if you were to allow the relationship to change from a counselling relationship into a friendship. To do so would damage their ability to trust the counselling process as a safe one that they could use in the future. DEBRIEFING Debriefing is a process used to enable counsellors to let go of the emotions that they inevitably experience as a consequence of listening to a distressed person. If a counsellor said to you, Till an experienced telephone counsellor — I don’t need to debrief because calls from people seeking help don’t trouble me’, would you believe them? All counsellors, however experienced, need to debrief, especially after particularly stressful counselling sessions. Although we are both experienced professional counsellors, we make it a regular practice to debrief after difficult or emotional counselling sessions. If we were not to do so, the service we provide would inevitably become less effective and we would suffer burnout symptoms. TCs are particularly vulnerable to the emotional after-effects of their counselling work. It is common for people in acute crisis to reach Telephone for the telephone to seek help. Consequently, FCs frequently receive counselling can be calls from people who are in extreme distress and/or panic. Not stressful for the counsellor surprisingly, telephone counselling often leads to crisis intervention (see Chapter 33). Because of the inevitable crisis content of telephone counselling, TCs will sometimes feel drained at the end of a shift on the phone. 1 heir callers’ emotional pain will at times inevitably trigger off personal emotional stress for them. TCs therefore need to be responsible by caring for themselves. After a particularly stressful call, we suggest that it is useful to take a break before accepting another call, and if at all possible talk to your supervisor or another counsellor about the feelings you are experiencing. At the end of each counselling shift, debrief once again by talking to your supervisor or another counsellor for a few minutes. Debriefing need not be a long process but it is an important one. PROBLEM CALLERS No discussion of telephone counselling is complete unless it gives some consideration to what are best described as problem callers. These are callers who create special problems for FCs. They may have goals that are incompatible with those of the counselling service and consequently may want to use the service inappropriately. Telephone counselling CHAPTER 3S 295Some of them may want to satisfy particular needs that are not being met elsewhere. However, problem callers are people with genuine needs, so TCs need to be able to deal with calls from them in a constructive way which fully addresses their counselling needs. Most problem callers fall into one of the following categories: 1 nuisance callers 2 regular Callers 3 callers who are troubled by chronic depression 4 sex callers. NUISANCE CALLERS Inevitably, there will be people who will call in to telephone counselling services with the aim of causing annoyance, or maybe of getting a laugh at the FC’s expense. Some of these will repeatedly ring up and then hang up, others will be openly abusive, and there will be those callers who make hoax calls. Sometimes angry or abusive callers will repeatedly knock the phone or slam it down. Such calls will naturally tend to make the counsellors receiving them feel frustrated and annoyed. We need to point out that it is normal to be frustrated, annoyed and possibly angered by such behaviour. Counsellors are human beings and as such we have our own legitimate emotions. Somehow, though, we need to deal with our frustration, annoyance and anger, so that we can feel OK and are ready and able to deal appropriately with these calls and with subsequent calls. 1 he best way of dealing with emotions resulting from nuisance calls is to talk with someone about them. If this is not possible then we suggest that you might like to try to alter the way you think about the caller so that you are more able to be constructive in dealing with them. Can you think of the nuisance caller not just as an annoyance hut also as someone whose needs are not being fulfilled in an adaptive way that enables them to have a satisfactory7 and fulfilling life? The reality is that any person who finds it necessary to harass a telephone counselling service most probably has a Very unsatisfactory and unfulfilled life. Could you be bothered to phone in to a counselling service just to be a nuisance? None of us could; we have much more satisfying ways of spending our time. Here are some suggestions as to why some people make nuisance calls: • They may be angry7 and unable to express their anger in a constructive and adaptive way. • They may be frustrated with life and not know how to deal with their frustration except by annoying others. • 1 hey may be bored and lonely. • They may be young people engaging in what for them is harmless fun. They may also want to impress friends by 'playing a joke1 on a counsellor. • They may be young people 'taking risks’ or acting impulsively but in a reasonably normal developmental way. 296 PART 6 Technology and counsellingI hey may be people who are testing the service before deciding whether or not to talk about more serious issues. All of these people have problems in their lives and are searching Nuisance callers also ' for something they cannot find. If you are able to think of nuisance have problemsand need to be valued callers as people dissatisfied with their lives who are hurting inside, then you may be able to develop constructive strategies for dealing with them. We don’t believe that there can be one correct way of responding to such callers because they are all different. What we try to do is to decide what, if anything, can be achieved when in conversation with such callers. We ask ourselves whether any of the following goals are realistic: • to let the caller know that they are a valued individual • to encourage the caller to talk about their real issues • to let the caller know why we believe that what they are doing is destructive • to let the caller know how we feel • to decrease the likelihood that the caller will repeat their nuisance-calling behaviour • to deal with the underlying issues that result in this unwanted behaviour. Can you think of other suitable goals? If you are able to remember your goals, then you may be able to deal with such callers constructively and effectively. At all times, remember that it is not a part of your role as a TC to be abused. You have a right to tell any abusive caller that you will not listen to abuse and to hang up if that is what you consider to be most appropriate. Of course, there are times when counsellors deliberately choose to listen to the abuse of an angry7 caller in order to allow such a caller to vent their anger and then to move on to dealing with constructive issues. As a counsellor, although the choice about whether to hang up or not will be influenced by the policies of rhe agency in which you are working, it is ultimately your choice, and you have a right to hang up if that is what you choose to do. • REGULAR CALLERS All telephone counselling agencies have problems with those callers who repeatedly call in over a long period of time. Some of these callers have genuine needs that can be appropriately met by counselling. However, many regular callers re-run the same story7 over and over again. Others try to engage the counsellor by using a variety of different names and stories, often with an underlying theme to their stories. Regular callers can cause a considerable problem for telephone counselling agencies because they take up valuable time that could be used in working with other callers. Also, they are likely to cause disillusionment and increased burnout in counsellors. Agencies that employ many counsellors have particular difficulty7 in dealing with regular callers because their counsellors are sure to find it difficult to recognise the regulars. Although there are exceptions, we do not think that it is helpful to allow regular callers to talk at length. To do this disadvantages other callers. Also, regular callers are more likely to dig themselves deeper into their regular caller’s rut if they are pennitted to talk for an extended length of time. Unfortunately, some regular callers are very Telephone counselling CHAPTER 3S 297adept at manipulating counsellors because they are experienced in talking to a counsellor. In this regard, regular callers commonly use a range of statements with the goal of convincing the counsellor that they should continue to listen. These include: You seem to really understand me. No one has ever been able to get close to me this way before. You are such a warm person that 1 feel so comfortable talking to you. I think I'll kill myself now. I just need to ask your opinion about one more thing. Other callers are much more important than me. Many telephone counselling agencies have lists of regular callers, giving details to assist counsellors in recognising the regulars, and also to give guidelines for handling these calls. If these callers do not receive consistent responses from counsellors then their best interests are not served and additionally they may cause a problem for the agency. It’s sensible to make clear decisions when handling such callers so that their real needs are met and they feel valued as people, and also so that they do not disrupt the service to the disadvantage of other callers. Most agencies set time limits for calls from regular callers, but terminating calls from some of them can be difficult. You may need to be very assertive (see Chapter 12). Regular callers can be frustrating and annoying at times, but we would like you to consider them from another perspective. Regular callers are often sad, unfulfilled people who would not call in if they were able to lead satisfying lives. Among them are the chronically sick, the mentally ill, people with disabilities, lonely people, people who are grieving heavily as a consequence of broken or lost relationships, the chronically depressed and people with significant past histories of abuse, lhey are all different from each other and unique as individuals. They each have their personal needs and deserve to be treasured in the same way that other callers are treasured, l hey have a right to receive care and counselling. ID avid will now describe some examples of regular callers who have been known to him. Caller 1 'Some counsellors at a particular telephone counselling agency felt that they were wasting time listening to an old lady who phoned in several times each day. _hen one day a woman phoned to say that the old lady was her mother and that she had died. The woman said that she was phoning to tell the counsellors how much her mother had valued the warmth and caring they had offered her during the last few weeks of her Life/ Caller 2 'One day, I met face to face with a seriously depressed regular caller who was boring TCs with his monotonous conversation. I was confronted by a sad. 298 PART 6 Technology and counsellingdisfigured and disabled person who had no friends and was avoided by strangers. He had little chance, if any, of improving his lifestyle. He could hardly stand or walk, his speech was impaired, his conversation was uninspiring, and he had barely enough income from his pension to survive. He lived alone. Almost his only human contact was by phone with the TCs who cared enough to listen.' Caller 3 'Once, to my surprise, a capable TC who was well-known to me confided that before becoming a TC she had for a time been a regular caller herself during a very difficult period in her life. Thanks to the counselling process she had been enabled to deal with her problems and to climb out of her trough of despair. She was now helping others.' T hese examples are, we believe, not unusual. Regular callers are valuable people and require patient caring, although sometimes it is not easy to be either patient or caring when counselling them. It’s easy to say, 'Oh, she’s a regular caller, and 1 really don’t want to listen to her/ It’s harder to say, 4T his is a challenge. Can 1 work with this caller in a way that will be satisfying for them and for me? If you are going to get satisfaction from helping a regular caller, you will need to be clear about your goals for each call. You will also need to be direct in telling the caller clearly what to expect from you. For example, you may say, 'Frank, I’m happy to talk with you for 15 minutes but then 1 would like to hang up so that other callers also have the opportunity to call in.’ By doing this you are being up-front and can use the call caringlv and constructively to achieve a goal. Here are some possible goals: • to raise the caller’s awareness of their 'broken record’ • to help the caller to recognise options • to empower the caller to do something different, however small • to help the caller to feel valued • to provide a listening ear for someone lonely. Can you think of other goals? Counselling goals listed in Chapter 31, about counselling those troubled by depression, may also be appropriate. CHRONICALLY DEPRESSED CALLERS A high percentage of regular callers fall into the chronically depressed category, so we have decided to give them special mention. r These people have Very sad lives and call for a high level of caring from those who counsel them. Strategies for counselling them are in some ways the same as but in other ways different from those used in general counselling. TCs therefore need to have appropriate strategies for working with such callers. Some of these strategies are described in Chapter 31. Telephone counselling CHAPTER 35 299SEX CALLERS Unfortunately, telephone counselling agencies are frequently troubled by callers who want to use counselling services to satisfy their sexual needs. In our experience almost all of these callers are male and generally they only want to talk with female counsellors. They7 will either recount a story with a high level of sexual content or may be direct in asking the counsellor if they may masturbate while talking. It is probable that many of these callers are obsessed by sex and have little or no chance of building a satisfying relationship with a partner. For others, sex may be an escape from the reality of a very7 unsatisfactory7 life and they may believe that they7 have no options to enable them to change their lives. We suspect that many of these men lack respect for women and have psychological problems related to their relationships with them. We can see no justification, regardless of circumstances, for a caller to attempt to use a counsellor for their own sexual gratification. For them to do this is sexual abuse, and it can be dealt with as such. However, counsellors need to be careful in assessing whether a caller is a nuisance \sex caller’ or not. There are callers who genuinely seek anonymous counselling help with regard to very7 personal sexual problems. Some of them would be too embarrassed to attend a face-to-face counselling session and may even be hesitant about talking to a TC. Clearly they need counselling help, even if only a sensible referral to a clinic or sex-counselling service. Unfortunately, it’s hard to separate these genuine Callers from the abusers. If a genuine caller is treated as though they are a sexually abusive caller, then their trust in the counselling process may be seriously damaged. We wish that we could tell you how to distinguish between the genuine and the non-genuine caller. We can’t. We suggest that all you can do is to use your judgement, and if you think that a caller is using you to fantasise sexually or to masturbate, then confront him. If the confrontation is done caringly, as explained in Chapter 19, the caller’s attitudes may be challenged and there is a possibility7 that they may seek appropriate help for dealing with their problem. Obviously, sex callers have genuine psychological or life issues. If they didn’t, they wouldn’t attempt to use telephone counselling services in such a way. Consequently, a caring counsellor might choose either to deal with the caller firmly but caringly or to be very7 abrupt and to hang up. Yes, we do believe that it can be caring to give very direct messages about the consequences of inappropriate behaviour. If you are abrupt and hang up, you are giving a clear message. Alternatively, you may decide to be explicit in telling the person how you feel about what they are doing, explaining that you intend to hang up, and in addition giving the caller an invitation to call back if they7 want to talk about real-life issues rather than using you as a sex object. However, it pays to be cautious or you may find the same caller pretending to tell you about ‘real-life issues’ while masturbating. There are some counsellors who will tolerate this. That is their choice, and if they are able to achieve worthwhile goals then their caring is to be admired. They need to be careful, however, on two counts: firstly, that they are not implicitly encouraging 300 PART 6 Technology and counsellinginappropriate behaviour that may be detrimental to other counsellors, and secondly, that they are not merely satisfying their own sexual or other needs. Here, supervision can be valuable in identifying the relevant issues. Certainly, all counsellors need to be aware of their own personal rights and to know that they are fully justified in protecting themselves from abuse by refusing to listen. CREATING COMFORTABLE CLOSURE OF A TELEPHONE COUNSELLING CALL Bringing a telephone counselling call to closure is an art, and if it is carried out expertly the caller will feel comfortable about hanging up, recognising that the call has come to a natural end. In order to achieve this result, the process of ending the call needs to be integrated into the conversation so that it occurs smoothly and is expected. Generally, the process involved in ending a counselling call of average or longer length will follow a sequence of steps. These steps prepare the caller to expect that the call will soon end. Naturally, each call is different and what is appropriate for one call will not fit another. Here are some recommended steps that can be used when ending a call: 1 Decide when to finish a call. 2 Warn the caller that the time to finish is approaching. 3 Summarise the call. 4 Give the caller some positive feedback. 5 l ake control. 6 Tell the caller that you are going to finish the call. 7 Invite the caller to phone back if appropriate. 8 Say 'Goodbye" and hang up. We will now discuss these steps in detail so that you can use them as a guide if you wish. However, remember that you are a unique individual and will need to develop your own way of ending calls. DECIDE WHEN TO FINISH A CALL As you know, there can be no standard rule about how long a telephone counselling call should be. However, we don’t believe that it’s useful to let calls continue after useful work has finished. If the call is losing energy, or not making constructive progress for the caller, then it’s time to move towards ending the call or to look for different strategies so that the call regains its usefulness. Generally, we find that it is not helpful to allow calls to continue for longer than one hour at the most, although occasionally there will be exceptions to the rule. We think that it is worth mentally evaluating what is happening in a call if it is still continuing after about 45 minutes. A decision can then be made about how to influence the process of the call so that the remaining minutes are useful to the caller. Telephone counselling CHAPTER 3S 301WARN THE CALLER THAT THE TIME TO FINISH IS APPROACHING h + + As with face-to-face counselling, it’s a good idea to warn a caller in advance that the counselling session or call is nearing its end. When you sense that it is appropriate, you may wish to say something like: ‘I realise that we have been talking tor a while now and hope that we have covered some useful ground together. 1 would like to finish our call within the next few minutes, and wonder whether there are some important things that you would like to say before we finish talking together’. This statement gives the caller an opportunity to deal with anything pressing that has been omitted. 1 he caller is also prepared for the impending closure. Notice that the statement is clear and owned by the counsellor: '1 would like to finish our calf. You may not be comfortable using this style and that is OK, because you are different from us. Personally, we like to let the caller know our expectations rather than be indirect. 1 he message is then clear and the caller can deal with it in any way they think fit. Having been warned that the call is nearing its end, the caller may take the opportunity7 to bring in new material. A judgement is then needed as to whether to deal with that material in the current call or whether to say to the caller something like: ‘You have now raised some important new It is best to give a issues and 1 think that they need to be considered carefully. Maybe clear message in preparation for the you would like to phone back another time to talk through those ending of a call issues. However, today 1 think that we should tty to summarise those things that we have talked about and then finish our conversation.’ SUMMARISE THE CALL AND GIVE POSITIVE FEEDBACK If the caller doesn’t raise new issues, then you, the counsellor, have the opportunity to move into summarising the content and possibly the process of the call. An example of a process statement included in a summary might be: ‘I notice that you seemed to be very distressed at the start of this call Many callers will when you were discussing ... and 1 get the impression that you are not have received positive feedback now more confident of your ability to handle the situation . Notice from anyone that in this statement the caller receives positive feedback. Wherever possible give your caller positive feedback, because people in crisis often do not feel good about themselves and may not be getting positive feedback from others. Sometimes it is hard to think of something positive to say, but it is rare not to be able to find something it you join with the caller effectively. Be careful, however, to ensure that the feedback you give is credible. Here are some examples of positive feedback: I am impressed by the way that you have been able to think through the issues and come to some decisions. ! have heard how you have struggled on your own against many difficulties. You strike me as a fighter; someone who doesn't give in easily. 302 PART 6 Technology and counsellingI think that you are remarkable to have done as well as you have when I take into account the negative messages you have received from your family. You must have a lot of internal strength. In spite of the personal setbacks you have suffered, you have persisted in your efforts to do the best you can. I think that you've done well. We do need to recognise that there will be times when a caller will still be experiencing a level of painful emotion at the end of a call. For example, it is not reasonable to expect that the counselling process will take away the sadness of a person who has lost a loved one. In a case like this, the counsellor might close the call by summarising and inviting the caller to call back: ‘You are going through a difficult time having suffered a terrible loss. My guess is that you will need to talk to someone from time to time, so please feel welcome to call back.’ TAKE CONTROL Having given the caller some positive feedback, or having invited them to call back, it is now time for you to take control in order to create a comfortable end to the call. This can often be quite difficult and is often more difficult than bringing a face-to-face counselling session to a close. In the face-to-face session, as Usually it is helpful discussed previously, it’s possible for the counsellor to stand up and to for the counsellor move out of the room, giving clear signals that the session is over. to take responsibility for 1 hese non-verbal signals are not available to the TC. Moreover, we ending the call human beings are Conditioned to believe that it is bad manners to assertively break off a conversation, particularly if the other person would really like to continue. Some people love to talk and would happily keep you on the phone for hours. Others just do not know how to close off a conversation. With both types of people it is important to be clear and assertive. CLOSING THE CALL l ake control! Tell the caller that you intend to finish the call now and at the same time reassure them that it is OK if they want to phone back. It is very important to do this, because some callers feel guilty about taking up a TC’s time and say things such as: 'There must be other people with much more important problems who need your help.' Such people need to be reassured that it is OK for them to ring up again. When ending a call it is important to avoid asking a question or reflecting content or feelings, because if you do, the conversation is certain to continue. Instead, use a positive statement such as: Thank you for sharing your personal difficulties with me. 1 have appreciated the way you have trusted me enough to be able to share so much. Please feel welcome to phone back if you think that I can be of help. Goodbye. telephone counselling CHAPTER 35 303It has been good to talk with you about the issues that have been troubling you. i hope that you will feel free to call back another day. Goodbye. I think that you were sensible to phone; everyone needs to talk about personal matters privately at times. Please call again when you need to. Goodbye. Notice that the statements are clear and end with ‘Goodbye/ Learning summary • • • • • • • • • • • • • Telephone counselling is, in some ways, more difficult than face-to-face counselling because the counsellor has Little non-verbal information. TCs need to prepare themselves personally before taking a call. Skill in cautiously building a relationship is paramount or the caller may hang up. Hang-ups are inevitable and are not necessarily bad. All of the counselling micro-skills are important; however, minimal responses are particularly important in telephone counselling so that the caller knows that the counsellor is attending. The TC needs to pay attention to the process of each call and if necessary will Influence that process with the goal of increasing the callers awareness. Each call can be thought of as one step in a flight of stairs being climbed by the person seeking help. The caller needs to be empowered to make their own decisions. Making notes and using the imagination helps to bring the caller's situation into focus. TCs need to set clear limits with regard to their relationships with callers. TCs need to debrief after troubling calls or they will bum out. Nuisance callers, regular callers, chronically depressed callers and sex callers can create difficulties for TCs, and appropriate strategies are required for counselling each of these. When closing a call it is not usually helpful to ask questions or reflect content or feelings. Further reading R osc n fi cl d, M. 1996, (Counselling by Telephone, S A GE, London. Roseiifickb M. 2013, Telephone (Counselling: A Handbook for Practitioners, Palgrave Macmillan, Houndmills. Sanders, P. 2007, ( 'sing (Counselling Skills on the Telephone and in (Computer-Mediated (Communications., 3rd edn, PCCS, Ross-on-Wye. 304 PART 6 Technology and counsellingInternet counselling In the last chapter we asked you to consider whether it would be harder to be a TC or a face-to-face counsellor. In this chapter we introduce another option: internet (online} counselling. How does internet counselling compare to telephone counselling and face-to-face counselling? The answer to this question is, we feel, quite complex due to the complexity of internet counselling itself. Part of this complexity comes from the ever-changing nature of the online counselling environment — it is relatively new and growing fast. One aspect that continues to grow is the many different modes of internet counselling now available. MODES OF INTERNET COUNSELLING There are many options available for people who choose to seek counselling support online. Here, we limit our discussion to individual counselling; however, we do acknowledge that there are many more counselling support options available including group counselling and support groups, self-help, psychoeducation or bibliotherapy, structured programs and more. Email real-time For interested read el’s, we have briefly explored these options in the chat, video conferencing and context of using technology to support young people in our book virtual platforms Counselling Adolescents: The Proactive Approach for Young People (2015). can all be used to We have listed the different options available for individual develop a distance internet counselling in Table 36.1, along with some examples of counselling these modes that are currently available online. Perhaps you would relationship like to explore the examples provided to get a sense of how counselling is presented and delivered online. Internet counselling can be provided via: 1 email 2 real-time chat 3 video conferencing 4 virtual settings. EMAIL One way to establish a counselling relationship over the internet is by sharing emails. This may be limited to a single exchange or develop into multiple email exchanges. Just as with telephone counselling, the counsellor s job can be challenging when Internet counselling CHAPTER 36 305Table 36.1 Modes of internet counselling 306 MODE OF COUNSELLINGEXAMPLES Email- The Australian Breastfeeding Association (breastfeeding.asn.au) provides email and telephone counselling support for breastfeeding mothers.

• beyondblue (beyondblue.org.au) provides email counselling for anxiety and depression. It also offers telephone and chat counselling.
• The Butterfly Foundation (thebutterflyfoundation.org.au) provides support via email counselling for individuals with eating disorders. They also offer telephone and chat counselling. Real-time chat- Counselling Online (counsellingonline.org.au) provides drug and alcohol counselling via chat and telephone.
• eheadspace (eheadspace.org.au) provides chat counselling for young people. In addition to telephone counselling, it also has face-to-face counselling centres.
• Kids Helpline (www.kidshelp.com.au) provides chat counselling for young people. It also offers telephone and email counselling. Video conferencing■ The Centre for Human Potential (cfhp.com.au) provides counselling support via Skype. It also offers face-to-face counselling. -- Psynaptic Psychology Counselling (ppccounselling.com) is an online counselling service providing support via the WebEx video conferencing system (webex.com.au).
• USC Telehealth (usctelehealth.com) is a US-based online counselling service which has developed a video conferencing system spec fically for online counselling. Virtual settings- The Center for Brain Health at the University of Texas (brainhealth.utdallas.edu) has developed a virtual world specifically for online counselling.
• Reaction Grid (ReactionGrid.com) and InWorld Solutions (inWorldSolutions.com) are companies that can be hired to develop virtual worlds that can be used as platforms for online counselling.
• Second Life (secondlife.com) is a commercially available virtual world that has been used by counsellors as a platform for online counselling. PART 6 Technology and counsellingusing email to communicate as visual cues are not available. As we discussed in Chapter 35, a lack of visual cues can make it difficult to identify a person’s presentation, feelings and response to the counsellor. In addition, verbal cues such as tone of voice, pace and breaks or pauses in a person’s narrative are also missing, which may increase the potential for misunderstanding the feelings and thoughts expressed by the person seeking help. There are many ways to make feelings and thoughts more explicit, such as the use of different fonts, formats, acronyms, emoticons and punctuation. We will explore the use of these techniques in more detail later in this chapter. While the lack of visual and verbal cues do present challenges for die counsellor, there are potential advantages. Many individuals who find sharing face to face too challenging may find the anonymity afforded by email disinhibiting, and therefore be able to disclose more information. 1 here also exists a decreased power imbalance, providing the person seeking help with a greater sense of control over the counselling process. While this can support disclosure, there is also the possibility that the person will exercise this power to end the counselling relationship quite abruptly. Consequently, the counsellor has to work hard to engage with each individual and prevent them from early withdrawal. It is very easy to simply not send another email or to discontinue a chat session. REAL-TIME CHAT While connecting via email is asynchronous (that is, there is a gap between replies), real-time chat, as its name implies, is synchronous. This can present an advantage over email communication as you do receive more information: for example, breaks or pauses in a person’s reply may provide the counsellor with clues as to information the person needs to reflect on or is finding difficult to share. In other ways, chatting over the internet can be more challenging as the counsellor does not get as much time to reflect on and form their response. 3 here also remains a lack of visual and verbal cues for the counsellor to draw on. This lack of cues may be minimised to some degree using video conferencing technology7. VIDEO CONFERENCING In some ways, counselling via a video messaging service, such as Skype, is more like face-to-face counselling than telephone counselling, in that the counsellor has access to more visual cues. The counsellor and the person seeking help can also communicate verbally, rather than via text. This can be a good option for people who are not as comfortable using online text-based approaches. One disadvantage of video conferencing is the potential for technical difficulties; being cut off mid­ session certainly isn’t helpful to the therapeutic process! Another concern is the security of video-calling. Clearly, both the person seeking help and the counsellor want to avoid unauthorised access to their sessions. Internet counselling CHAPTER 36 307VIRTUAL SETTINGS A less common, but growing, option for internet counselling is to meet in a virtual environment. In this instance, the person seeking help and the counsellor are represented online by avatars of their own choosing. The avatars then ‘meet m a virtual setting and communicate either by text or verbally, using a microphone, lhe virtual setting could be anything from a virtual counselling room to a beach, a rainforest or even a completely imaginary environment. While visual cues are again lost, the choice of avatar does provide the counsellor with a visual clue as to the individual’s self­ image. Discussing a person’s choice of avatar may reveal important insights for both them and the counsellor about the person’s view of self. In saying this, we would encourage the counsellor to guard against projecting assumptions, particularly negative ones, about the person seeking help. How, for example, would you feel about engaging in a counselling relationship with a demon? What thoughts and feelings would this evoke? If you are comfortable engaging with a demon avatar, what type of avatar do you think you would find challenging? Depending on the mode of communication, verbal cues may or may not be present in a virtual session. Readers interested in finding out more about counselling in a virtual environment may like to read the article on avatar therapy by Nagel and Anthony (2011). You will notice in Table 36.1 that many services offer multiple modes of internet counselling, and sometimes telephone and face-to-face approaches are also offered alongside online modes. This mixing of modes and approaches is very common. What could be some advantages to offering counselling support via multiple internet, telephone and face-to-face approaches? What are some disadvantages? SUITABILITY OF INTERNET COUNSELLING FOR THE COUNSELLOR AND PERSON SEEKING HELP l he unique nature of internet counselling requires specific skills and characteristics from both counsellor and the person seeking help. As such, we would suggest that not all counsellors and individuals are suited to online work. We list a number of questions in Table 36.2 to consider for both the counsellor and the person seeking help before commencing internet counselling. The questions in fable 36.2 cover the following skills and characteristics: 1 counselling micro-skills 2 computer skills 3 personal characteristics 4 presenting issues. COUNSELLING MICRO-SKILLS Before considering the commencement of support over the internet, the counsellor needs to be well-practised in the counselling micro-skills described throughout Parts 2 to 4 of this book. We will discuss in more detail how these micro-skills apply in the section on the internet counselling process. Here, we would like to focus on the 308 PART 6 Technology and counsellingdifferences between face-to-face and internet counselling more generally. At the ver}" least, some level of visual cues is lost when using video conferencing, therefore making it not only more challenging for the counsellor to accurately understand a person’s presenting concerns and related feelings but also to relay their presence, empathy and concern to them. This effect can be increased when using text-based modes, as both visual and verbal cues are lost. Therefore, the counsellor must be ver}" skilled in adapting their face-to-face counselling micro-skills to the online environment in order to build an effective and supportive counselling relationship. COMPUTER SKILLS It is important for both the counsellor and the person seeking help to be computer literate and familiar with communicating online before commencing internet counselling. It is also essential to have the required technology. You may need to consider your computer specifications, video, microphone, headphones, internet connection and access to technology support m case of a failure in any one of these components. Finally, it is important to be familiar with cyber-culture; for example, how people interact online and how the virtual It is important for environment is perceived. It is important to recognise that for many an internet counsellor to be internet users, their virtual life, including the relationships formed well-practised in online, are very real. Gan you think of any other computer skills and using micro-skills requirements that would be useful for a counsellor or individual who face to face is considering internet counselling? PERSONAL CHARACTERISTICS Perhaps the most important personal characteristic to have as an internet counsellor is flexibility. Individuals who seek support online may do so because they find it difficult to access traditional face-to-face support, which is often restricted to the working day. How would you feel about working after-hours? Some individuals may also request impromptu sessions. Indeed, this is how some of the services listed in fable 36.1 offer support. Do you feel this is appropriate? How would you respond to an impromptu request for support from someone? Another area you may have to be flexible in is the mode of internet support. Are you happy to offer multiple modes or would you prefer to stick with one? I here is no right or wrong answer for many of these questions — it depends on what the counsellor is comfortable offering. However, we would encourage any potential internet counsellors to be upfront from the start about how they offer services. You could achieve this by having accessible and comprehensive information about your availability, mode of support, how often and when people can expect responses and how you charge for services. What other information would be important to provide to individuals seeking internet counselling support? PRESENTING ISSUES As with face-to-face counselling, it is important to practise within your area of competence and to seek supervision if you are unsure about working with a Internet counselling CHAPTER 36 309particular individual or presenting issue. More specifically, the suitability of internet counselling has been questioned for a number of people. For example, it can be challenging to provide appropriate crisis support for a person who chooses to remain anonymous. If they only provide their email address as a means of contact, how do you ensure their safety? Some ideas are provided in the ethical considerations section of this chapter. Other groups potentially not suited for online support are those experiencing severe mental health challenges and It can be challenging those requiring medication, for example, individuals experiencing to provide appropriate crisis psychosis or severe depression and anxiety. This doesn’t mean that support over the internet counselling cannot occur, but it may be necessary to also internet link the person seeking help with appropriate face-to-face support. . ... J . fa .1. J . . THE INTERNET COUNSELLING PROCESS Once you have determined your suitability and that of the person seeking support, how do you go about engaging in online support? Again, this can be complicated and depends on many factors. Do you intend to offer short- or long-term support? Would you prefer to stick with one mode or are you happy to offer counselling via mixed modes (email, chat, video conferencing, face-to-face, telephone)? Clearly, how support is offered and, therefore, the skills required, will vary. However, the counselling process as presented in Figure 16.1 (see page 135) can be useful as a framework for internet counselling. It is important to recognise, as highlighted in Table 36.2 Questions to consider before engaging in internet counselling 310 Questions for the counsellorAm 1 experienced and do 1 feel comfortable counselling in a face-to-face setting? Am 1 well-practised in using counselling micro-skills in a face-to-face setting? Do 1 know how to adapt these skills to the online environment? Am 1 familiar with cyber-culture? Am 1 flexible? Does my lifestyle or work schedule allow for flexibility? Questions for the counsellor and the person seeking supportAm 1 comfortable communicating online via text? Or via a microphone? Am I computer literate? Do 1 have access to the required technology? Questions for the person seeking supportDoes the person seeking help require face-to-face support? Is the person seeking support experiencing severe mental health challenges, such as severe depression/ anxiety or psychosis, or do they require medication that needs monitoring? Are they in need of crisis support? PARTS Technology and counsellingChapter 35, that not all counselling relationships will follow these stages exactly, but it can be helpful to recognise the steps involved in the counselling process, including when to follow the person’s lead and when to guide the process to meet the person’s expressed need. PREPARATION Before you engage in any form of counselling, it is important to A similar prepare yourself so you can be as effective as possible. It is difficult to counselling process support someone else if you are feeling in need of support yourself! can be used as a We have made four suggestions m the previous chapter for framework for both preparing for telephone counselling, which can also be used to face-to-face and prepare for internet counselling. We have listed these ideas again for internet counselling you below. What other ways would be helpful for preparing for internet counselling? 1 Talk through your own problems with your supervisor. 2 Own your intruding thoughts by telling a colleague that they exist. 3 Use relaxation, meditation or prayer, depending on your spiritual orientation. 4 Engage in physical exercise. JOINING As with telephone counselling, an online counsellor doesn’t have as long to connect with the person seeking help compared to face-to-face counselling. It is veiy easy for an individual to end the session with a quick click of the mouse or simply not to return an email. As highlighted before, forming this connection can also be challenging in light of the decrease in, or complete absence of, visual and verbal cues. Micro-skills particularly important when joining with the person seeking help are reflection and paraphrasing. These two micro-skills are perhaps even more essential in internet counselling as there is a need for more clarification to compensate for the loss of visual and verbal cues. It can be much easier to misinterpret a written statement without the accompanying tone of voice and body language that provide an emotional context. You may also need to use more direct questioning to confirm a person’s emotion or implied thoughts if you are unsure. We discuss the use of questioning online in more detail next. In addition to connecting with the person seeking help, there are also a number of other goals for the online counsellor when joining with the individual. Obtaining appropriate information early in an initial internet counselling session is helpful for determining the person’s identity so that follow-up is possible. Information gathering allows for screening and assessment to determine whether the internet is an appropriate mode for the person seeking help. Counsellors may also engage in contracting and setting ground rules during the joining phase. It is a good idea to discuss ethical concerns specific to internet counselling, or to provide information about these to the person seeking help prior to the first session, so that they can make an informed choice about whether to continue online counselling. We discuss Internet counselling CHAPTER 36 311ethical concerns in more depth later in this chapter. Achieving these goals requires skill in order to introduce them at the right time and in an understanding way. You don’t want to overwhelm the person with a barrage of closed questions! ACTIVE LISTENING As in the joining phase, reflection and paraphrasing are two important micro-skills during the active listening stage in order to show the person seeking help that they are being heard and understood. To support this process, clarification by using questions may be required. However, questions need to be approached with care. Have you ever been the recipient of an abrupt question via email or chat? How did it make you feel? It is very easy to come across as more harsh than intended online without the softening effect of visual and verbal cues. Therefore, much more care must be taken when introducing and wording a question. Another important micro- skill, especially when using chat, is the use of minimal encouragers to show that you are still listening. You could, for example, type ‘Hmmm ...’ or ‘1 see’. How else could you let the person seeking help know that you are still listening? Due to the increase in the potential for misinterpretation and miscommunication, it is also important for the counsellor to monitor judgements, assumptions, interpretations and projections throughout this process of active listening. How might you remind yourself to identify the development of any negative projections? The lack of visual and verbal cues can also lead to an increased sense of privacy or anonymity for an individual. This can have the advantage of increasing disclosure via what is known at the disinhibition effect. The disinhibition effect can also, however, increase transference and counter-transference; this is certainly something to be aware of so that you are able to reflect on its possible presence and respond accordingly. EMPHASIS ON EMOTIONS Just as content can be misunderstood when communicating online, so can emotions. How do you usually identify others’ emotions? While people will explicidy state their emotions, counsellors usually draw on the visual and verbal cues of the person seeking help to identify their emotions, cues which are reduced or missing in the case of internet counselling. This can be particularly’ significant when a person’s expressed feelings don’t match the emotion evident via their visual and verbal cues. When you are unsure of an individual’s emotional state, it could be helpful to provide a tentative interpretation by reflecting and seeking clarification with a carefully worded question. Apart from the use of feeling words, there are many ways that individuals may7 express their emotions via text. For example, many people make use of emoticons (smiley faces) and acronyuns for feelings or other expressions. Table 36.3 has some examples of emoticons and acronyms (both feelings and more general abbreviations) commonly’ used in written communication via the internet. A more comprehensive list can be found at PC.net under the ‘Online slang’ and ‘Emoticon’ tabs. Formatting and punctuation can also be used to convey7 feeling through text, for example, using bold, capital letters or exclamation marks can be used to increase the intensity’ of an emotion. 312 PART 6 Technology and counsellingTable 36.3 Examples of commonly used acronyms and emoticons EXAMPLESMEANINGS AcronymsAFK BBS bf cya gf LOL ROFL SOS thxAway From Keyboard Be Back Soon Boyfriend See You Girlfriend Laugh Out Loud Rolling On the Floor Laughing Someone Over Shoulder Thanks Emoticonsor f XD or =

( or :( or =( :_( or :'( =/ Xd O.oHappy Laughing Sad Crying Mad Angry Confused ^different Surprised :O Pitch of voice can also be represented by formatting. For example, individuals may use different fonts, colour, bolding, exclamation marks, capitals, repeated letters (sooooo ...) and so on. The pace of a person’s narrative can also be implied by aspects of the text. An unpunctuated block of text which contains changes in subject matter without pause or time for reflection suggests a fast pace which may imply a sense of urgency or anxiety. In contrast, an email with minimum content may imply a slower pace that could reflect a person’s difficulty disclosing information or putting their thoughts and feelings into words. A little more information about pace is available when using chat, as you get a sense of any pauses or breaks in the dialogue with the person seeking help. These breaks could be equivalent to breaks in eye contact in face-to-face counselling, or suggest that the person has difficulty sharing certain information. Other clues to an individual’s emotional state include layout, presentation, sty le, and the avatar or symbol chosen by the person to represent themselves. There are many We feel it is important to note that many of the market's for ways to express feelings online emotion could be affected by many factors other than emotional including feeling state, such as gender, culture, disability, faith, family of origin, Current words, emoticons, situation or circumstances at the time of writing, or the social and acronyms, font, economic context. This brings us back to our initial suggestion of formatting and style asking for clarification if you are unsure of an individual’s emotions. Internet counselling CHAPTER 36 313EMPHASIS ON THOUGHTS Due to the use of text to communicate via most online modes, internet counselling is well-suited to word-based therapies, such as Rational Emotive Behaviour Therapy (Chapter 20), Narrative Therapy (Chapters 13 and 21) and the use of metaphor (Chapter 11). What other word-based therapy could be successfully adapted to internet counselling? EMPHASIS ON BEHAVIOUR As with an emphasis on thoughts, when working with a person to support behaviour change, word-based therapies or strategies can work well online. Some skills to consider include confrontation (Chapter 19), Motivational Interviewing (Chapter 29) and solution-focused (Chapter 22) approaches. As we discussed earlier, more care is required when introducing and wording confrontation statements and questions online. CLOSURE As a session or counselling relationship is coming to a close, it can be useful to draw on summary skills in order to outline the session and prepare an individual for closure. Preparing someone for closure is particularly important as there is an increased risk of the person terminating internet counselling prematurely, compared to face-to-face counselling. 1 he process of closure as described in Chapter 35 can also be useful in bringing an internet counselling session to an end. Depending on the needs of the person seeking help, it may also be necessary to make appropriate referral options available during the closure stage of internet counselling. When, for example, might it be necessary to refer a person to face-to-face counselling? Alternatively, you may like to provide the individual with follow-up options. However, when providing follow-up options it is important to set clear post-counselling boundaries, as the borders between personal and professional can be lessened online, as we discuss in more detail below. As with any form of counselling, it is important for the counsellor to debrief regularly with other counsellors or their supervisor. Debriefing helps the counsellor to release emotions experienced as a result of their counselling work, thereby protecting against burnout and ensuring they remain effective. We discuss the debrief process in more detail in Chapter 35 and other self-care strategies to manage burnout in Chapter 42. ETHICAL CONSIDERATIONS While we do cover ethical concerns in Chapter 40, we feel it is important to end this chapter by discussing some of the ethical considerations that are unique to the online environment. Drawing on your own personal experience of using the internet, what are some potential ethical concerns that come to mind regarding online counselling? How might you proactively address these concerns? In the coming discussion we draw on the guidelines produced by the Australian Psychological Society (APS, 2011) for using technology in counselling. A number of organisations also exist to support and provide resources for professionals practising 314 PART 6 Technology and counsellingonline including the International Society for Mental Health Online (ismho.org), the Association for Counselling and Therapy Online (vvww.acto-uk.org) and the Online Therapy institute (onlinetherapyinstitute.com). COUNSELLOR EXPERTISE As we noted earlier in this chapter, it is important for counsellors to first be well-practised in face-to-face counselling before moving into Providing counselling over the internet counselling. Once face-to-face micro-skills are well- internet presents a developed, counsellors can then look at adapting their skills to the number of unique online environment. Internet counsellors also need to increase their ethical knowledge and understanding about working online, including the considerations current research into adapting counselling skills and strategies to the internet, it is important for internet counsellors to become familiar with any relevant legal and registration requirements. Is it, for example, OK to offer counselling to people who reside outside your registration area? Counsellors may develop their skills and knowledge through training and supervision. INFORMED CONSENT As with any counselling relationship, informed consent must be obtained from the person seeking help before commencing counselling. This is particularly important when counselling online for two reasons. Firstly, as internet counselling is a relatively new field, it is important that people are properly informed about the advantages and disadvantages, effectiveness and risks so that they understand the potential limitations before commencing support. Secondly, as mentioned earlier in this chapter, a person choosing to remain anonymous can present difficulties when faced with a crisis situation. It is also important to identify an individual to ensure the service offered is appropriate. For example, what if parental consent is required? What might be some ways for internet counsellors to identify the person seeking help? CONFIDENTIALITY During the informed consent process, it is important to highlight the way that confidentiality7 could be limited by using the internet. In particular, it is important to share how the individual’s privacy^ is being protected from unauthorised access. This might include how their electronic data and information are stored and backed up, and what security measures are used, such as password protection and data encryption. Guidance or ideas may also have to be shared with the person seeking help regarding protecting the privacy of their counselling session, for example, password protection and not forwarding on personal information to others. BOUNDARIES The internet is used extensively for developing personal relationships; therefore, there is an increased need to protect professional boundaries. One way to maintain Internet counselling CHAPTER 36 315boundaries is to highlight them before commencing an online counselling relationship. Some questions to consider include: • How quickly and often will you reply to emails? • How long will chat sessions run for? • Will you schedule sessions or reply to emails after-hours? • Will you offer impromptu sessions at a person’s request, or only pre-scheduled sessions? Maintaining your professional boundaries can also be made easier by using professional language. Learning summary • • • • • • There are a growing number of modes available for internet counselling, including email, real-time chat, video conferencing and virtual settings. Before engaging in internet counselling, counsellors need to consider their Suitability with respect to micro-skills, computer skills and their personal characteristics. It is also important for counsellors to consider the suitability of the person seeking help regarding their computer skills and presenting issue. While each counselling relationship is unique, the process of internet counselling can follow the same stages as face-to-face counselling, including preparation, joining, active listening, emphasis on emotions, emphasis on thoughts, emphasis on behaviour, and closure. All counselling micro-skills are important in internet counselling, however, they may need to be adapted. Internet counsellors may have to seek clarification more frequently, word their questions and confrontations more carefully, and make more use of reflection, paraphrasing and written minimal encouragers. There are a number of unique ethical considerations when using internet counselling. Guidelines produced by the APS encourage counsellors to consider implications with respect to counsellor expertise, informed consent confidentiality and professional boundaries. References and further reading Australian Psychological Society (APS) 2011, Guidelines for Providing Psychological Services and Products I 'sing the Internet and Telecommunications Technologies, APS, Melbourne. Evans, J. 2009, Online Goan selling and Guidance Skills: A Practical Resource for Trainees and Practitioners, SAC IE, London. Geldard, K., Geldard, D. & Yin Foo, K. 2015, Counselling Adolescents: The Proactive Approach for Young People, 4th cdn, SAGE, London. Kraus, K., Stricker, G. & Speyer, C. 201 1, Online Counseling: A Handbook for Mental Health Professionals, 2nd edn, Elsevier Academic Press, London. Nagel, D.M. & Anthony, K. 201 L ‘Avatar Therapy’, The Gapa Quarterly, Issue 3, 6—9. 316 PART 6 Technology and counsellingPART 7 PROFESSIONAL ISSUES In this, the final part of the book, we focus on professional issues of which every counsellor needs to be aware. We consider the counselling environment, keeping records, cultural issues, confidentiality and other ethical issues, counsellor training and the need for supervision and looking after yourself, faking these issues into account is essential for maintaining our effectiveness as counsellors.The counselling environment In earlier chapters we discussed the way in which counselling involves the creation of a safe, trusting relationship between the person seeking help and the counsellor. In order to assist in the promotion of such a relationship, it can be helpful when counselling in a face-to-face situation if the counselling environment is one that will enable the person seeking help to feel comfortable and at ease. Unfortunately, it is not always possible for counsellors to have the use of a specially designed counselling room. In some situations, counsellors are visitors to a home, an agency, a school or a government department, and have to make the best use of spaces that are intended for other purposes. Where this is the case, it is desirable for the counsellor to do whatever is possible to protect the privacy of the person seeking help. Many adults and children don’t like others to know that they are seeing a counsellor. In offices and schools the confidentiality of the counselling process may be compromised at some level by lack of privacy. Clearly, counsellors need to do their best to find the most private facilities and arrangements possible. THE COUNSELLING ROOM Whenever we walk into a room, that room has an effect on us. Is it the same for you? Have you noticed that sometimes when you have entered a room you felt comfortable and at ease, almost as though the room welcomed you? At other times you may have entered a room that felt clinical, cold and unwelcoming. A well- designed counselling room will have a warm, friendly feel about it. In addition to the room being warm, pleasant, welcoming and comfortable, it is an advantage if it can be set up so that it is especially suitable for counselling. Where a counsellor has their own personal room, that room can reflect something of their individual personality. Our counselling rooms are decorated with plants and pictures. Pictures on the walls are peaceful, showing natural scenes of trees and landscapes. The colours are muted and not harsh, and these combine with comfortable furnishings to provide a welcoming, relaxed atmosphere. Your room will be different from ours because we are all different and have different tastes. We suggest that you tty to make your room an extension of yourself so that you feel at ease in it, and then in all probability'- the people who seek your help will feel comfortable in it too. 318 PART 7 Professional, issuesPreferably the furnishings in your counselling room should include comfortable chairs for yourself and the person seeking help, together with other furnishings appropriate to a professional office. You may need to write reports, draft letter's, keep records and carry out some administrative duties. A counselling room Hence a desk, telephone and filing cabinet will be useful, together needs to be inviting with bookshelves for a professional library’. GB.4.44l.4.44>.l. 4.4a9.4.4 aBB.4.4aB.4. 44bB. 4.44l. 4.4iiB |.4.4 LAYOUT OF THE ROOM 1 he sketch in Figure 37.1 shows a suitable layout for a counselling room for the personal counselling of individuals who seek help. Notice that the desk and the filing cabinet are unobtrusively in a corner facing the wall, where their importance is diminished. While we use the desk for administrative work, when counselling we invite the person seeking help to sit in a comfortable chair and we sit in a similar chair facing them and at their level. We deliberately avoid sitting at the desk, as to do so brings inequality into the relationship. Additionally, we prefer to have open space rather than a table separating us from the person. Using this arrangement enables the person to join with us as an equal partner as they explore their issues, and we are not perceived as a powerful expert separated by a desk or table. If we do need to sit at the desk to do some written work in the person’s presence, we make sure that the desk doesn’t separate us from them. We don’t have a visitor’s chair and a counsellor’s chair, but rather two chairs that are similar. When a person seeking help enters the room they are invited to sit in whichever chair they choose. However, if they hesitate we will direct them to a chair. This is a small point, but an important one. A person seeking help will usually Figure 37.1 Counselling room arrangement PLANT PICTURE I -- DESK DOOR a PHONE FILING CABINET BEANBAG WHITEBOARD jCLOCK PICTURE / ARMCHAIRS PICTURE POT PLANTS WINDOW BOOKSHELVES I he counselling environment CHAPTER 37 319

• 4 » « +be anxious when they come into a counselling room, because it is not their space and they may also be worrying about the counselling process. Some people will be more at ease if they can choose their seat, while others will be happier if you direct them to a chair. Formality won't We try to arrange the chairs so that they do not face directly into enhance the counselling light coming trona a window. Looking towards a window can be relationship unpleasant, as after a while the glare may cause eyestrain. During a counselling session, the person seeking help and the counsellor will be looking at each other most of the time, so the background against which each is framed is important for comfort. Preferably the chairs will face each other but at a slight angle, with enough space between them so that the person seeking help does not feel that their personal space is being invaded. EQUIPMENT NEEDED We prefer to have a whiteboard in every counselling room. People who predominantly operate in a visual mode are likely to focus more clearly and gain in awareness if important statements are written on the board, and if their options are listed there (see Chapter 11 regarding personal differences in modes of awareness). Sometimes a person’s dilemma can be expressed through a sketch that metaphorically describes their situation. A whiteboard is particularly useful when helping a person to challenge irrational beliefs or to construct assertive statements. It may also be used as an aid when Carrying out educational and administrative tasks, which counsellors inevitably undertake as part of their duties. We always have a box of tissues in a handy place in our counselling rooms. It is inevitable that at times some people seeking help will cry. Having tissues at hand helps reduce their embarrassment. THE NEED FOR PRIVACY As discussed in Chapter 40, confidentiality is essential when counselling. A person will not feel comfortable about disclosing intimate personal details unless they are confident that they will not be overheard. If they can hear voices from outside the counselling room, they may be justified in fearing that they can be Privacy is essential heard by others. It is therefore preferable for counselling rooms to be when counselling suitably soundproofed, although this ideal is often not achievable. If at all possible, the counselling process should be uninterrupted by the intrusion of people knocking on the door, entering the room or phoning in unnecessarily. For this reason, many counsellors have a rule that when a counselling room door is closed, no attempt should be made by others to enter the room except in unusual circumstances, hi many counselling agencies, when a counselling room door is shut, the procedure for contacting the counsellor when unusual circumstances make this necessary is for the receptionist to use the phone. Except in serious emergencies, the receptionist allows the phone to ring a few times only and if it is not answered then the counsellor is left undisturbed. This minimises the possibility that the person 320 PART 7 Professional issuesseeking help might he interrupted at an important stage in the counselling process. It enables them to feel that confidentiality is assured, and allows them to express their emotions in privacy without the risk and embarrassment of being observed by others. SAFETY ISSUES It is important for counsellors to take whatever measures are required and appropriate for their own protection. It is inevitable that at some time a counsellor will be confronted by a person who has violent or sexually aggressive tendencies. This is a problem for all counsellors, but it needs to be The safety of recognised that female counsellors are especially vulnerable. counsellors needs to be ensured We believe that it is essential for all agencies and government facilities that provide counselling services to have alarm buttons in their counselling rooms. Then, if a counsellor is in danger, the alarm can be pressed to alert other workers so that they can respond appropriately. Clearly, there needs to be a suitable protocol in place so that when an alarm does sound the action taken is appropriate. Because of the safety issue some counsellors prefer to arrange the seating so that they are seated nearest to the door, enabling them to leave the room without being obstructed. ■ x 4 4 a *. .1 j a i, i .1.4 a fa > 4 ■ ■ *. 4 4 ■ fc >.4 * k t >.4 b i. a SETTING UP YOUR OWN ROOM Setting up a counselling room gives a counsellor an opportunity to be creative, and to use their own personal ideas to generate a suitable environment where a person seeking help may feel comfortable enough to explore their issues openly. We enjoy experimenting with the layout and decoration of our counselling rooms so that they reflect our personal tastes and are welcoming to others. We hope you find similar satisfaction in setting up your own counselling room. Learning summary • • • • • • Counselling rooms need to be person-friendly. It is preferable for the chairs for the counsellor and the person seeking help to be similar and have no barriers between them. This can assist in the creation of an empathic relationship. Looking towards a window is unpleasant. If chairs are too close, personal space may be invaded. Ideally a counselling room should be soundproof and have whiteboards and a supply of tissues. It is useful to have procedures to ensure that counselling sessions are not interrupted. ' he counselling environment: CHAPTER 37 321Keeping records of counselling sessions We, like many counsellors, find the administrative and clerical duties associated with counselling a chore. However, it pays to keep detailed and up-to-date records on each counselling session. Ideally, report writing should be done immediately after the counselling session, while all the relevant information is fresh in the counsellor’s mind, and before other inputs have had time to intrude. In today’s society we can either type or dictate records using speech recognition software directly into a computer. Alternatively, we can keep handwritten records on printed forms or cards. Where records are computerised, adequate security measures are required to protect confidentiality. Similarly, handwritten records need to he kept in secure locations (see Chapter 40). IDENTIFYING THE PERSON SEEKING HELP Records of people seeking help need to he clearly identified so that there can be no confusion, because in large agencies it is not unusual to find two people with the same name. Identifiers might include: • family name (surname) • other names • date of birth (if known) • address • contact phone numbers. Where handwritten records are kept, it can be an advantage to label each page of the record with the person’s full name so that the possibility of pages being inadvertently placed in the wrong file is minimised. ADDITIONAL DEMOGRAPHIC INFORMATION ABOUT THE PERSON SEEKING HELP Commonly, when the information is available, records may include any of the following: • marital status • name of partner or spouse • names and ages of children • referral source. 322 PART 7 Professional. issuesNOTES ABOUT EACH COUNSELLING SESSION The notes for each counselling session may include: 1 date of the session 2 factual information given by the person 3 details of the person’s problems, issues or dilemmas 4 notes on the process that occurred during the session 5 notes on the outcome of the counselling session 6 notes on interventions used by the counsellor 7 notes on any goals identified 8 notes on any contract between the person and the counsellor 9 notes on matters to be considered at subsequent sessions 10 notes on the counsellor’s own feelings relating to the person and the counselling process 11 the counsellor’s initials or signature. We will now describe the content of the notes in more detail under the headings listed above. However, although these headings are discussed individually, in practice, notes often How together as the headings overlap. Handwritten notes need to be legible so that if a person transfers to another counsellor for some reason, notes can easily be read, with the person’s permission. DATE OF THE SESSION This heading is self-explanatory, When reviewing progress over time, it’s very useful to know the dates of counselling sessions. FACTUAL INFORMATION GIVEN BY THE PERSON SEEKING HELP During a counselling session the person seeking help is likely to divulge factual information, which may be useful in subsequent sessions. Sometimes small facts, person’s mind, or could, if remembered, provide the counsellor with a clearer included in a counsellor’s notes could be: She has been married for 13 years and during that time left her husband twice, once two years ago for a period of two weeks, and secondly six months ago for a longer unspecified period. She has considerable financial resources, Lacks a social support system, had an affair some years ago and has kept this a secret from her husband. DETAILS OF THE PERSON'S PROBLEMS, ISSUES OR DILEMMAS Keep the record brief, so that it can be read quickly when required this part of the record would be: Keeping records of counselling sessions CHAPTER 38 323Mary suspects that her husband may be sexually involved with another woman, is afraid to ask her husband whether this is so, and is confused about her attitudes to him. She can't decide whether to pluck up courage and confront him, to leave him now or to continue in what she experiences as an unsatisfactory relationship with him. She is not willing to consider relationship counselling with her husband. NOTES ON THE PROCESS THAT OCCURRED DURING THE SESSION t he process is independent of the facts presented and of the person’s issues, and is concerned with what occurred during the counselling session, particularly in the person-to-person counselling interaction. For example: He initially had difficulty talking freely, but as the counselling relationship developed he was able to explore his confusion and look at his options. Although he was unable to decide which option to pursue, he seemed pleased by his ability to see his situation more clearly. NOTES ON THE OUTCOME OF THE COUNSELLING SESSION The outcome could be that a decision was made, or that the person remained stuck or that a dilemma was identified. Alternatively, the outcome might be described in terms of the person’s feelings at the end of the session. Examples of notes under this heading are: She decided to confront her husband. She left feeling sad and determined. She said that she could now see things clearly. NOTES ON INTERVENTIONS USED BY THE COUNSELLOR Notes under this section are intended to remind the counsellor of particular interventions used. For example, the notes might say: Taught relaxation. Coached in the use of assertive statements. Discussed the anger control chart. NOTES ON ANY GOALS IDENTIFIED These may be goals for the person to achieve in the world outside, or in counselling, for example: He wants to learn to be more assertive. She wants to use the counselling process to sort out her confusion and make a decision regarding her marriage. She wants to experiment by taking risks. 324 PART 7 Professional issuesNOTES ON ANY CONTRACT BETWEEN THE PERSON AND THE COUNSELLOR It is important to remember any agreements that are made with the person seeking help. These may be with regard to future counselling sessions, for example: She contracted to come for counselling at fortnightly intervals for three sessions and then review progress. It was agreed that counselling sessions would be used to explore his relationships with the opposite sex. I contracted to teach relaxation during the next session. NOTES ON MATTERS TO BE CONSIDERED AT SUBSEQUENT SESSIONS Often during the last few minutes of a counselling session a person will bring up an important matter that is causing pain and is difficult to talk about. If this is noted in the record, then the counsellor can remind the person at the start of the next session, enabling them to deal with the issue in question, if they wish. Sometimes, as a counsellor, you will realise at the end of a session that aspects of a person s situation need further exploration. It can be useful to make a note as a reminder. NOTES ON THE COUNSELLOR'S OWN FEELINGS RELATING TO THE PERSON AND THE COUNSELLING PROCESS These are required to help the counsellor avoid letting their own feelings inappropriately interfere with the counselling process in future sessions. Such notes can be invaluable in the counsellor's own supervision, and may be useful in helping them to improve their understanding of the counselling process. An example is: I felt angry when he (the person seeking help) continually blamed others and failed to accept responsibility for his own actions. THE COUNSELLOR'S INITIALS OR SIGNATURE By initialling or signing case notes, a counsellor takes responsibility for what is written in them. In many agencies, counsellors work together with other counselling team members. In such agencies, over a period of time more than one counsellor may see a particular person. Also, a person may come back to an agency for further counselling after a particular counsellor has left. In such situations it can be helpful for the person if their counselling history is available, subject to the normal constraints of confidentiality7. As stated previously, writing records of counselling sessions can be a chore. However, a counsellor who does this diligently will quickly become aware of the advantages. The effectiveness of future counselling sessions may be improved if the counsellor reads the record of previous counselling sessions relating to a person before meeting with them each time. By doing this the counsellor is able to ‘tune in’ Keeping records of counselling sessions CHAPTER 38 325to the person right from the start of the interview and will not waste time on unnecessary repetition. Clearly, records need to be detailed, accurate and legible if they are to be maximally useful. However, when writing records, be aware of the confidentiality issue (see Chapter 40) and of the possibility that the legal system may demand that such records be made available to a court. Also, bear in mind when writing records that the person they relate to may later ask to read them. Clearly, a person seeking help has the right to read their own records if they wish to do so. Learning summary • • • Ideally, report writing should be done immediately after a counselling session. Records need to include: » the date » factual information and details of the person's issues » notes on the process and outcome of the session » notes regarding interventions used, goals set, contracts made and matters to be considered in the future » notes regarding the counsellor's own feelings. Writing records can seem a chore, but a counsellor who keeps diligent records quickly becomes aware of the advantages. Further reading Bor, R. & Watts, M. 2010, The Trainee Handbook: A Guide for Counselling & Psychotherapy Trainees^ 3rd edn, SAGEh London. PART 7 Professional issuesCultural issues Often, counsellors have only limited information about the ethnic, cultural, social, family, community and general environmental backgrounds of the people who seek their help. This is unlikely to cause problems when the person seeking help and the counsellor happen to come from the same ethnic and cultural groups; however, difficulties may arise when they come from different groups. Not surprisingly, it has been found that people who are seeking help usually prefer counsellors from their own ethnic group. 1 his does not mean that counselling won’t be effective unless the person seeking help and the counsellor are front the same cultural background. What it does mean is that for a counsellor to be maximally effective when counselling a person from another culture, they need to use behaviours and strategies that fit for the person concerned. As with any person seeking help, the counsellor needs to tty to perceive the world in the way that the person perceives the world. In order to be able to do this with someone from a different cultural background from their own, the counsellor needs to tty to gain an understanding of the Establishing a person’s family, social and cultural environment. This understanding trusting relationship should ideally include information about cultural norms, attitudes, is critical beliefs and values. Additionally, counsellors need to be aware of their own assumptions, attitudes, beliefs, values, prejudices and biases. For successful outcomes to occur, the most important factor when counselling a person from another culture is the counsellor’s ability to join with the person so that a good, trusting working relationship can be established. Also, strategies and techniques that will fit comfortably with the person’s culturally specific ways of relating need to be used. AWARENESS OF ASSUMPTIONS, ATTITUDES, BELIEFS, VALUES, PREJUDICES AND BIASES As counsellors, each of us needs to be aware of our own racial and cultural heritage and to understand how that heritage has affected our attitudes, beliefs, values, prejudices and biases. By being aware of these, it will be easier for us to recognise when the problems we encounter while counselling stem from our own cultural background or come from some other source. Once we recognise the source of our difficulties, these can be addressed in supervision. Cultural issues CHAPTER 39 327DIFFICULTIES FACING PEOPLE FROM OTHER CULTURES In our modern world many people have to cope with living in a society where the cultural beliefs, values and behaviours prevailing in their country of residence are different from, and in some ways incompatible with, the cultural beliefs of their family and close friends. This inconsistency often creates psychological, emotional and behavioural problems tor such people, with the consequence that they may seek counselling help. LIVING WITHIN A DIFFERENT CULTURE A major problem for many people who live in a cultural environment that is different from that of their family is stress arising from internal conflicts. These conflicts occur when the culturally determined social and moral values of their families conflict with those of the wider society7. While recognising the person Living in a different as an individual who is experiencing difficulties that might be faced by culture from your own can be any other person, counsellors also need to be aware of the possibility that stressful the difficulties being experienced may be related to, or compounded by, issues of race, ethnicity, gender or socioeconomic status. Additionally, counsellors need to be aware of any discriminatory practices at a social or community7 level that may be affecting the person’s cultural group so that these can be properly understood if issues relating to them are raised during a counselling session. PERSONAL SEARCH FOR IDENTITY WITHIN A DIFFERENT CULTURE Many people who live in cultures that are different from their own encounter personal identity problems. It has been suggested that there are generally a number of stages during which such people engage in a search for their personal identities. In the first stage, the person from a minority group may accept the values and attitudes of the majority culture in an effort to fit in and be part of that culture. Surprisingly, this often includes internalising negative views of their own group. This stage of identity development may continue until the person concerned has a personal experience of racism or prejudice that forces them to see themselves as a member of a minority group. This awareness may then lead them to a personal ethnic identity7 search. The search involves efforts to learn more about their own culture and is often likely to be highly emotional. In this stage, emotions such as anger and outrage may be directed towards the majority society. When a person is experiencing the emotional problems involved in an ethnic identity search, the counsellor needs to try to help them achieve a satisfactory’ outcome with regard to this search, so that the person concerned can develop a deeper sense of belonging to a group. 328 PART 7 Professional, issuesCULTURAL FACTORS THAT INFLUENCE A PERSON'S VIEW OF THEIR WORLD Before considering specific strategies that may be useful for counsellors when counselling a person from a different cultural group to their own, we need to consider a number of factors that impact on an individual’s perceptions of their world. These factors will influence the person’s emotional responses, thoughts, beliefs, attitudes, biases, relationships and behaviours. We will discuss these factors under the following headings: • individual and relationship issues • the way decisions are made • who is perceived to be a natural helper? • attitudes of the extended family • gender and gender roles • perceptions of time • use of language • spirituality • physical or emotional issues • experience of trauma. INDIVIDUAL AND RELATIONSHIP ISSUES In Western society we place considerable emphasis on individuality Some cultures and uniqueness, and a high value on a person’s individual rights. In emphasise particular, it is generally believed that a person has the right to make individuality their own decisions and to follow a lifestyle of their individual choice. whereas others Many other cultures place a much greater emphasis on community emphasise the and see an individual person in terms of the community rather than community as a separate entity. In these cultures there is a sense of community responsibility and collective destiny. There is often a focus on harmonious blending and cooperation, accompanied by a high respect for the role of the elderly. Many families from southern Italy, China, Japan, Puerto Rico, Mexico and families ot African American and Indigenous Australian origin share these views. Respect from children for their parents is a very strong value in many Chinese families. This respect is shown not only by holding parents in high esteem but also by obeying them. This contrasts markedly with Western culture, where elderly people are often not greatly valued but parental obligation to children and respect for children’s rights is emphasised as being of great importance. Counsellors need to be aware of cultural differences such as these so that they can recognise conflicts that may arise in a person as a consequence of pressure caused by being exposed to conflicting cultural value systems. Inner conflict may also arise in a person when they are faced with choosing between loyalty to parents and the pursuit of their own individual goals. Cultural issues CHAPTER 39 329THE WAY DECISIONS ARE MADE

the way in which people make decisions depends to a great extent on their cultural background. In some cultures making decisions is most appropriately done in the company of other family members. In other cultures, when making decisions a higher priority is placed on maintaining harmonious relationships than on expressing an individual point of view. This is generally the case for Aboriginal people, where decisions to seek help may be the result of a community concern rather than a response to the personal problem of an individual. Typically when Aboriginal people seek help from non-Aboriginal helpers, they will make the request for help informally and through a casual meeting in an everyday social setting. Counsellors who are not Aboriginal themselves and are working with Aboriginal people also need to be aware of a number of other issues. They may need to use a ‘go-between', particularly if the business to be discussed is so sensitive that the person cannot discuss it openly. Additionally, the gender of the counsellor is important, because some issues fit into the categories of women’s Informal settings business or men’s business and cannot be discussed with members of are more comfortable for the opposite sex. Also, it is important that the person be given the people from some choice of the meeting location. In some cases, they might choose to cultures use a community facility, but in other cases it may be more appropriate to use a less formal setting. When helping a family it may be more appropriate to use an area outside of the family’s home rather than expect to go into the home, particularly as inviting a non-Ab original stranger inside the house would be contrary to normal practice (Vicary & Andrews, 2000). Decisions in Chinese families are generally made in quite a different way from decisions in Western families. In many Western families, decisions are made through democratic discussion and negotiation. However, in Chinese families communication patterns tend to flow down from those of perceived higher status. Consequently, in many families the father makes major decisions with little input from others. p i- - t - ri- - f - r ff - - - WHO IS CONSIDERED TO BE A NATURAL HELPER? Some Asian cultures put a high value on age and respect for elders, and will consult with elders when they need advice or counselling help. Because of this, people from these cultures prefer to work with older counsellors, and may find it difficult or impossible to work with young ones. In this regard it is sometimes useful for counsellors to seek the assistance of someone who is aware of cultural norms. This person can then assist by acting as a consultant to provide guidance and information with regard to possible ways of helping a particular person. When a non-Ab origin al counsellor is working with an Aboriginal person or persons, it may be useful to talk with local elders first. This can be helpful in enabling networks to be developed. Elders can then provide introductions and permission to talk with others. This is useful in building trust, which is likely to promote more positive outcomes for the counselling process. 330 PART 7 Professional issuesATTITUDES OF THE EXTENDED FAMILY Whenever possible, it is advantageous for a counsellor to gain an understanding of the prevailing social system in the family of the person who seeks help. It can be useful for the counsellor to familiarise themselves with family customs and rules, particularly with regard to verbal exchanges between people. For example, Aboriginal families generally include a wide network of people, many of whom are related in ways that could be considered distant in non-Aboriginal society. Relationships within the extended family are characterised by obligation and reciprocity. Strong restrictions are typically imposed on contact or sharing of information between certain categories of relatives. It is Care needs to be also important to note that in Aboriginal societies it is forbidden to taken to avoid offending say the name of a deceased person, see any photograph of the person traditional customs or use anything belonging to the person until a significant period of time has elapsed since the death. It can be useful for a counsellor to learn about the child-rearing practices of a person who seeks their help, if these are relevant to counselling — these practices vary markedly across cultures. For example, in some cultures there may be emphasis on the nuclear family, whereas in others the emphasis is on the extended family. Generally, in Chinese families child-rearing practices are focused on emphasising the importance of family ties and obligations. Praise is given for actions that are seen as benefiting the family and guilt-inducing techniques are used to maintain discipline. Children are expected to retain emotional ties with the mother, and a respectful attitude towards the father, even when they have become adults. Consequently, it is not unusual for counsellors to find that some people from a Chinese background will find it difficult to make the choices they would prefer to make because of concern that they may upset their parents. From a Western perspective this concern could be incorrectly perceived as the person being overly dependent. However, Western counsellors need to take care when working with such people, because assisting a person to become more independent might have undesirable consequences for them. Clearly, a person’s cultural background needs to be respected so that they are empowered to make decisions that fit for them. GENDER AND GENDER ROLES 1 he norms regarding relationships between members of the same sex and members of the opposite sex vary markedly across cultures. In order to join effectively with a person when trying to help them with relationship issues, it is advantageous if counsellors are able to gain some understanding of cultural norms with regard to relationships. Additionally, gender-based norms regarding behaviour, roles and expectations vary depending on culture. We will now consider a few examples to illustrate cultural differences relating to gender. In some Aboriginal communities, mothers- and sons-in-law rarely speak directly to each other, and similar taboos also exist between other members such as men and their brothers-in-law. In these communities certain topics (for example, sexual activity) Cultural issues CHAPTER 39 331should not be discussed with a person of the opposite sex. As a result, the fears, expectations and consequences of violating culturally accepted codes will obviously have a large impact on a person’s willingness to talk about these issues in counselling. PERCEPTIONS OF TIME For most cultures a linear view of time is appropriate. However, for several South American countries, and for Australian Indigenous people, time is viewed in terms of 'being’. Previously agreed-upon times for meeting may not necessarily hold. 1 his needs to be remembered and respected by counsellors who come from other cultural backgrounds where time keeping is the expected norm and failure to keep time is considered inconsiderate and impolite. Consequently, We need to respect when negotiating appointment times with people from cultures where that the person seeking help may time is not considered to be linear, it is sensible and respectful to have a different recognise the person’s perceptions of rime and time keeping, and to concept of time adjust expectations. For example, when arranging a meeting rime with from ours an Aboriginal person, it may be helpful for the person to be invited to select the times that suit them best. When working in a cultural environment where time is viewed in terms of 'being’, it is generally not advisable to miss or change meeting times, as consistency can be a major factor in promoting trust so that the individual or family can develop a positive relationship with the counsellor. What is required is consistency with flexibility. USE OF LANGUAGE The way language is used will have a significant influence on the effectiveness of communication between the person seeking help and the counsellor. Figures of speech, complex communication, proverbs and quotations may either be familiar or confusing depending on the person’s culture. Additionally, it is important to recognise that there may be significant or subtle differences in the vocabulary and meanings of words in different cultural environments. Consequently, the fact that a person is communicating in English with an English-speaking counsellor may be misleading if the counsellor does not realise that there are subtle differences in the use and meaning of particular words. Martine Powell (2000) lists a few differences that can be useful when counselling Aboriginal people. For some Aboriginal people the word half may mean a small part but not necessarily 50 per cent. Afternoon may refer to the cool part of the day from 4.30 pm to dusk. The word guilty may be used only in reference to murder. 1 he term brother may include cousins and other extended family members. Some Aboriginal groups use he and him to refer to males, females or objects and to more than one person. Aboriginal groups, when referring to past events, frequently use the present tense when speaking in English. When working with Forres Strait Islanders it should be remembered that the word kill does not necessarily mean to kill dead. 332 PART 7 Professional, issuesSPIRITUALITY For many people throughout the world, spiritual beliefs hold a very high level of importance. If these beliefs are challenged or questioned the person concerned may well be alienated. As counsellors, when working with people from other cultures, or people who have different beliefs from ours, we need to suspend our own beliefs. In order to join with and help a person we need to try to It is important to understand their spiritual beliefs and to see their world in the context of respect a person s spiritual values and those beliefs. This may be particularly important with respect to a beliefs person’s beliefs with regard to the role and function of traditional healers and spiritual and religious influences. Spirituality pervades every aspect of the lives of people from most indigenous cultures. For example, Aboriginal communities have strong spiritual traditions where dreams and beliefs about how mystical forces can influence nature figure prominently. PHYSICAL OR EMOTIONAL ISSUES When listening to a person’s story it can be useful to remember that not everyone appreciates the value of using a systematic flow of ideas with careful delineation of issues. To use a metaphor, some people prefer to allow their thoughts to wander around rather than to be focused on heading in one direction. However, this process can be useful, as what is likely to occur is that their thoughts will add significant elements to central themes in their story from time to time. Particular cultural groups who have a common histoiy of past experiences that unite them and help them to define who they are may also experience emotions which are common to the group. It is useful to understand the common history and the emotions that are associated with that history7. For example, counsellors of any ethnic background who meet with people with a histoiy of white oppression need to understand, appreciate and respect the anger that this generates; counsellors need to understand their own response to that anger, whatever that may be, and deal with that response appropriately so that the counselling relationship is enhanced. Issues brought to counselling sometimes reflect connections between the individual and the community. For example, the Aboriginal perception of connections between the individual, the community and the land influences the way in which Aboriginal people view problems. This has implications for counselling. For example, individuals from non-Ab original communities might view alcohol abuse as being a personal problem requiring an individual treatment program. However, this solution may make little sense to some Aboriginal people who may perceive the origin of the difficulty as related to external forces such as the stolen generations, poor prospects of employment, or racism. It would clearly be counterproductive, and in our view unethical, for counsellors with different beliefs to these to tty to change such cultural beliefs. As counsellors, if we are to assist those who seek our help so that we maximise their opportunity to change in ways that are appropriate for them, then we must fully respect, and work within, the frameworks that make sense to them and that result from their cultural heritage. Cultural issues CHAPTER 39 333Many Maori people view the physical environment as personified with the power to influence physical and emotional healing. Additionally, any insights that a Maori person discovers will be viewed as having a spiritual container (Bowden, 2000). Clearly, a counsellor working with a Maori person needs to recognise, respect and understand this. In traditional Chinese culture emotional expression is restrained and displays of emotional reactions do not typically occur outside the family. Feelings are usually not openly expressed except by young children. Often, if a counsellor attempts to encourage a Chinese person to express emotions directly they may be met with resistance and this is likely to be counterproductive. Additionally, such people may have difficulty in identifying, acknowledging and communicating emotional states, because they are not used to doing this. The emphasis in counselling should therefore be on the indirect expression of positive and respectful feelings. For example, interest may be shown in the ways that members of a family show how they care for each other. This focus on behaviour is respectful and indirect. EXPERIENCE OF TRAUMA The way that individuals respond to traumatic experiences will differ depending on their cultural beliefs. People from some cultures hold the belief that individuals are responsible for their own misfortune. In contrast to this, people from other cultures may view misfortune as being imposed on an individual by an outside agency such as bad luck, or may view misfortune as the consequence of bad behaviour. STRATEGIES AND TECHNIQUES WHEN COUNSELLING A PERSON FROM ANOTHER CULTURE As counsellors, we need to develop culturally relevant ways of helping each person. Ideally, a counsellor should have knowledge about the particular group and culture of the person seeking help. However, it is obvious that this will not always be the case. There are many occasions when a counsellor will not have much information about the person’s cultural background. In such cases it may be useful to encourage the person to extend their Story to include relevant information relating to cultural issues. If a counsellor can do this successfully, they may be able to further their knowledge about the person’s family, values, attitudes, beliefs and behaviours. Additionally, they may discover information about the characteristics of the person’s community, and the resources in that community and in the family concerned, enabling them to understand, join with and be more helpful to the person. While exploring cultural issues with a person seeking help, it is important for the counsellor to be aware of and recognise their own By joining with the cultural beliefs so that these do not intrude on the person-to-person person we can learn from them about counselling relationship. In any exploration of cultural issues the aim their cultural is to produce a better relationship with the person and to understand background their problems more fully. During a counselling session it is not 334 PART 7 Professions! issuesjustifiable for a counsellor to explore cultural issues out of curiosity or merely to satisfy their own personal needs. As a counsellor it is essential to avoid stereotyping people in relation to their racial or ethnic background. We need to remember that all human beings are unique individuals. Even though we all have particular ethnic backgrounds, the extent of our individual differences makes us into very different people. However, just as an overemphasis on cultural issues may obscure the personal and individual issues of a person, an overemphasis on individuality may obscure cultural issues. As counsellors we need to treat each person as an individual, recognising their personal issues in the wider context of their cultural background and the cultural background of the wider society in which they live. Counsellors need to be aware that not only are there individual differences between the people from a particular ethnic group but also there may be significant differences between subgroups within an ethnic group. For example, Aboriginal culture and language differ markedly across different groups, and members within any particular group differ in their adherence to the group’s cultural traditions and practices (Powell, 2000). When counselling a person from a different culture, the counsellor may need to take responsibility for helping the person to understand the counselling process and issues relating to goals, expectations, legal rights and the counsellor’s orientation. Negotiation and contracting may be required in order to provide a counselling service that is acceptable and useful for the person. It can be useful for a counsellor to be able to engage in a variety of verbal and non-verbal helping responses so that they are able to send and receive both verbal and non-verbal messages accurately and appropriately, hi order to do this satisfactorily, it can be helpful for a counsellor to be aware of the ways that their own communication style is different from that of the person seeking help. This will enable them to recognise how differences in style may interfere with the counselling process. Counsellors also need to recognise that there is almost always more than one method or approach suitable for helping any particular person, and that some helping styles may be culture-bound. Counsellors should have an open mind so that they are able to use alternative ways of working. For example, it may be useful for a counsellor to consult with or work in conjunction with a traditional healer or spiritual leader when counselling a person from another culture. ESTABLISHING RAPPORT When counselling people from some cultural groups, joining and engaging may involve a lengthy process. For example, when working with Aboriginal people, counsellors need to spend time discussing their own background, where they have lived and worked, and who they might know in other Aboriginal communities. By doing this it may be possible to create an atmosphere of trust by identifying some common connections with other people or places. Cultural issues CHAPTER 39 335EYE CONTACT Attending behaviours vary from culture to culture and from individual to individual. In fact, individual differences among people may be as important as cultural patterns. In some cultures, when listening to a person, direct eye contact is appropriate, but when talking, eye contact should be less frequent. This pattern may be directly opposite or may not apply in other cultures. In particular, many Aboriginal people find direct eye contact unfriendly and intimidating. BODY LANGUAGE AND PHYSICAL SPACE Most counsellors pay a lot of attention to the body language of the person seeking help. However, as counsellors, we need to be very care fill about interpreting body language. The only person who can accurately and consistently interpret a person’s body language is the person themselves. Even so, as counsellors, it is important for us to learn what we can from body language cues. When a counsellor works with a person from the same cultural background as their own, the meaning of body language is often fairly clear, and this can easily be confirmed by checking with the person. When working with a person from a different culture, it is far more difficult to make interpretations regarding body language because there are considerable variations in cultural nonns. In most cultures, when two people are holding a conversation they prefer the distance between them to be at least an arm’s length. However, this norm is not universal. In some Arab and Middle Eastern cultures a conversational distance of 30 cm or less is generally the accepted practice. Such close proximity would be uncomfortable for mafty Western people. Shaking hands is generally seen as a sign of welcome m Western culture. However, it can be risky to assume that this is the case in other cultures. Indeed, in some cultures if a male gives a female a handshake, this may be seen as giving a sexual invitation. In Aboriginal culture restlessness does not necessarily indicate inattention. Additionally, eye, head or lip movements may be used to indicate direction of motion, or the location of a person or event being discussed. LANGUAGE AND TRANSLATION ISSUES People are best able to express themselves meaningfully in their own language (Ivey et al., 2012). It may therefore sometimes be sensible and appropriate for a counsellor to make use of an interpreter in a counselling session. We have done this on a number of occasions with success, but recognise that there are some problems in doing this. Firstly, unless the person seeking help feels comfortable with and trusts the interpreter, they may not feel able to disclose important and relevant personal information. Secondly, it is possible that the interpreter’s own personal issues might intrude on the counselling process. Additionally, where highly emotional personal issues are raised, it may be necessary for the Interpreters have counsellor to help the interpreter to debrief. If this is not done, the feelings too! interpreter may be left with uncomfortable and disturbing feelings. ■I -------------------------------- *■" f / 336

PART 7 Professional, issuesWhen working with an interpreter, the counsellor's understanding of the interpreter’s use of language is important. Sometimes, in the transfer of information from the counsellor to the interpreter to the person seeking help, and from the person to the interpreter to the counsellor, subtle and important changes in meaning may occur. MICRO-SKILLS When working with a person from a different cultural background the most important thing for a counsellor to remember is to focus on creating a trusting relationship. This may mean making progress more slowly rather than attempting to encourage the person to talk through sensitive personal issues too early in the process. It is also important to be congruent and this requires the counsellor to be honest and open about their limitations, particularly with regard to their understanding of the person’s cultural background. Once rapport has been developed, it may be sensible and possible for a counsellor to invite the person to give them feedback if they become uncomfortable with any part of the process. Counsellors need to be familiar with the use of all of the micro-skills described earlier in this book. However, early in the process of relationship building it may be useful to focus more heavily on active listening than on using other skills. In particular, it needs to be remembered that a question-a nd-answer style of gathering information may be alien to people from some cultures, so until you are confident of a person’s cultural norms in this regard, it is wise to avoid the use of questions as much as is possible and to use a less intrusive and more indirect style of relating. Particularly when working with Aboriginal people, direct questions should be avoided, as they are considered intrusive and discourteous. When seeking personal details relating to people from this group, counsellors may gain by sharing information about themselves and then allowing some time for silence. This can give an indirect indication of the type of information that may be useful, without an obligation to respond immediately. This is important, because silence is a positively valued part of Aboriginal conversations. Consequently, Aboriginal people typically take longer to respond. Generally, the most useful information obtained from counselling sessions with them is information that emerges freely in a narrative style of conversation. This is likely to occur when people are encouraged to provide an account of events or situations in their own words, at their own pace and without interruption. Learning summary • • The most important factor in producing successful outcomes when counselling a person from another culture is the counsellors ability to join with them so that a good, trusting working relationship is established. Counsellors need to be aware of their own racial and cultural heritage, and to understand how that heritage has affected their attitudes, beliefs, values, prejudices and biases. Cultural issues CHAPTER 39• The emotional responses, thoughts, beliefs, attitudes, biases, relationships and behaviours of a person seeking help will be affected by a number of factors. These include individual and relationship issues, the way decisions are made, who is perceived to be a natural helper, attitudes in the extended family, gender and gender roles, perceptions of time, use of language, spirituality, physical or emotional issues, and experience of trauma. References and further reading Bowden, R. 2000, ‘Psychotherapy as a container for bi-cultural practice in Aotearoa', Psychotherapy, 7(1): 10—15. Ivey, A.E., D’Andrea, M. & Ivey, M.B. 2012, Theories of Counselling and Psychotherapy: A Multicultural Perspective, 7th edn, SAGE, Thousand Oaks, CA, Ivey, A.E., Ivey, M.B. & Zalaquctt, C.P, 2016, ‘Multicultural competence, ethics, positive psychology, and resilience', in A.E. Ivey, M.B. Ivey M C.P. Zalaquctt, Essentials of Intentional Interviewing: Counselling in a Multicultural World, 3rd edn, Cengage Learning, Boston, pp. 20—49. Powell, M.B. 2000, ‘Pride: the essential elements of a forensic interview with an Aboriginal person’, Australian Psychologist, 35(3): 186—92. Vicary, D. & Andrews, H. 2000, ‘Developing a culturally appropriate psychotherapeutic approach with Indigenous Australians’, Australian Psychologist, 35(3): 181—5. 338 PART 7 Professional issuesConfidentiality and other ethical issues The first part of this chapter will be devoted exclusively to confidentiality, because it is one of the most important ethical issues for a counsellor. Other aspects of professional ethics will be considered in the second part of the chapter. CONFIDENTIALITY For counselling to be maximally effective, the person seeking help must feel secure in the knowledge that what they tell the counsellor is to be treated with a high degree of confidentiality. In an ideal world they would be offered total confidentiality so that they would feel free to openly explore with the counsellor the darkest recesses of their mind, and to discuss the most intimate details of their thoughts. As new counsellors we naively believed that we could at all times give those who sought our help an assurance that what was said in a counselling session was between them and us and would not be discussed with others. We very soon learnt that this was an idealistic belief and found that in practice it is generally not possible, advisable or ethical to offer total confidentiality. As a counsellor you may at times be troubled by some personal difficulties regarding confidentiality and may need to talk with your supervisor about these. Counsellors are faced with a dilemma with regard to confidentiality. Unless we give a person who seeks our help an assurance that what they tell us will be in confidence, they are unlikely to be open with us. However, there are limits to the level of confidentiality that we can offer, and we Absolute need to be clear with the people who seek our help about these confidentiality is often not possible limits. Most importantly, as counsellors we need to be aware of the limits to the confidentiality that we are offering. Many experienced counsellors would agree that promising total confidentiality is unethical (Shillito-Clarke, 2009). It is certainly true that confidentiality is compromised by the following: • the need to keep records • the requirements of the counsellor’s own supervision • the need to protect others • working in conjunction with other professionals • participation in educational training programs, conferences, workshops and seminars Confidentiality and other ethical issues CHAPTER 40 339cases where the law requires disclosure of information. 1 he above list will now be discussed in detail. THE NEED TO KEEP RECORDS As explained in Chapter 38, there are compelling reasons for keeping good records. Counsellors who work in agencies frequently use computerised systems or centralised filing systems for such records. This may make it possible for other counsellors and non-counselling staff such as receptionists and filing clerks to have access to confidential records. Some counsellors omit to note certain categories of sensitive material on their record cards as a way of protecting those who seek counselling help. However» there are obvious consequences if this policy is adopted, as important information may be overlooked or forgotten during subsequent counselling sessions. Clearly, for the protection of those who seek help, computerised records need to be protected by adequate security systems. Similarly, hard-copy records should not be left lying around in places where they can be read by unauthorised people, and should be stored in lockable filing cabinets or in a secure filing room. REQUIREMENTS OF THE COUNSELLOR'S OWN SUPERVISION 1 he requirements of professional supervision, as described in Chapter 41, demand that counsellors be free to fully disclose to their supervisors material relating to people who are seeking help. This is essential if the best possible service is to be provided, and is also necessary for the wellbeing of Counsellor counsellors themselves. Some counsellors openly talk with the supervision is in the best interests of the people who seek their help about the requirements of professional people who seek supervision and sometimes it can be reassuring for a person to know help that their counsellor is receiving supervision. THE NEED TO PROTECT OTHERS Experienced counsellors sometimes work with people who are contemplating suicide, with people who can be dangerous, and with those who have committed serious offences against other people and may possibly repeat such behaviour. Counsellors have responsibilities to those who seek help and also to the community’. Consequently, there may be instances where a counsellor needs to divulge information to protect the person who is seeking help from self-harm, or to protect a third party. For example, if a counsellor knows that the person who is seeking their help possesses a gun and intends to kill someone, then it would be unethical and irresponsible if the person at risk, the police and the psychiatric authorities were not informed. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. The aim should be to ensure that the person seeking help receives a high level of care that is as respectful of their capacity for self-determination as circumstances permit, while also ensuring the safety of others who may be at risk. 340 PART 7 Professional, issuesWORKING IN CONJUNCTION WITH OTHER PROFESSIONALS Professionals such as psychiatrists, medical practitioners, psychologists, social workers, clergy and welfare workers frequently phone counsellors It may be advantageous for to talk with them about people who are seeking their help, and also the person seeking seeking the counsellor’s help. It is sometimes in the interests of such help if the people for other professionals to be appropriately informed about their counsellor works in situations. It is also desirable for counsellors to maintain good working collaboration with relationships with other helping professionals. Sensible judgements need other professionals to be made about what information can be, and is, disclosed, and what is withheld. It is important to try to avoid compromising a person’s trust in you as a counsellor and to respect their lights as a person. If as a counsellor you believe that it is desirable that sensitive material relating to a person seeking help be disclosed to another professional, then, unless there are unusual and compelling reasons for not doing so, the permission of the person concerned should be obtained. Obtaining their permission involves informing them about what you wish to do and why. They are then able to give informed consent. Preferably, this informed consent should be verified in writing so there can be no misunderstanding. Many agencies have a standard consent form which can be used when information is to be shared. 1 he general practice is for this form to be discussed with the person concerned and then signed by both the person and the counsellor. Where two or more members of a family require counselling help, family therapy may be useful. However, if family therapy is not possible, or is considered inappropriate, then the helping professionals involved with individual members of the family are likely to achieve more successful outcomes if they consult with each other, have case conferences and work together as a team. If such cooperation and teamwork is to occur, the process needs to be made transparent to all family members involved, and their consent for the sharing of information needs to be obtained. Sometimes you may discover that a person who is seeking counselling help from you is also consulting another counsellor. There is rarely justification for two counsellors to work with the same person, so after discussion with the person it is sensible to contact the other counsellor to decide who will take over the case. However, as with most situations, there can be exceptions. In a small number of cases, if good contact is maintained between two counsellors, it may be possible for them to both remain involved provided that they agree in setting clear boundaries and goals for the work that each of them will undertake. EDUCATIONAL TRAINING PROGRAMS, CONFERENCES, WORKSHOPS AND SEMINARS Another problem area regarding confidentiality concerns ongoing training, upgrading of skills and sharing of new techniques. Counsellors need to grow and develop as people and as counsellors. This can partly be done through personal supervision and partly through large group sharing at conferences, seminars, Confidentiality and other ethical issues CHAPTER 40 341workshops and case conferences. Material presented at such events to people who sought or are seeking help can sometimes be disguised by changing names and other details, but often this is not possible, particularly when DVD recordings of counselling sessions are used. However, we should stress that it would be unethical to use material in this way without the prior written consent of the people involved who sought or are seeking help. Moreover, there could be legal as well as ethical problems if consent is not obtained. WHERE THE LAW REQUIRES DISCLOSURE OF INFORMATION Confidentiality may be limited by legal intervention. Sometimes counsellors are subpoenaed to give evidence in court and in such cases withholding information may be in contempt of court. Additionally, mandatory reporting is required by counsellors from certain professions in some countries or states with regard to issues such as child abuse. RESPECTING A PERSON'S RIGHT TO PRIVACY Clearly, from the preceding discussion, there are many reasons why confidentiality in the counselling situation is limited. However, it is the counsellor’s task to ensure that confidentiality is preserved as far as is sensibly, legally and ethically possible. Assure the people who seek your help that you will do this to the best of your ability, because they need to feel that whatever they share with you is protected information, which will not be carelessly or unnecessarily divulged to others. It is quite unethical to talk about a person who is seeking help, or material related to them, to any person whatsoever, except in the circumstances previously described in this chapter. What a person shares with you We all like to have is personal property and must not be shared around, so if you do our privacy respected have a need to talk about a person seeking help or their issues, talk with your supervisor. You will need to make your own decisions, m consultation with your supervisor, about how best to deal with the confidentiality issue. Our policy is to be up-front with the people who seek our help and to explain the limits of confidentiality as they apply. For example, when we worked for an agency that had a particular confidentiality policy, we were careful to inform the people seeking help of the policy from that agency. As private practitioners, if we believe that it would be useful or sensible to divulge information for an ethically acceptable and professional reason, then we obtain the informed consent of the person involved. PROFESSIONAL ETHICS T he issue of confidentiality has been discussed in some detail. However, there are many other ethical issues for counsellors, and a new counsellor needs to be informed of these. Many counsellors belong to professional associations with codes of ethical 342 PART 7 Professional, issuesconduct. These codes are readily available on request, and it is sensible for a new counsellor to read through the relevant code for the relevant profession. Some important ethical issues are included in the list below, and these will be discussed in subsequent paragraphs: • respect for the person seeking help • limits of the person-to-person counselling relationship • responsibility of the counsellor • counsellor competence • referral • termination of counselling • legal obligations • self-promotion. RESPECT FOR THE PERSON SEEKING HELP Regardless of who the person seeking help is, and regardless of their behaviour, they have come to you for help and deserve to be treated as a human being of worth. If you treasure them, through feeling valued they will be given the optimum conditions in which to maximise their potential as an individual. Most helping professionals agree that within each of us is the potential for good, and for that potential to be realised we need to feel OK about ourselves. Counsellors therefore have a responsibility to facilitate the process that enables those who seek their help to feel OK about themselves, and to increase their feelings of self-worth. If we try to impose our own moral values on the people who seek our help, we are likely to make them feel judged and to damage their self-worth. Moreover, they are likely to reject us as counsellors and to reject our values too. Paradoxically, if we are able to accept them, with whatever values they have, we are likely to find that as time passes they will move closer to us in their beliefs. This is inevitable because, as counsellors, we are, whether we like it or not, models for the people who seek our help. We have a responsibility to be good models. In this regard, it can be useful to create opportunities for those who seek our help to give us feedback about their experience of the counselling process. By doing this we can demonstrate respect for their views and their right to have some influence in the c ou nselling relatio nsh i p. We need to remember that the interests of the person seeking help must take precedence over the counsellor s during the counselling process. It is not ethical to use counselling sessions with people who seek help to work through our own issues. The correct time tor working through our issues is in supervision sessions. LIMITS OF THE COUNSELLING RELATIONSHIP In all our relationships we set limits. Each of us has a boundary around us to preserve our identity as an individual. The strength of that Boundary, and its nature, depends on who the relationship is with, and on the context of the relationship. The person- to-person counselling relationship is a special type of relationship, established by the Confidentiality and other ethical issues CHAPTER 40 343person seeking help for a particular purpose. I hey enter into the relationship entrusting the counsellor with their wellbeing and expecting that the counsellor will, throughout the relationship, provide them with a safe environment in which they can work on the issues that trouble them. As discussed previously, the person-to-person counselling relationship is not an equal relationship and, inevitably, whether the counsellor wishes it or not, they are in a position of power and influence. Counsellors often work with people who are in highly emotional states and are consequently very vulnerable. I he way that a counsellor relates to a person seeking help is not characteristic of human behaviour generally. A counsellor devotes most of their energy to listening to and understanding the person, so the person sees only a part of the counsellor’s character. In these circumstances, they may perceive a counsellor as unrealistically caring and giving. I he counsellor’s power and the person’s biased perception combine to make the person very vulnerable to offers of friendship or closeness. I he counsellor is also vulnerable. In the counselling relationship, the person seeking help often shares innermost secrets, and so inevitably there may develop a real closeness between the person and the counsellor. Counsellors learn to be empathic, and so they develop special relationships with the people they seek to help. If they are not careful they too become vulnerable to offers of "1................................................ closer relationships than are appropriate. Counsellors therefore need Counsellors can be to be careful not to discount signs that the counselling relationship is vulnerable too! being compromised. Unfortunately, it is almost always unhelpful and damaging to the person seeking help when the counselling relationship is allowed to extend beyond the limits of the counselling situation. If such an extension occurs, the counsellor’s ability to attend to the person’s needs is seriously diminished, and there may well be serious psychological consequences for them. As a counsellor, it may at times be hard to refuse invitations to resist forming a closer relationship with a person seeking help than the counselling situation allows. However, it is important to remember that if we do not set appropriate boundaries we will be satisfying our own needs at the expense of the person seeking help. We will have abused our special position of trust as a professional, and we will have to live with that knowledge, and with any more serious consequences. Unfortunately, when counsellors breach appropriate boundaries they may damage or diminish the usefulness of the counselling process and reduce the possibility that the person seeking help will in the future seek further counselling help. Be aware of the danger signals if you notice that your relationship with a person seeking help is becoming too close, and bring the issue into the open by discussing it with your supervisor and with the person, if that is appropriate. Counsellors need to exercise care if they physically touch a person seeking help in any way. Unwelcome touching is not only unethical but may also be construed as sexual harassment. 344 PART 7 Professional, issuesRESPONSIBILITY OF THE COUNSELLOR Counsellors frequently experience a sense of conflict between their responsibilities to the person seeking help, to the agency that employs them and to the community. You will at times need to make your own decisions about which of these responsibilities needs to take precedence, and in our view the decision is unlikely to always be the same. If you are in doubt about any particular decision, consult your supervisor. Clearly, the counsellor has a responsibility to the person seeking help and needs to directly address their request for counselling help. When a person conies to you for confidential help, you have an obligation to give them that, or alternatively to be clear with them about why you are not able to do that. You cannot ethically fulfil their needs if providing a person with confidential help would: involve working in opposition to the policies of the organisation ................................................................... ......... 4 ------- that employs you Counsellors have a ♦ involve a breach of the law responsibility to the person seeking help, put other members of the community at risk ♦ their employer, the be impossible for you personally. community and However, in these situations you need to be clear with the themselves person seeking help about the situation, so that they understand the conditions under which they are talking to you. Counsellors who are employed by an organisation or institution have a responsibility to that employing body. All the work they do within that organisation or institution needs to fulfil the requirements of the employing body, and to fit in with the philosophical expectations of the employing body. For example, when we (Kathryn and David) worked for the Child and Youth Mental Health Service in Queensland, it was our responsibility to comply with the policies of the Queensland Department of Health. If we had not been able to do that, then we would have had an ethical responsibility to discuss the issue with our employer, or to resign. Counsellors have to be aware at all times of their responsibilities to the community at large. As discussed earlier, this raises problems with regard to confidentiality7. Whenever a member of the community is at risk, property’ is likely to be damaged or other illegal actions are likely to occur or have occurred, then a counsellor needs to make a decision regarding what action is needed. Often such decisions do not involve choosing between black and white, but rather between shades of grey, and sometimes counsellors find it difficult to decide what is most appropriate in order to serve the needs of the person seeking help and the community in the long term. At these times the sensible approach is for the counsellor to talk through the ethical issues with their supervisor. COUNSELLOR COMPETENCE A counsellor has a responsibility7 to ensure that they give the highest possible standard of service. This cannot be done without adequate training and supervision. All counsellors need to attend to their own professional development and to have Confidentiality and other ethical issues CHAPTER 40 345supervision from another counsellor on a regular basis. Failure to do this is certain to result in the counsellor’s own issues intruding into the counselling process, and this will be to the detriment of the people who seek their help (see Chapter 41). A counsellor also needs to be aware of the limits of their competence. We all have limits professionally and personally, and it is essential that as counsellors we are able to recognise our limits and to be open with people who seek our help about those limits. They have a right to know whether they are seeing someone who has, or does not have, the necessary abilities to give them the help they require. REFERRAL When a person’s needs cannot be adequately met by a counsellor, that counsellor has a responsibility to make an appropriate referral, in consultation with the person, to another suitable professional. However, it is not appropriate for a counsellor to avoid all difficult and unenjoyable work by excessively referring people to others. There is a responsibility on all counsellors to carry a fair load, and to be sensible about referral decisions. Such decisions are best made in consultation with a counsellor’s supervisor. Instead of referring to a more qualified and experienced counsellor, it may sometimes be appropriate for a counsellor to continue seeing a person seeking help while undergoing intensive supervision. If this happens, the counsellor has a responsibility7 to inform the person and seek their approval. Often referral is useful where people have special needs. For example, people with particular disabilities, people from other cultures and people who speak another language may benefit from referral to an agency (or professional) that can provide for their specific needs. When referring a person to another professional, it may be useful to contact the professional to whom the referral is being made, with the person’s permission, to ensure that the referral is acceptable and appropriate. TERMINATION OF COUNSELLING Termination of counselling needs to be carried out sensitively and with appropriate timing (see Chapter 12). It is not ethical to terminate counselling at a point where the person seeking help still needs further help. If for some unavoidable reason (such as leaving the district) you need to do this, then it is incumbent upon you to make a suitable referral to another counsellor who can continue to give the necessary7 support. LEGAL OBLIGATIONS Counsellors, like all other professionals and every7 other member of the community, need to operate within the law\ Therefore, as a counsellor, you need to familiarise yourself with the relevant legal requirements for your profession. It is particularly important to know whether reporting of specific behaviours (for example, suspected child abuse) is mandatory. 346 PART 7 Professional issuesSELF-PROMOTION Most professional associations for counsellors have specific rules about advertising. 1 here is clearly an ethical issue with regard to the way in which counsellors describe themselves and their services. It is unethical for a counsellor to make claims about themselves or their services that are inaccurate or cannot be substantiated. Counsellors who do this not only put the people who seek help at risk, but may also face the possibility of prosecution. Learning summary • • • For counselling to be most effective, a high degree of confidentiality is required. Confidentiality is limited by: the need to keep records; professional supervision; the law; the protection of others; participation in training conferences; and cooperation with other professionals. Professional ethics relate to issues such as: respect for the person seeking help; limits to the relationship with them; responsibility to them; the employing agency and the community, competence, referral to others, termination of counselling; legal obligations; and self-promotion. References and further reading Bond, T. 2015, Standards and Ethics for Counselling in Action, 4th edn, SAGE, London. Corey, G., Corey, M.S., Corey, C. & Callanan, P. 2015, Issues and Ethics in the Helping Professions, 9th cdn, Cengage Learning, Stamford, CT. Shillito-Clarke, C. 2009, ‘Ethical issues in counselling psychology’, m K. Woolfc, S. Strawbridge, B. Doughs &’ W. Dryden (rds), Handbook of Counseling Psychology, 3rd cdn, SAGE, London, Confidentiality and other ethical issues CHAPTER 40 347Counsellor training and the need for supervision In order to qualify as a professional counsellor, a person needs to complete an accredited course of study and training; have ongoing supervision, and meet the requirements of the relevant counselling professional body in their country of residence. In Australia there are two professional bodies. Membership of either of these can lead to national registration as a counsellor. The two bodies are the Psychotherapy and Counselling Federation of Australia (PACFA) and the Australian Counsellors Association (ACA). We believe that it is not sufficient for counsellors just to complete an academic training course. Additionally, it is desirable that training should include either personal therapy or experiential groupwork, and also attendance at professional development workshops. Both during and subsequent to training all counsellors need to undergo ongoing supervision so that they can debrief, discuss their work, improve their skills and address personal issues that might be triggered as a consequence of counselling others. When m supervision counsellors often find themselves in a position similar to that of a person seeking counselling help, as they seek to resolve their own personal issues which may have been triggered by the work they are doing, or have done, as a counsellor. Counsellors are required to maintain their current accreditation by undergoing professional development activities to demonstrate a commitment to ongoing training and development. Most importantly they are required to practise in accordance with the relevant code of ethics for counsellors in their state or country of residence. WHY IS SUPERVISION NEEDED? As counsellor’s we must value the people who seek our help so that we offer them the best possible counselling service. It is therefore not ethical for a person seeking help to be seen by a new counsellor unless that counsellor is being adequately supervised. Additionally, our belief is that all counsellors, new and experienced, should have ongoing supervision. There are several important and quite different reasons for this, including the following: • to enable the counsellor to work through their own personal issues • to enable the counsellor to upgrade their skills • to provide an external review of the counselling process • to address issues concerning dependency and professional boundaries. We will now consider each of the above. 348 PART 7 Professional issuesTO ENABLE THE COUNSELLOR TO WORK THROUGH PERSONAL ISSUES You may be surprised at the suggestion that supervision is required to enable a counsellor to work through their own personal issues. You may be asking, 'If counselling is for the benefit of the person seeking help and not the counsellor, why should the counsellor use counselling supervision in order to deal with their own issues?’ The answer is simple: unless a counsellor owns and deals with their own issues, these issues are quite likely to interfere with their ability to counsel effectively. Frequently, a counsellor will feel emotional pain when a person seeking help discusses issues similar to the counsellor’s own unresolved emotional issues. Consequently, when issues are discussed that are painful for the counsellor as a result of unresolved issues, the counsellor may consciously or unconsciously avoid their own pain in a number of ways during the counselling session: • The counsellor might deflect away from the painful issue by encouraging the person to talk about something else. • The counsellor might try to comfort the person rather than help them deal with the issue. • l ire counsellor might attempt to encourage the person to pursue a course of action that in some way satisfies the counsellor's own needs, bhe counsellor may wish, for example, that they had taken a particular course of action in their own life and may encourage the person to take a similar course. • bhe counsellor may avoid facing both their own issue and the person’s by failing to recognise the issues and subconsciously suppressing them. A perceptive supervisor will spot counsellor behaviour that demonstrates avoidance of painful issues and will ask the supervisee to explore whatever was happening emotionally within them when the avoidance occurred. 1 his means that counsellors need to be prepared to own and explore their own issues on an ongoing basis, otherwise these issues are likely to diminish the effectiveness of counselling. Most people don’t look closely at their own emotional problems unless they are causing them considerable distress. It is a natural human defence to suppress uncomfortable feelings and not to delve into them without good reason. However, a counsellor must delve into uncomfortable feelings, because if they have a problem that they can t face, then it will be quite impossible Effective for them to help a person with a similar problem. As counsellors, counsellors explore and resolve their therefore, we need to explore and deal with all of our own painful own personal issues issues as they come into our awareness, bhe spin-off for us is that our personal growth is enhanced when we do this. TO ENABLE THE COUNSELLOR TO UPGRADE THEIR SKILLS Everi experienced counsellors find it useful and valuable to learn from other counsellors. We all have a different range of skills and use differing styles when counselling. During our counselling careers we have both discovered that our own counselling styles have continued to change. This has enabled us to integrate new skills into our Counsellor training and the need for supervision CHAPTER 41 349work and to continue to take a fresh approach to counselling, rather than sink into a rut and become stale. We find that it is sometimes useful for us to receive input from counsellors who use different frameworks from ours. By doing this we Effective usually find that we learn some new ideas for enhancing our work. counsellors never stop learning Although didactic learning can be useful for counsellors, it seems to us that the experience of personal supervision is more powerful in promoting professional development. Learning through supervision can integrate skill training with personal growth. Additionally, the counsellor is reminded in supervision of what it is like to be in the position of a person seeking help. This can be helpful in enabling a counsellor to continually meet with each person seeking help as a person of equal value. TO PROVIDE AN EXTERNAL REVIEW OF THE COUNSELLING PROCESS Often a person seeking help will not see what seems obvious to the counsellor, This is because the person is personally and deeply involved in their situation. In comparison, the counsellor, after joining with them and trying to see the world in the way they do, can stand back to take a more objective view and see more clearly. A parallel process happens when a counsellor is being supervised. The supervisor is able to view the counselling process and the case details in a different way from the counsellor. I he supervisor may recognise processes that are occurring for the person seeking help or the counsellor that have been unrecognised. Therefore, a supervisor is able to provide useful input on ways of working with particular people who are seeking help. Additionally, helpful supervisors have the benefit of experience, which can be a source of useful information for the supervisee. TO ADDRESS ISSUES CONCERNING DEPENDENCY AND PROFESSIONAL BOUNDARIES As discussed in the previous paragraph, a supervisor may recognise processes that have not been recognised by the counsellor. Of specific Both people seeking help and importance are issues of dependency and respect for professional counsellors boundaries. experience It can sometimes be hard for new Counsellors to recognise when dependency issues the time for terminating a series of counselling sessions has been reached. I his may be partly due to issues of dependence that inevitably will develop in some counselling relationships (see Chapter 12). Sometimes it is hard for a counsellor to recognise whether the person seeking help really does have a need for further counselling or whether dependency is occurring on the part of the person or the counsellor themselves. People who become dependent on the counselling relationship sometimes produce new material for discussion when the counselling process is moving towards closure. This may be as a consequence of a subconscious or conscious desire to prolong the relationship. By discussing cases in supervision, a supervisor may be able to recognise when dependency 350 PART 7 Professional issuesis interfering with appropriate termination processes. Additionally, a supervisor may be able to help a counsellor devise suitable strategies for managing dependency issues. Some counsellors have difficulty in recognising when their own personal feelings towards a person seeking help could result in behaviours that would inappropriately transgress professional boundaries, and consequently interfere with the counselling process. Additionally, new counsellors sometimes have difficulty in knowing how to respond to direct or indirect invitations for friendship and closeness from people seeking their help. Once again, supervision can help a counsellor to recognise inappropriate processes that are occurring and to develop appropriate strategies to deal with these processes. WHAT DOES SUPERVISION INVOLVE? There are a number of ways in which supervision can occur: 1 by direct observation with the supervisor in the counselling room 2 by direct observation through a one-way mirror 3 by obseivation using a closed-circuit TV 4 by use of audio or DVD recording and analysis 5 by direct obseivation together with audio- or DVD-recording and analysis 6 by use of a verbatim report. These methods will be discussed in turn. DIRECT OBSERVATION WITH THE SUPERVISOR IN THE COUNSELLING ROOM Trainee counsellors are usually apprehensive during their first few counselling sessions. A good way to help them adjust to the counselling environment is for trainees to sit in on counselling sessions conducted by their supervisors. Naturally, the permission of the person seeking help is required. Student counsellors who are allowed to do this need to understand what their supervisor expects of them. We prefer our students to take a low profile and to sit quietly out of the line of vision of the person seeking help. This reduces the likelihood of the person feeling the need to interact with both the counsellor and the student simultaneously, leaves us free to conduct the session in the way that we choose, and enables the trainee to observe without feeling pressured to participate. As the trainee's level of comfort increases, some participation by them can occur. Adopting this approach allows them to directly observe the counselling process, and to feel at ease while being in a situation where counselling is occurring. The method allows the trainee to gradually make the transition from being a passive observer to being an active counsellor under supervision. The process just described is excellent for beginners who have had no previous counselling experience, but there can be problems connected with having both the trainee and the Supervisor in the room together. Obviously* some of the intimacy of the counselling relationship is lost, and as a consequence the person seeking help may find it difficult to deal openly with sensitive issues. Counselor training and the need for supervision CHAPTER 41 351DIRECT OBSERVATION THROUGH A ONE-WAY MIRROR I he one-way mirror system as shown in Figure 41.1 provides an alternative to direct Observation^ Many counselling centres have a pair of adjacent rooms set up like this for training purposes and for family therapy. The one-way mirror allows a person in the observation room to watch what is happening in the counselling room without being seen. A microphone, an amplifier and a speaker system provide sound for the observer, so that they are able to see and hear what is happening. Ethically, it is imperative that a person seeking help who is being observed from behind a one-way mirror should be informed in advance about the presence of the observer or Observers, and that consent is obtained for the session to proceed in this way. I he one-way mirror system can initially be used to enable a trainee or trainees to watch an experienced counsellor at work. Later, the trainee can work as a counsellor while being observed by their supervisor and possibly by other trainees also. I he system has the advantage that the supervisor is not present in the counselling room and therefore does not intrude on the counselling process. However, they are available to take over from the trainee if that becomes necessary, and they can give objective feedback after the session is completed. OBSERVATION USING A CLOSED-CIRCUIT TV A similar method to the one-way mirror system is to have a camera in the counselling room connected to a TV monitor in another room. However, this method doesn’t provide as much visual detail as is obtained with the one-way mirror Figure 41.1 Counselling and observation rooms PERSON SEEKING HELP COUNSELLOR INTERCOM PHONE X CEILING MICROPHONE COUNSELLING ROOM VIDEO CAMERA ONE WAY MIRROR BENCH AT DESK HEIGHT INTERCOM PHONE

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AMPLIFIER SUPERVISOR . 1 SPEAKER VIDEO RECORDER OTHER TRAINEES / OBSERVATION ROOM 352 PART 7 Professional issues t^oA/ MONITORsystem. It is often difficult to see facial expressions if the camera has a wide-angle lens to enable most of the room to be in the picture. USE OF AUDIO- OR DVD-RECORDING AND ANALYSIS One of the best methods of supervision is by use of DVD recordings. Audio recordings can also be used, although their usefulness is more limited because non-verbal behaviour cannot be observed. DVD recordings of counselling sessions are a rich source of information. Not only may selected segments of a session be viewed repeatedly, but it is also possible to freeze the picture so that non-verbals may be studied. The supervisor and the counsellor can then review and analyse parts of the recordings. Often it can be useful for the counsellor to review additional recordings on their own in order to recognise unsatisfactory processes and to improve their counselling techniques. Whenever an audio or DVD recording is to be made, it is essential to obtain the prior written consent of the person seeking help, and to tell them who will have access to the recording and when it is to be erased. Many agencies have standard consent forms for this purpose. It is sensible to have such forms checked for their legal and ethical validity. DIRECT OBSERVATION TOGETHER WITH AUDIO- OR DVD- RECORDING AND ANALYSIS A combination of a one-way mirror system together with audio- or DVD-recording is a very powerful arrangement for counsellor training. Trainees can be directly observed during practice sessions, and may later process their work in detail with their supervisors by analysing and reviewing the audio or DVD recordings. DVD recordings can be a valuable learning tool USE OF A VERBATIM REPORT Another method of supervision is by use of the verbatim report. A verbatim report is a written report that records, word for word, the statements made by the person seeking help and the counsellor’s responses, it may be produced from memory, or as a transcript of an audio recording. Here is an example of a verbatim report. Note that this example is invented and does not relate to a real person or counsellor. VERBATIM REPORT Name of counsellor: Fiona Smith Name of person seeking help: Simon Anonymous Date of counselling session: 19.01.11 Background information about the person: Simon is 36 years old, has been married twice and has two children: a girl 12, and a boy, 10. Both children are Living with Simon's second wife. He lives alone. Counsellor training and the need for supervision CHAPTER 41 353This was Simon's second visit to see me. He came a week ago feeling tense and depressed. He told me that he was worried about his inability to build lasting relationships with women, and he couldn't understand why. My feelings and attitudes prior to the session: I was feeling good and was looking forward to working with Simon again. I believed that I had built a good relationship with him during the previous session and that this would enable him to talk freely with me. l/l/hat occurred prior to the responses given below: When Simon arrived for this session he looked pale and was very subdued. During the first 15 minutes of our time together his body looked tense and he seemed reluctant to talk. After a few minutes of silence, I felt as though he had put a barrier between us and I spoke. Fl Seems like there's a barrier between us. [Said quietly] 51 Ah what... what da ya mean? [/ thought he sounded defensive] F2 Like we're separated by a barrier. [I used my hands to suggest a barrier] 52 Separated? [Said with non-verbals that suggested disbelief and questioning. I felt very shut out from Simon now] F3 Yes, I feel shut out by an invisible barrier. Sometimes you open it up a ... [Simon interrupted heatedly] 53 No, no, it's a double brick wall with a door in it. The door is usually closed and that's because it keeps me safe. F4 That brick wall's important to you! 54 It sure is! F5 It protects you. [Simon started to talk freely and easily after this] 55 Yes, it does ... [He went on to explain how vulnerable he would feel without the waif and then started to cry. I waited] ... You see, I've been hurt too much in the past, and !m scared that if !m me, if I'm really me, and open up, then I'll be rejected again. F6 The barrier protects you from the pain of rejection. [Long pause] 56 It also prevents me from getting into a relationship and I'm not sure that I like that. [Said carefully, slowly and firmly] F7 You don't sound sure about whether you want the barrier or not. 57 Well, it would be hard to tear it down. I'm so used to it now. You know, I realise that the barrier's been there for a long time now. Goodness knows what might happen if I didn't have it there. F8 It would be risky to tear it down. 58 It would. [He paused to think for what seemed a long time. I had difficulty staying silent because I wanted to tell him what he was discovering for himself] ... You know, I would get hurt for sure, and what's worse, I'd have to take responsibility for the ways I hurt the women I get close to. [He laughed] That's worse. That's worse! I can't bear it when I hurt someone I love. F9 Getting close involves lots of hurt. [He interrupted, fortunately, before I was able to take him off track by suggesting getting close could also involve pleasure. I was bursting to tell him!] 354 PART 7 Professional issuesS9 Yes, it seems like that to me ... [He then told me in detail about his pain at losing his wife. He couldn't understand how he hurt so much when he had left her] ... It's not over yet. How can I still be hurting after so long? F10 I get the impression that you're still grieving. S10 I should be over her by now! [Sa/d despairingly] Fll It takes time to grieve. Can you give yourself time? (From here on the process flowed naturally as he dealt with his grief ! got the strong feeling that his barrier would gradually disintegrate as he worked through his grief.) My feelings after the session felt good because Simon had moved forward to a fuller awareness of himself and his behaviour. Additionally, I realised that I had been infected by some of his sadness. What I have learnt from the session (or things I would do differently another time) I Learnt that it was helpful for Simon when I shared with him my own feelings (of separation, see Fl, F2 and F3). Because he interrupted (F9 and $©), I discovered that it was better to follow his path. If I had brought the focus onto the pleasure associated with closeness, then I would have made it more difficult for him to address the underlying issue of his grief. I learnt that my desire 'to make him feel good' could have been counterproductive.. I'm pleased he interrupted and prevented me from doing this. Structure of the verbatim report As you will see from the example of a verbatim report, the report begins with background information about the person seeking help, their problems and their emotional state. The first part of the report may also summarise the process and outcome of previous counselling sessions. 1 he next section of the report concerns the counsellor s own feelings and attitudes prior to the counselling session. This information is required because a counsellor’s behaviour and performance are often influenced by their mood, feelings generally, and feelings towards the person seeking help, and their preconceived ideas and attitudes concerning them and their behaviour. A central component of the verbatim report is the section containing statements made by the person seeking help and the counsellor responses. This section usually contains only about 10 to 20 responses from each person. It would be very laborious to write out a transcript of a substantial part of a counselling interaction and this is unnecessary. Preferably the trainee counsellor will select a portion of the session that demonstrates some important learning or highlights some difficulties. Often a new counsellor will find that a part of the interaction seems to ‘go wrong’ inexplicably. Such a segment provides ideal material for a verbatim report and subsequent discussion in supervision. Notice that responses are numbered and identified by the initial letter of the person’s name, for example, statement F7 is Fiona’s seventh in the report. After Counsellor training and the need tor supervision CHAPTER 41 355each statement other significant information is recorded, in parentheses, including non-verbal behaviour, silences and the feelings and thoughts of the counsellor. Immediately before the verbatim record of the conversation is a description of what occurred in the earlier part of the session, and immediately after the record of rhe conversation is a brief description of what occurred in the remaining part of the session. These descriptions are required so that the statements that are recorded verbatim are seen in the context of the whole session. The verbatim report concludes with sections that describe the counsellor’s feelings after the session and what they have learnt for the future. It is then signed. The value of verbatim reports Verbatim reports enable a supervisor to tap into trainee issues that might have blocked them from satisfactorily helping a person to work through their issues. Such reports also enable the supervisor to identify unsatisfactory processes and inappropriate counsellor responses, and to help the trainee discover better ones. CONFIDENTIALITY Audio recordings, DVD recordings and verbatim reports require the same level of protection as other records concerning people seeking help, in order to ensure that confidentiality is preserved (see Chapter 40). It is essential that electronic records of counselling conversations and reports are not left in places where they might fall into the hands of unauthorised persons. IN CONCLUSION By using any of the methods described in this chapter, a supervisor can help a new counsellor to improve their skills and to understand the process that occurred during a particular counselling session. This chapter has discussed ways in which you may be supervised as a new counsellor. Your initial training is just the beginning, and there is no end to the ongoing need for further Ongoing training. A good counsellor never stops learning from their own supervision is the key to good experiences and from what others can teach them. In order to improve, counselling it is essential to continue in supervision even as an experienced counsellor. The counselling strategies described in this book are the basic ones. Once you have mastered them, you may wish to continue to learn from experienced counsellors who have advanced skills or who are skilled in specialised counselling techniques. We believe that ongoing training can best be carried out through experiential training in workshops and seminars, together with hands-on experience under the supervision of a qualified and experienced practitioner. 356 PART 7 Professional, issuesLearning summary • • • • • Counsellors need to complete an accredited course of study and training, have ongoing supervision and meet the requirements of the relevant counselling body in their state or country (PACFA or ACA in Australia). Counsellors are bound by a code of ethics determined by the relevant professional body. It is essential for new counsellors to have adequate supervision. A counsellor's own unresolved issues may adversely affect the counselling process. Common supervision methods involve direct observation, observation using a closed-circuit TV, audio- or DVD-recording and analysis, and use of verbatim reports. Further reading Bor. K. & Watts, M. 2010, The Trainee Handbook: A Guide for Counselling & Psychotherapy Trainees* 3rd edn, SAGE, London. Cotey, G., Corey, M.S., Corey, C. & Callman, P. 2015, and Ethics in the Helping Professions, 9th edn, C'engage Learning, Stamford, CT. McMahon, M. & Patton, W. (eds) 2002, Supervision in the Helping Professions: A Practical Approach, Pearson Education, Frenchs Forest, Australia. Walker, M. & Jacobs, M. 2004, Supervision: Questions and Ansivers for (Counsellors and Therapists, Whurr, London. Counsellor training and the need for supervision CHAPTER 41 357Looking after yourself A counsellor’s own wellbeing is of paramount importance. Firstly, counsellors are human beings with their own needs, so it is appropriate for them to be sensible in caring for themselves. Additionally, from a professional point of view, it is essential for counsellors to look after themselves, because counsellors who are not feeling good are unlikely to be fully effective in helping the people who seek their help. Counselling can be draining, so counsellors need support, otherwise they are likely to find themselves emotionally depleted. If they are to feel good they must resolve their own personal issues satisfactorily while receiving the support they need. This can be done as described previously, through regular supervision from an experienced counsellor (see Chapter 41). In recent years, it has become clear that all counsellors at times experience what is known as burnout. Burnout is disabling, but if it is recognised in its early stages, it is comparatively easy to take remedial action. Even experienced counsellors fail at times to recognise the onset of burnout and try to convince themselves that the symptoms they are experiencing are due to some other cause. It is difficult for many counsellors to admit to themselves, let alone to others, that they are burning out, even though there is now general acceptance that burnout is a common problem. 1 he first step in dealing with burnout is to be aware of the symptoms. BURNOUT SYMPTOMS 1 here are many symptoms that come under the general heading of burnout. These symptoms give an indication that a counsellor is becoming drained emotionally by the counselling work. Counsellors may experience a feeling of being totally overworked and of having no control over their workload. Every counsellor is They may perceive themselves as swimming against the tide and at risk of burnout unable to keep their heads above water. This leads to feelings of hopelessness and helplessness. 4. t + * 4 |

• ft ? + + -.h + 4 - fa . .b 4. . i. 44 - !■». 4 - PHYSICAL AND EMOTIONAL SYMPTOMS Counsellors experiencing burnout are usually tired physically, emotionally and mentally. They start to feel that they can’t face another counselling session. Typically, a counsellor may say to themselves while counselling: ‘ 1 really can’t bear to be here. 1 wish this person would just go away.’ 1 he counsellor may also experience being physically debilitated and find it hard to drag themselves to work. 358 PART 7 Professional, issuesTheir enthusiasm has evaporated and they may have physical symptoms such as headaches, stomach-aches, skin disorders, high blood pressure or back and neck pains. Their susceptibility to viruses and other infections is increased. NEGATIVE ATTITUDES Burnt-out counsellors may develop strong negative attitudes towards the people who seek their help. They may develop a cynical attitude to them and blame them for creating their own problems. 1 hey may even start to treat them in an impersonal way, as though they were objects and not human beings. Consequently, the counselling relationship will suffer and counselling will become a chore, rather than an interesting, challenging and creative activity. Such counsellors no longer find satisfaction in their work. Negative attitudes may also be experienced towards fellow workers, supervisors, other staff and the employing organisation. DISILLUSIONMENT Disillusionment with the counselling process is a major burnout symptom. Counsellors start to question the value of their work and begin to wonder if what they are doing is worthwhile. Burnt-out counsellors will often be unable to see any evidence of success in their work. They feel frustrated by what they perceive as their inability to bring about change in the people who seek their help and are dissatisfied with their job, believing that it involves giving and getting nothing in return. This leads to feelings of failure and low self-esteem. The demands of people who seek their help become too great and the counsellor may just want to withdraw from the helping situation. In the advanced stages of burnout, counsellors start taking days off sick, and may start frantically looking for a new job so that they can resign. PERSONAL CONSEQUENCES One of the sad consequences of burnout is that it is likely to affect the counsellor’s personal life. As a counsellor’s self-esteem diminishes, their personal relationships may be put in jeopardy and other people may become targets for feelings of anger, frustration, helplessness and hopelessness. I he symptoms of burnout that we have outlined above can occur quite suddenly but at other times they build up gradually. Because of this, it can be useful to check from time to time to determine how well you are doing in keeping burnout at bay. A good way of doing this is to measure your burnout score using an inventory such as the one below. We, the authors, developed this inventory especially for counsellors. A MAJOR CAUSE OF BURNOUT What is the primary cause of burnout? Well, we can’t be certain, and all counsellors are different, but it seems likely that a major cause of burnout is the stress of the interpersonal counselling relationship. This is an unbalanced relationship, with the counsellor doing most of the giving and the person seeking help doing most of the receiving. Looking after yourself CHAPTER 42 359Burnout inventory In order to obtain a burnout score, you need to answer each question m the following list by putting a ‘X' on the rating scale after each question. It is best to put each lX: directly under one of the alternatives (such as 4mildly agree’) rather than at an intermediate point between two possibilities. After completing the inventory use the instructions provided at the end to obtain your score. 1 I have positive attitudes to counselling and think that the work is really worthwhile. 2 AgreeStrongly agree UncertainMildly agreeAgreeStrongly agree Uncertain Mildly agreeAgreeStrongly agree Mildly agreeAgreeStrongly agree I am always willing to do extra work. Mildly disagree Disagree 1 Uncertain 1 1 My personal life is suffering as a result of my counselling work. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree I feel as though I need to hide my inadequacies and faults. Strongly disagree 360 Mildly disagree Disagree 1 6 Mildly agree I always relate to the person seeking counselling on a personal and individual basis and do not treat them just as cases to be dealt with. Strongly disagree 5 Mildly disagree Disagree Strongly disagree 4 Uncertain There is too much to do in a day. Strongly disagree 3 Mildly disagree Disagree Strongly disagree PART 7 Disagree Professional, issues Mildly disagree Uncertain Mildly agree7 When I go home I usually forget about the people who come to me for counselling and get on with the rest of my life. Strongly disagree 8 Mildly disagree Uncertain Mildly agree Strongly agree Agree I don’t blame the people who come to counselling for their problems. Strongly disagree 9 Disagree Disagree Mildly disagree Uncertain Mildly agree Strongly agree Agree I usually look forward with pleasant anticipation to people coming for counselling help. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Ag ree Strongly agree 10 I can’t do the job the way I think is best. There are too many don’ts. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree 11 The system at work needs changing, but 1 don’t have the power to change it. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree 12 I often feel like saying to people who come for help, ‘you think you have problems; what about me?’ Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Looking after yourself Strongly agree CHAPTER 42 36113 I find it easy to talk to other counsellors about my feelings. Strongly disagree Disagree Mildly disagree UncertainMildly agreeAgreeStrongly agree Mildly agreeAgreeStrongly agree 14 I feel emotionally depleted. Strongly disagreeDisagreeMildly disagreeUncertain 111i 15 I just can’t cope with some types of people who come for counselling help. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree 16 I feel as though I’m losing my ability to get in touch with the feelings of some of the people who come for counselling help. Strongly disagree Disagree Mildly disagree Uncertain Mildly agreeAgreeStrongly agree Mildly agreeAgreeStrongly agree Mildly agreeAgreeStrongly agree 17 Counselling is all giving with no return. Strongly disagree DisagreeMildly disagree i1 Uncertain People hold counsellors in high regard. Strongly disagree Disagree Uncertain Mildly disagree 1 1 19 Many people who come for counselling deserve to suffer because they just don’t live by acceptable standards. Strongly disagree 362 PART 7 Disagree Professional, issues Mildly disagree Uncertain Mildly agree Agree Strongly agree20 I really need to take a break from counselling. Disagree Strongly disagree 21 Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree AgreeStrongly agree I feel warm and friendly towards my fellow counsellors. Disagree Strongly disagree Mildly disagree Uncertain Mildly agree 22 I believe that my standard of counselling is improving. Disagree Strongly disagree Mildly disagree Uncertain Mildly agree 23 My relationship to people who come for counselling help is suffering due to my negative attitudes. Disagree Strongly disagree Mildly disagree Uncertain Mildly agree Strongly agree Agree 24 I often feel angry when I hear about what the person who is seeking counselling has done. Disagree Strongly disagree Mildly disagree Uncertain Mildly agreeAgreeStrongly agree Mildly agreeAgreeStrongly agree 25 I feel physically fit and have lots of energy. Strongly disagree Disagree 1 Mildly disagree Uncertain 1 26 The people who come for counselling are forever grasping, self-centred and unappreciative of my efforts. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Looking after yourself Strongly agree CHAPTER 42 36327 Counselling gives me a lift in life and inspires me to move forwards. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree I haven’t enough energy left for my family and fid ends. Counselling takes too much of me. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree 29 I feel worn out by the people to come to see me. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree 30 I can’t let off steam in my counselling workplace. I’ve got to be calm, patient and caring all of the time. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree 31 I feel enthusiastic about the value of counselling. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree 32 I often get caught up in the emotional feelings of the person seeking help and feel upset or angry myself. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree 33 I often wish that person seeking help would just go away. Strongly disagree 364 PART 7 Disagree Professional, issues Mildly disagree Uncertain Mildly agree34 I know what my supervisor thinks of my performance as a counsellor. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree 35 The agency I work for really cares about me and my work is appreciated. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree Agree Strongly agree 36 I get a hopeless feeling. Nobody can fix up all the problems are there. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree AgreeStrongly agree AgreeStrongly agree 37 I hardly ever give an automatic type of response. Strongly disagree Disagree Mildly disagree Uncertain Mildly agree 38 Counselling has given me the satisfaction that I originally expected to get from it. Strongly disagreeDisagree 1I UncertainMildly agreeAgreeStrongly agree Mildly disagreeUncertainMildly agreeAgreeStrongly agree Mildly disagreeUncertainMildly agreeAgreeStrongly agree Mildly disagree 39 I feel irritable quite often. Strongly disagreeDisagree 11 40 I rarely feel uptight. Strongly disagree Disagree Looktng after yourself CHAPTER 42 365Instructions for scoring the burnout inventory Each item on the burnout inventory receives a score from 1 to 7. The following item numbers are scored in the same way 1, 3, 4, 7, 8, 9, 13, 18, 21, 22, 25, 27, 31, 34, 35, 37, 38, and 40. These items score as follows: Strongly disagree Disagree Mildly disagree Agree Mildly agree Uncertain Strongly agree 3 Items 2, 5, 6, 10, 11, 12, 14, 15, 16, 17, 19, 20, 23, 24, 26, 28, 29, 30, 32, 33, 36, and 39 are scored in the following way: Strongly disagree Disagree Mildly disagree Uncertain I Agree Mildly agree 1 Strongly agree 1 5 We suggest that you write the score for each item on the right-hand side of the page against that item. In order to obtain your total burnout score, add together the scores for all items. Use the key below to interpret your result and then consider whether you think that this assessment of your burnout level accurately fits with your own belief about your level of burnout. You are the best judge and need to trust your own inner feelings. Key 366 ScoreSuggested interpretation 40-80You are a fully functioning counsellor 81-120You're doing well 121-200Why not give yourself more caring? Remind yourself that you are loveable and capable1 201-280With a score in this range we suggest that you might want to see your professional supervisor and decide what action to take so that you feel more comfortable. PART 7 Professional issuesIn the early chapters of this book, heavy emphasis was put oil establishing an empathic relationship, and on the need to join with the person seeking help. It is essential that, as a counsellor, you learn to do this effectively, because empathy is one of the essential ingredients of successful counselling. However, being empathic can be hazardous to a counsellor’s health! That is, unless proper precautions are taken. People who seek help are often in a highly emotional state, and if a counsellor listens with empathy and joins with an emotional person, then the counsellor is likely to be infected by their emotional state. Emotions, like viruses, are catching, which is probably why people who aren’t counsellors try to calm their friends down when they are emotional. After all, who wants to be emotionally distressed? In contrast to most friends, many counsellors encourage people to experience and express their emotions fully. Empathic counsellors are certain to experience, at some level, emotions similar to those of the people they aim to help. Clearly, no counsellor can afford to be emotionally distressed for a significant part of the working day, because to allow this to happen would be Emotions can be certain to result in burnout. Counsellors who are working mainly infectious! with emotionally disturbed people are therefore very much at risk and need to take special precautions to avoid burnout. PROTECTING YOURSELF With experience, you will learn how to walk beside a person with empathy and also how to protect yourself from the excesses of emotional pain by at times moving back for a while, grounding yourself, and then joining more fully with them again. Certainly, if you are to protect yourself from burnout, you will need to learn how to do this. David will describe the technique he uses for himself, and then you will need to experiment for yourself, to find out what works best for you. USING AN IMAGINARY SPACE-BUBBLE In a counselling session, when I notice that 1 am starting to excessively experience the emotional pain of the person seeking help, 1 will set about grounding myself. I his grounding process takes only a second or two to happen, but will take longer to describe. 1 imagine myself to be encapsulated by a plastic space-bubble that separates me from outside emotions, but enables me to observe them, and allows me to respond to them appropriately. I then slow down my breathing and relax my body, so that my troubled emotional state is replaced by a more peaceful state. In my imagination, 1 float, in the space-bubble, upwards and backwards to a position several metres behind and above my body. It is as though the part of me in the bubble is able to observe both the person seeking help and the physical me, which is still sitting in my counselling chair. 1 am still able to concentrate fully, but am more detached and less involved. In this position, 1 can make sensible decisions with regard to the counselling process. However, 1 can in a split second travel back in my imagination Looking after yourself CHAPTER 42 367to my counselling chair, to give empathic attention and empathic responses to the person seeking help. The imagination is a powerful thing, and 1 have trained myself to relax quickly, when necessary- You will need to experiment for If you are becoming yourself, to devise an effective way in which you can protect yourself overwhelmed, move back to a more from emotional damage due to exposure to excessive emotional pain. objective position Despite the above discussion, there will inevitably be times when, as a counsellor, you are affected by the emotional traumas of the people who seek your help, as at times 1 am. Personally, 1 don’t think that it is helpful to let a person know that I have been emotionally affected by what they have told me. Most people are caring and do not like to upset others. Consequently, if a person thinks that I have been emotionally disturbed by what I have heard, then they may be less likely to tell me about other disturbing information. Counsellors therefore need to control the expression of their own emotions appropriately, so that the people who seek their help feel able to talk freely. RECHARGING If you are left in an emotionally disturbed state after a counselling session, talk to your supervisor about your feelings as soon as possible. If your supervisor isn’t available you may need to talk with another counsellor. If another counsellor isn’t available, an alternative is to debrief by writing down your feelings and thoughts and allowing yourself to express your emotions in an appropriate way. Remember: the counselling relationship is substantially a one-way relationship, in which the counsellor is the giver and the person seeking help is the taker. Such a relationship will inevitably drain the counsellor of emotional energy. Unless a counsellor recharges, they will experience the symptoms of burnout as they become drained. REFLECTIVE PRACTICE Another way to guard against burnout is to ensure you are continually reflecting on your work as a counsellor. Developing insight through reflective practice is helpful in identifying the early signs of burnout. Some questions to consider include: • How am 1 feeling generally? Am I tired or rundown? Have 1 been getting sick more often? • How do 1 feel about my counselling work? Do 1 feel overworked or overwhelmed? Do 1 feel like what I do matters? • How do 1 feel about my clients? Am I beginning to develop negative attitudes? • Do 1 think about my clients when Fm not at work? Are emotions from work beginning to impact on my personal life? While you can certainly reflect on these questions individually, it can also be very’ helpful to discuss them with your supervisor, as we suggested above. Seeking another perspective can be useful in increasing your insight into the development of burnout and identifying ways to address burnout. Those interested in learning more about 368 PART 7 Professional issuesreflective practice and how it applies to other areas of counselling may like to refer to the book on reflective practice edited by Stedmon and Dallos (2009). OTHER FACTORS THAT LEAD TO BURNOUT OVER-INVOLVEMENT It is sensible to be aware of the dangers of over-involvement with the people who seek your help and their issues. We all have different personalities and differing capabilities for coping with emotionally stressful situations. Some counsellors get over-involved with the people who seek their help and take their problems home with them, whereas other people are more philosophical and are less affected by their counselling work. A while ago, while working at a crisis counselling agency, David trained himself so that when he left his place of work, he would allow himself to think about material related to people who were seeking his help only until he reached a particular set of traffic lights. Once he had passed these lights, he gave himself the option of going back to work to think about his counselling work, or of thinking about other things and continuing his journey home. He invariably continued his journey. SUICIDAL PEOPLE Experienced counsellors who offer help to suicidal or violent people have an extremely stressful time and are particularly prone to burnout. A counsellor who has a high case load of people who have suicidal thoughts or intentions has little option but to accept that, even with the use of properly accountable practices, eventually one of the people they are aiming to help may succeed in killing themselves. This knowledge creates anxiety in the counsellor and increases the likelihood of burnout. Remember that it is not appropriate to blame yourself for what you are unable to prevent. Protect yourself, as a new counsellor, by ensuring that such people are referred for appropriate professional help. ISOLATION Being isolated and working alone puts a counsellor at increased risk of burnout, because of a lack of peer support during the working day. After all, if we are being drained of our energy, we need to be able to get some back by interacting with others who can meet with us in more equal two-way relationships. PERSONAL STRESS A stressful personal life is almost certain to make a counsellor more susceptible to burnout because of diminished emotional resources. Looking after yourself CHAPTER 42 369COMBATING BURNOUT As stated before, many counsellors are afraid to admit to themselves, let alone to other people, that they are starting to experience burnout symptoms, because they feel that it would be an admission of failure. This is understandable for many reasons. Firstly, most of us have learnt from childhood to appear to be strong enough to cope with our load, whatever that may be. This learning is based on a myth that human beings are inexhaustible, which is obviously not true. Secondly, new counsellors invariably start counselling with very’ high ideals and unrealistically high expectations of what they will be able to achieve. HAVING REALISTIC EXPECTATIONS Our own experiences as counsellors lead us to believe that usually the outcomes of counselling interventions are helpful for the person seeking help. However, there are times when a person does not seem to be helped by the counselling process, and when this does happen it would be easy for us to become disillusioned. At times like this we remind ourselves of the need to look at the overall picture. Outcomes for people who seek counselling help are often different from what the counsellor would prefer, and it is therefore necessary to have realistic expectations in order to avoid disillusionment. The idealism of the new counsellor can easily be eroded and lead to later dissatisfaction if unrealistic expectations are not fulfilled. Giving with no expectation of return, caring for people unconditionally and being dedicated to counselling work are all attitudes that are implicitly absorbed as part of many counsellor training programs. These attitudes conflict strongly with feelings that may be experienced during burnout. It is therefore not surprising that counsellors find it difficult to own burnout feelings. ACCEPTING THAT BURNOUT IS NORMAL It is strongly recommended that counsellor training programs always include education for trainee counsellors about the inevitability of burnout occurring at times, even in the most dedicated counsellor. If counsellors realise that burnout feelings do occur in normal, competent, capable and If we accept that caring counsellors, then they will be able to start accepting their burnout is inevitable we can own burnout feelings and to share those feelings with their peers and deal with it other professionals. appropriately Burnout comes in cycles and it is helpful to expect these cycles to occur. It is healthy to say, ‘Ah-ha, Im starting to recognise some of the symptoms of burnout.’ By making that simple statement, a counsellor is able to admit truthfully what is happening and is then empowered to take the necessary action to deal with the problem. Most counsellors start their job with some feelings of nervousness, but very soon this is followed by enthusiasm and excitement. However, it doesn’t take long for 370 PART 7 Professional issuesother feelings to set in. 1'hese may be feelings of stagnation and apathy, or even of frustration and annovance. In other words, the counsellor’s initial enthusiasm and excitement will, from time to time, be replaced by feelings associated with burnout. In the same way, by using sensible burnout management techniques, the initial enthusiasm about counselling can be re-experienced. ACTIVELY DEALING WITH BURNOUT Quite often people will look for a new job or resign as a result of burnout. That is one way of dealing with it, but it is not necessary to do that if you recognise the symptoms early enough and do something positive to deal with them. Experiencing burnout is not a disaster if it is recognised and dealt with effectively. For a counsellor, dealing with burnout can be compared to a car owner servicing a car. 1 he car needs to be serviced regularly or the car will not function well. Similarly, as a counsellor you need to take steps to continually look after your own needs. If you become aware of burnout feelings, take the appropriate action to recharge yourself, and to regain your enthusiasm and the excitement you experienced at the beginning of your counselling career. This can be done time and again, so you can work as a counsellor for a lifetime if you choose by recharging yourself and starting afresh from time to time. Here are some suggestions for dealing with burnout: 1 Recognise and own the symptoms. 2 Talk with someone about your feelings. 3 Re-schedule your work. 4 Cut down on your workload. 5 Take a holiday. 6 Use relaxation or meditation. 7 Use positive self-talk. 8 Lower your expectations of yourself, the people who seek your help, your colleagues and your employer. 9 Allow yourself to enjoy life and have a sense of humour. 10 Use thought-stopping to stop worrying about the people who seek your help when not at work. 11 Use your religious or other belief system for support. 12 Care for yourself as a person by doing some nice things for yourself. Consider some of these ideas. Firstly, it is interesting to note that simply admitting that you are experiencing burnout will affect your behaviour and enable you to cope better. Talking with your supervisor or someone else may also be helpful, as by doing this you may be able to clarify your options more easily with regard to suitable methods of intervention. It can be helpful to re-schedule your work so that you have a feeling of being in control. You may need to be assertive if your boss doesn't understand your need for a reduced workload. Reducing your workload may not be sufficient initially, and you may need to take a few days off, to have a holiday or to recuperate. Help yourself to Looking after yourself CHAPTER 42 371feel more relaxed, more in control and fitter. Build into your lifestyle proper times for rest, recreation, exercise, lighthearted relief and relaxation. Doing relaxation exercises or meditating can be helpful. Use positive self-talk to replace negative self-statements and challenge the negative self-statements you make Take action to lead about others. This involves changing your expectations of yourself the a balanced life people who seek your help and your peers. A useful way to deal with burnout is to take a less serious view of life, to allow yourself to have a sense of humour and to be less intense in your work. Be carefree and have fun. Most importantly, do not take the problems of the people who seek your help home with you. If you do catch yourself doing this, practise thought­ stopping. The first step in thought-stopping is to recognise that you are thinking about the problems of the people who are seeking your help when you should be relaxing. Then recognise your choice, to continue thinking about these problems or to focus your attention on something in your present environment. This may involve doing something physical or it may involve concentrating on something specific such as listening to music. Focus all your energy and attention on the 'here and now’ to block out the intruding thoughts. Sometimes you may find that the intruding thoughts recur and catch yourself saying, Tf 1 don’t think about this problem now, then 1 will never deal with it and that will be bad for the person who is seeking my help’. If such a thought comes into your mind, write a note in your diary to deal with that issue at a particular time when you are at your place of work, and say to yourself, ‘OK, at 10 o’clock tomorrow morning, at work, 1 will devote half an hour to thinking about that problem, but right now 1 will get on with doing and thinking about things that are pleasant for me.’ Some counsellors find strength in their religious beliefs and gain through prayer and meditation. They find that by doing this they receive an inner strength that enables them to be more effective in their work. Similarly, counsellors with other philosophical belief systems can use their philosophy of life as an aid in combating burnout. If you care for yourself, and take appropriate action to attend to your own needs by leading a less pressured and more balanced life, then your burnout symptoms are likely to fade and you will be able to regain your energy and enthusiasm. However, if you are like most counsellors, you will have an ongoing struggle with burnout which will come and go. T here will always be times when you will give too much of yourself, and then need to redress the balance so that your own needs for recharging are adequately met. GAINING SATISFACTION FROM COUNSELLING If you are proactive in caring for yourself, you will be more able to care for others. You will be likely to get satisfaction from counselling and to enjoy being a counsellor. We hope that you, the reader, will gain as much personal fulfilment from counselling as we have. We wish you all the best tor your work. 372 PART 7 Professional, issuesLearning summary • • • • • Counselling can be emotionally draining for the counsellor. Regular supervision is a good way to avoid burnout as it provides an opportunity for resolution of the counsellor's own issues. Burnout includes the following symptoms: feelings of disillusionment, being emotionally and physically drained, somatic symptoms, and negative attitudes to people seeking counselling help. Burnout comes in cycles, but with self-awareness, reflective practice and adequate supervision recharging can occur. Methods for dealing with burnout include: » recognising the symptoms and talking with someone about them » changing your workload or schedule » taking a break » using relaxation, meditation or positive self-talk » lowering your expectations » taking Life less seriously and having a sense of humour » using thought-stopping » using your religious or other belief system for support. Further reading Skovholt, T,M. & '[’rotter-Mathison, M. 2011, Hie Resilient Practitioner Burnout Prevention and Self-care Strategies for Counsellors, Therapists, Teachers and Plea!th Professionals, 2nd edn, Taylor and Francis Group, New York. S ted mo n, J - &' 1a 11 o s, R. (e ds) 2009, Reflectire Practice in Psychotherapy and Counselling, Open University Press, Berkshire. Wicks, KJ. 2008, The Resilient Clinician, Oxford University Press, New York. Looking after yourself CHAPTER 42 373Glossary ABODE model Underlies REST. An activating event (A) triggers an irrational belief (B) leading to emotional and behavioural consequences (C). Disputing (D) this irrational belief and replacing it with a more constructive belief w ll hopefully, bring the effect (E) of more helpful emotions and behaviours. action plan Steps that can be helpful in supporting a person seeking help to take action to achieve goals. addiction A behaviour that is difficult for a person to stop engaging in, and when the behaviour is ceased results in physical, emotional or psychological consequences that often impact on their ability to lead a satisfying and fulfilling life. alter ego strategy Counselling strategy in which the counsellor takes on the role of the person seeking help and expresses what they feel the person might be thinking and feeling. ambivalence Presence of two opposing ideas, attitudes or emotions within a person that decreases their readiness to change. avatar An electronic character chosen by an individual to represent themselves online. beliefs Those ideas in which we believe or that we accept as truth. biases One-sided or closed-minded approaches, blocks Internal emotional and psychological constraints that prevent the person seeking help from moving forward. 374 boundaries Appropriate limits put in place to ensure the counselling relationship remains professional. burnout A state characterised by feeling emotionally drained and overworked as a result of providing counselling support. career questions Questions that highlight the choices, and consequences of those choices, that a person seeking help has now regarding their future life path. catharsis A healing process of emotional, release. cheerleading questions Questions designed to highlight positive changes in behaviour. choice questions Questions that invite the person to think about and consider alternative choices. Choice Theory Please refer to Reality Therapy. circular questions Questions that explore someone else's feelings, thoughts, beliefs or attitudes, rather than those of the person seeking help. closed questions Questions that lead to a specific answer. Cognitive Behavioural Counselling Approach to counselling with a focus on changing thoughts and behaviours in order to help people to feel better and behave more adaptively. common factors Factors common to all counselling approaches that have a positive influence on the experience of the person seeking counselling and on the effectiveness of counselling.confidentiality Responsibility of the counsellor to keep personal information of the person seeking help private. confrontation A micro-counselling skill used to raise the awareness of the person seeking help by presenting (often unpalatable) information that they are overlooking or failing to identify. congruent Being genuine, integrated and a whole person as a counsellor. constructive belief A belief associated with helpful or adaptive emotions and behaviours, contracting The process of creating a counselling contract. counselling contract An agreement between the counsellor and the person seeking help outlining expectations of counselling such as confidentiality, goals, the counselling process, counselling methods and concerns to be discussed. counselling micro-skills Verbal counselling behaviours that have been found to enhance the effectiveness of the counselling process. counter-transference Process during which the counsellor falls into playing the role in which the person seeking help sees them, for example, feeling and behaving like a father or mother. crisis An event of high risk during which the person's sense of safety is threatened and that may result in physical, emotional or psychological damage. Crises can fall into the categories of natural disaster, accidental, medical, emotional, relationship and developmental. culture Distinct collection of attitudes, customs, beliefs and behaviour of a particular group of people. cyber-culture Cultural context of online settings and how these settings are perceived by computer-users. debriefing The process by which a counsellor releases any distressing emotions or thoughts associated with the counselling process by talking with an experienced colleague or supervisor. defence mechanisms Unconscious mechanisms that provide some protection for a person against current pain but block the person from dealing with underlying causes of distress. dependency When the person seeking help becomes dependent on the counsellor and/or vice versa. depression Feeling sad or low; becomes a serious mental health issue when experienced intensely over an extended period of time. Related symptoms may include loss of interest, lack of energy and sleep difficulties. disinhibition effect The lowering of inhibitions often experienced when engaging with other individuals over the internet linked to an increased sense of anonymity. duty of care Responsibility held by the counsellor to limit the risk of harm towards the person seeking help or others. Glossary 375ego The part of Freud's model, of the human psyche which mediates between the instinctual impulses of the id and the external world through problem-solving. empathic Joining with the person seeking help so that there is a feeling of togetherness, empty chair Approach from Gestalt Therapy in which an empty chair is used to represent someone with whom the person seeking help has an issue with. ethnicity Group of people sharing common cultural characteristics. exception-oriented questions Questions that aim to promote change by drawing attention to times or situations where an undesirable behaviour did not or does riot occur. Existential Humanistic Counselling Approaches to counselling with the underlying bel ef that a person has within them the potential to solve their own problems. The counsellor is a facilitator of change. The person seeking help is the expert. experiential counselling skills Skills, such as role-play, used during counselling that are designed to support the person seeking help to experience their bodily sensations, emotional feelings and thoughts more fully. externalising Counselling skill originating in Narrative Therapy, with the goal of separating the troubling problem from the person seeking help. externalising interview Approach developed by Roth and Epston. in which the problem is 376 Glossary externalised and then role-played by the person seeking help. feedback Respectful reflection on a person's behaviour that is interfering with the counselling process. feeling mode of awareness Experiencing and interpreting the environment through kinaesthetic senses. Also known as kinaesthetic mode of awareness. foundation skills Counselling processes and micro-skills that provide a foundation on which to build more specialised skills. Gestalt awareness circle Gestalt counselling approach that describes how raising a persons awareness can support them in clarifying problems, exploring options and making decisions. Gestalt Therapy Counselling approach developed by Frederick Peris that has the goal of raising a person's awareness by helping them to integrate information from bodily sensations, thoughts and emotional feelings. Emphasis is placed on encouraging a person to take personal responsibility and to stay in the current 'here and now' experience. goal-oriented questions Direct questions that invite exploration of ways in which things could be different and so support the person seeking help to identify changes that they might like to make. grief Response to a loss. guru questions Questions that encourage the person seeking help to give themselves some advice as if they were an expert or guru.guru strategy Counselling strategy where the person seeking help is invited to step into a guru role in order to give themselves advice. hearing mode of awareness Experiencing and interpreting the environment through auditory senses. Also known as auditory mode of awareness. 'here and now' One of the central concepts of Gestalt Therapy in which behaviours, thoughts and feelings in the present are the focus of counselling. iceberg model Model of human personality that illustrates the opposites of an individual's personality and the fact that some aspects of personality can remain hidden 'below the waterline'. id The part of Freud's model of the human psyche which represents a person's instinctual impulses. informed consent Process of obtaining the agreement of the person seeking help to engage in the process of counselling with full knowledge of the advantages and possible consequences of doing so. integrative approach Counselling approach that involves integrating skills from different theoretical and practical sources. internet counselling A counselling relationship taking place over the internet, rather than face to face, and includes contact via email, real­ time chat, video-calling technology or a virtual setting. introjects Values and beliefs which have been accepted and incorporated unquestioningly by an individual usually during childhood. irrational beliefs Unhelpful or self-destructive beliefs associated with uncomfortable emotions and/or maladaptive behaviours. □ohari window Model developed by Luft and Ingham to illustrate the process of self-discovery, joining The process of engaging and connecting with the person seeking help. kinaesthetic mode of awareness Please refer to Feeling mode of awareness. metaphor Describing one thing in terms of something else. Milan Model of Family Therapy Approach to family therapy developed by Mara SeLvini Palazzoli, Luigi Boscolo, Gianfranco Cecchin and Builiana Prata that focuses on the systemic context of the family rather than the behaviour and/ or individual. seen to be the problem. minimal responses Verbal or non-verbal behaviours used to show that the counsellor is listening to the person seeking help and, at times, to communicate a message. miracle questions Questions that support the person seeking help to identify what would be different if their situation changed for the better and so begin to find hypothetical solutions. Motivational Interviewing A counselling approach drawing on principles and strategies from Person- Centred Counselling and Cognitive Behavioural Therapy with the aim of increasing a person's motivation to change. Glossary 377Narrative Therapy Counselling approach developed by David Epston and Michael White that places emphasis on separating the problem from the person. It encourages the person to reconstruct their story so that, the problem does not dominate their life. Neuro-Linguistic Programming Approach to helping people developed by Richard Bandler and John Grinder that recognises the need for a counsellor to match the person's way of experiencing the world through the use of particular senses and the usefulness of reframing. non-verbal behaviour Communication behaviours including facial expressions, body language and gestures that are not speech. normalising Counselling skill that supports the person seeking help to recognise that their emotions, behaviour or experiences are normal and appropriate for the situation or their developmental stage. online counselling Please refer to Internet counselling. open questions Questions that give the person seeking help scope in order to disclose the information that they fee! is relevant, paraphrasing Please refer to Reflection of content, physiological cues Changes in bodily sensations that are linked to changes in emotional feelings. polarities model Model of personality from Gestalt Therapy that emphasises the concurrent existence of polarities in the 'here and now' which are to be fully accepted and integrated so they can be accessed freely as a person chooses. post-traumatic stress Emotional and psychological after-effects that result following a severe crisis. prejudices Preconceived opinions, often negative, without a firm base of reason or experience. primary counselling skills Core counselling skills, including joining, Listening, paraphrasing content and reflection of feeling, which can be useful at any point within a counselling session, privacy Right of the person seeking help to keep their personal information protected, projection Process during which a person projects characteristics of significant others from the past onto people in their current life. personal identity Self-understanding of what makes a person who they are.Provocative Therapy Brief psychotherapy approach developed by Frank FarreLly, which makes use of reverse psychology and humour in order to support the person seeking help to develop insight into their behaviour and make choices about this behaviour. Person-Centred Counselling Approach developed by Carl Rogers, initially called Client-Centred Counselling, during which emphasis isPsychoanalytic Psychotherapy Approach developed by Sigmund Freud during which the counsellor encourages the person to talk freely while they parroting Repeating word for word what a person has said to you. 378 placed on the counselling relationship and on reflecting back to the person what they have said. Glossaryprovide their undivided attention. Emphasis is placed on the person's past and on childhood experiences. The counsellor is seen as the expert who interprets what the person shares, with the goal of helping them to gain insight and; in turn, change. race Group of people sharing similar physical characteristics from a common ancestry. Rational Emotive Behaviour Therapy (REBT) A model of counselling based on Albert Ellis' idea of supporting a client to challenge irrational beliefs and replace them with more constructive beliefs, so as to relieve uncomfortable emotions and/or change maladaptive behaviours. REBT is based on the ABCDE model. readiness to change Measure of a person's level of motivation to change that can be represented by a stage model developed by Prochaska et al. including precontemplation, contemplation, determination, action, maintenance and relapse. Reality Therapy Counselling approach developed by William Glasser, later called Choice Theory, that encourages a person to take responsibility for their behavioural choices and to get their own needs met without infringing on the rights of others, real-time chat A synchronous form of text-based communication available online. reflection of content A counselling micro-skill in which the counsellor paraphrases or reflects back to the person what they have said. reflection of feelings A counselling micro-skill in which the counsellor reflects back the emotional feelings expressed by the person seeking help. reflective practice The process of actively reflecting on the counselling process in order for a counsellor to learn from and improve upon their practice. reframing Counselling skill used to encourage a change in the way a person seeking help perceives events or situations. relaxation techniques Strategies designed to support people to relax, releasing any tension or anxiety. resistance Apparent lack of cooperation with the therapeutic process by the person seeking help. risk factors Factors that increase the risk of suicide. Rogerian counselling skills Counselling skills identified and extensively used by Carl Rogers that provide a foundation onto which other skills can be added. scaling questions Asking the person seeking help to rate a particular concept on a scale, usually from 1 to 10. seeing mode of awareness Experiencing and interpreting the environment through visual senses. Also know as visual mode of awareness. self-destructive beliefs Unhelpful beliefs associated with uncomfortable emotions and/or maladaptive behaviours. self-disclosure Disclosing a limited amount of personal information in order to support the counselling relationship. Glossary 379self-efficacy A persons belief in their own capacity to learn to cope and survive. social system Organisation of the relationships between individuals within various groups. Solution-Focused Therapy Brief counselling approach that focuses on strengths, resources and competencies, rather than on problems, deficits and limitations. Based on ideas proposed by Milton Erickson and further developed by Steve de Shazer. spiritual beliefs Faith in a supernatural dimension and/or power. stages of grief Process of grieving including shock, denial, psychological and somatic symptoms, depression, guilt, anger, idealisation, realism, acceptance, readjustment and personal growth. storying Approach used in narrative therapy in which a new and preferred alternative story is created to replace an existing story in which a problem is influencing a persons life. suicidal thoughts Thoughts about killing oneself. suicide Act of taking one's own life. suicide attempt Attempt to end ones own life that was not successfully completed. summarising Counselling micro-skill during which the counsellor reflects back a summary of the overall content of what the person seeking help has said. 380 Glossary super-ego The part of Freuds model of the human psyche which attempts to control the instinctual impulses of the id, encouraging the ego to fall in line with the values and morals internalised from society. supervision The process during which a counsellor's practice is supervised. supervisor Counsellor who provides supervision. telephone counselling A counselling relationship taking place over the telephone, rather than face to face. termination The process of bringing a counselling session or the counselling relationship to an end. therapeutic alliance A collaborative working relationship developed between the counsellor and the person seeking help that recognises the persons ability to self-heal and bring about change. thought-stopping Strategy in which a person silently says 'STOP' to themselves in order to interrupt unwanted thoughts. transference Process during which the person seeking help behaves towards a counsellor as though the counsellor were a significant person from their past, usually the person's mother or father. transitional question A question that returns the focus of the conversation to an earlier part of the discussion.unconditional positive regard Accepting the person seeking help non- judgementally as someone of value, regardless of strengths and weaknesses,counsellor, events leading up to and following the verbatim section and the counsellor's reflection on what they Learned. values Personally held principles that determine what an individual defines as important and which guide decision-making and behaviour.video conferencing A synchronous video messaging service available online. verbatim report Written report that records what was said word for word during a counselling session. The report can also include background information, feelings of the virtual setting An electronic environment available online in which individuals, represented by avatars, meet. Communication between avatars can be via text or microphone. Glossary 381Index ABCDE model 166 abilities 85 Aboriginal people 330-3, 335-7 abuse 272-3 see also violence accidental crises 259 accreditation 348 acronyms 312-13 action (readiness to change stage)

141. 202-10, 232, 234, 250 active listening 138-9 see also listening activity 250 see also action (readiness to change stage) adaptive change 291 addiction 230-5 advertising (service) 347 advice giving 8, 263 age 270 agencies 230, 235, 268 aggression 321 see also anger agreement, expressing 37- 8 alter ego strategy 215 ambivalence 231, 275, 276-7 anger 56, 278, 296, 333 anger control flow chart 240 anger control problems 174 blocked anger 152, 246-7 bottled-up 237 dissipating 237-8 expressing verba.ly 237-8 externalising 244 versus frustration 247 as grief reaction/stage 255 -6 persons troubled by 237-44 physical distance from 241 repressed 186 statements comparison 243 suppressing 246 use of the empty chair 237-8,246 warning! 238 annoyance 296, 298 anonymity 294, 315 anxiety 55, 84, 146-7,152,161, 196. 261, 273, 320 about time constraints 92 anxious person versus person troubled by 174 increases with exercise 219 reframinc as blocked excitement 192 see also stress appointments, ongoing 93-4,158, 325-6 arguments (avoiding) 235 assertiveness 93. 240, 242 3, 243, 298 Association for Counselling and Therapy Online 315 assumptions 114, 327 attentiveness (of counsellor) 16-17 attitudes 110, 137,167, 327, 355 of extended families 331 negative 359 opposing 231 opposites in 187 382 audio- or DVD recording and analysis 353 Australian Counsellors Association (ACA) 29, 348 Australian Psychological Society (APS) 314 avatars 307, 313 awareness 162, 164- 5 awareness circle see Gestalt awareness circle of cultural differences 327 heightening 73- 4 modes of 84-5 Sandier, Richard 113 behaviour addictive see addiction annoying 153 attention-seeking 191 behavioural exceptions 115 consequences 114 counsellor behav our 235 emphasis on 141, 202, 248, 314 facilitating change 130 finalising affairs/giving away possessions 272 helping oeople to change 113, 130, 238-44 inappropriate 300-1 maladaptive 153,166 neurotic 112 normalising changes in 147-9 opposites in 187 repetitive 164 self-harming see selCharmmg behaviour skills addressing 290-1 unacceptable 174 unconscious processes origins 110 unhelpful 202 see also unethical behaviour beliefs 28, 76,110, 137, 168-9 awareness of 327 challenging 241-2 constructive 166 dealistic 339 involving unrealistic expectations 169-72 irrational 114, 166, 240 opposites in 187 religious 256, 287, 372 self-destructive 128- 9, 166 -72, 241-2, 340 suspension of 333 that don't fit 169 what ’fits’and what doesn't 168- 9 biases 327, 344 bibliotherapy 305 blocked anger 246-7 blocks 198,204-6 bodily sensations 85,112,211 12,217 body language 336 body posture 37. 40 boundaries 315- 16 of counselling relationships 341, 343-4 preserving identity 343-4, 350-1 setting 95, 294-5 burnout 91-2, 297, 314 acceptance of normality of 370 1 actively dealing with 371-2 combating 370-2 factors leading to 369 inventory 360-6 major cause 359 personal consequences 359 protecting oneself from 367-9 symptoms 358-9, 370 calmness 127, 263, 272 care, need for 147 career questions 75 catharsis 52, 56, 215, 291 change additional skills for promoting 146- 59,161-82,184 -200, 202-22 afso under individual skill being positive about changes 181-2 combining skills to facilitate 134-42 crises as opportunities for 261 developmental life changes 3 expectations of 118 facilitating 2, 126-30 helping people to change 113, 125-6, 167, 238-44 integrative approach 124-32 in lifestyle or routine 273 long-term change 8 motivation for 230-1 normalising behavioural changes 147- 9 promoting 108-15, 118 -32, 134-42’" readiness to 231 3 short term change, dangers of 9 through open exploration 20 cheerleading questions 182 childhood beliefs 168-9 experiences 110 child rearing practices 331 children 20. 109, 148, 168,185-6, 238, 252, 296, 307 Chinese people 309, 334 choice questions 74-5 Choice Theory 74, 114 choices 167 decision making - making a choice 197-9 positive 242 responsibility for 114 'right' choice myth 199 see also decision- making choosing (making choices) 197-9 chronic depression 247-51, 291, 299 circular questions 75 -6 clarification 203 counsellor's role clarification 138 of problems 140 of values 22 via questions 73 closed questions 69, 71, 78 closed-circuit TV 352-3 closure 141-2 dependency issues 94 6, 350-1 of internet counselling 314 of a session 91-3, 314, 350-1 of telephone counselling call 301-4 seea/so termination of counsellingclues 85, 284 codes of ethical conduct 342-3 Cognitive Behavioural Counsellina 28-9, 52, 65. 113-14, 230 cognitive change 128-30 collaboration 118 -23, 341 see also therapeutic alliance colleagues 286-7, 341 comfort 39, 91-3, 301 4. 318 common factors 119-21 communication 16-17, 289 90 community 329, 330, 333, 345 competence 257, 292 3, 345-6 counselling thrust 115 compromising the counseling process 67-8 computer literacy 309 computerised records 340 conferences 306, 307, 341-2 confidence 9 confidentiality 163, 318, 320-1, 322, 326, 339- 42 limits to 339 online 315 preserving 356 conflict 21-2, 234, 345 confrontation 112,161-5, 300, 314 confronting dependency 96 direct 291 effective 162-5 examples 163-5 self-examination prior to 162 when to use 162-5 confusion 19, 80. 112, 199 congruence 13-14 constructive beliefs 166 contact, maintaining 265 contemplation (readiness to change stage) 232-3 continuity of contact 265 contracts/contracting 9-10, 94, 278, 311-12, 325, 335 control anger control 174, 240 of conversation 68 'out of control' feelings 56 over events 150-1 process control 291, 303-4, 307 when ending sessions 93 conversation 46, 67-8, 74, 211, 336 counselling approaches 125 -6. 130 see also integrative counselling approach boundaries and limits 343-4, 350-1 confrontation in 161-2 date of session 323 definition 2-10 effectiveness of 7,118-21, 314 ending sessions 91-3 environment for 237, 318 -21 external review 350 as facilitator of self-change 125 gaining satisfaction from- 372 iceberg model, usefulness in 186 individual 91-3, 319 integrative approaches 12-17,65, 108-15,124-32 internet counselling 305-16 lengthy methods 111 models 28-9, 124 natural skills for 29 people from other cultures 334- 7 positive outcomes 118, 243 practice sessions, length of 32 purpose and goals 7,11-17, 96. 248-9, 297, 299, 311-12, 324 reasons for use 188 record keeping 322-6 resources 314-15 skills-models match 29 techniques/strategies 130, 273, 275-8, 334-7, 371 technology and 284-304, 305-16 by telephone see telephone counselling theory and practice 108 15 counselling contract see contracts/ contracting counselling process 253 compromising process 67 8 dependency on 95 normal process use for depression 245 notes 324 process control 291, 303-4, 307 relationships as central to process 3-4 review of 350 stages 135, 136-42, 248 counselling relationship see counsellor-help seeker relationship counselling rooms 30, 318 -21, 351-2 Counselling Skills in Everyday Life 2, 146 counsellor behaviour 235 counsellor burnout see burnout counsellor expertise 315 counsellor help seeker relationship 3-6 case note-taking 91-2 contracting in 9-10 dependency issues 94 6, 350-1 desirable qualities 11-12 ending session series 96-7 focusing on 63 importance of 17 ongoing appointments 93-4, 325 qualities 119 warning of session ending 92-3 counsellors approaches 335 being integrative see integrative counselling approach collaboration with other professionals 341 competence 257, 292-3, 345-6 counselling relationships 3-6, 11-17 dependency issues 95, 350-1 desirable qualities 12-17,119 duty of care 266 effective 28, 30-1 expectations/agenda 136-7 goals 8. 311-12 individuality of 47, 85, 318 initials/signature 325-6 internet counselling, suitabi.ity of 308-10 limitations 235, 278 9, 337 looking after oneself 139, 358-72 measuring burnout score 359-66 obligations (legal) 346 own cultural backgrounds 335 own experiences 136-7 own feelings 137, 275, 325, 355 own needs 68. 267, 344 own croblcms 285-7 own supervision, requirements 340 personal growth and development 341-2, 348-56 personal issues 343, 346, 348-9 personal qualities 309, 318 perspective of 7, 8-9 protecting others 340 reasons for becoming 6-7 registration of 348 responsibilities 340, 345 roles 138, 212-13 safety of 321 self disclosure, restricting 253 self-promotion 347 specific instructions during crisis intervention 266 telephone counsellors (TCs) 4. 284-304 temptation - encourage, persuade or push 202, 205-6 see also blocks training 341-2, 345-6, 348-56 uniqueness of 84-5 values, influence of 19 -22 vulnerability of 321, 344 wellbeing 340, 358 work between sessions 91-2 work enhancement frameworks 350 see also counsellor-help seeker relationship counter transference 110, 156 creativity 199 crises 95, 295, 315 after-effects see post- traumatic stress counselling interventions 263-4 counsellor's personal response 262-3 dangers and value of 261-2 developmental crises 147-9, 260-1 differing views 258 emotional/physical crises 2-3 as opportunities for change 261 practical solutions 264-6 types of 258-61 crisis intervention 258-67, 295 crying 52, 53. 55. 73-4, 127, 139, 257, 320 cues 57, 239 culture/cultural considerations ctying 53 cultural differences, difficulties 328 cultural factors 328 34 cyber-cultures 309 issues 327-37 curiosity 68, 73 cyber-cultures 309 cynicism 359 danger 8 -9. 222, 244, 261-2 de Shazer, Steve 115 Index 383death 252, 254-5 see also dying debriefing 251, 267, 295, 314, 348, 368 need for 91-2 decision making 8-9, 216-17, 345 blocks 198 deciding when to end a call 301 exploring options 197 finding options 196-7 giv ng permission to stay stuck " 196, 200 making a choice 197-9 methods 330 referral decisions 346 regarding anger 241 see also choices: choosing imak ng choices) deep breathing 239 defence mechanisms 110 defensiveness 154,161, 234 demographic information about persons seeking help 322 denial (grief stage) 254-5 dependency issues 94-6,350-1 depression 152,186,196, 272, 291 as blocked anger 246-7, 278 deep or prolonged 245, 278 exceptions 250 people who suffer from chronic depression 247-51 persons troubled by 245-51 reasons for 245 specialist treatment for 245 use of activity 250 determination (readiness to change stage) 232, 234 developmental crises 147-9, 260-1 developmental life change, stress due to 3 developmental stages 147- 8 dialogue 214 16 dilemma 141,197 creative solutions for 199 ethical issues regarding confidentiality 339 model 205 records of 323-4 resolution of 199 staying stuck 196, 200 direct observation 351 3 disagreement, expressing 37-8 disappointment 260 disclosure (of information) 3-4, 66, 138, 320 judgements regarding 341 legal requirements 342 material interpretation 111 permission for 341 restricting counsellor self­ disclosure 253 to supervisors 340 see also self-disclosure discrepancy 235 discussion 68,140, 150,156 see also conversation; talking disillusionment 297, 359 disinhibition effect 312 distress 3,110,126-7,196, 289, 295, 349, 367 documentation 322-6 duty of care 266, 268-9, 272 384 Index DVD recording see audio or DVD recording and analysis dying 254-5 see also death dynamic counselling experience 92 dysfunct onal relationships 252, 260 educational training programs 341-2 ego 110, 215 Ellis, Albert 114, 128-9, 166 emails 305, 306, 307 embarrassment 320 emergencies, response to 264-5 emoticons 312-13 emotional burn out symptoms 358-9 Emotional Expression in Psychotherapy 128 emotions 36, 39, 110, 328, 355 arising from nuisance calls 296 'coding down' 241 dealing with 'here and now' 292 emotional change 126-8 emotional crises 2-3, 260 emotional draining 113, 295, 358, 368 emotional issues 333-4 emotional sain 29, 249-50, 303, 349, 367-8 emotiona. pressure 52, 56 emphasis on 139-40, 202, 312-13 expressing 257, 312 13 grief symptoms 255 links with smell, taste and touch 84 negative 185-6 normalising emotional states 147 opposing 231 range of 186 strong 51 see also feelings; iceberg model empathy 14 15, 38, 40, 47, 139, 235, 367 employ:ng body, responsibility to 345 empowerment 187, 293 empty chair, use of 237 8, 246 energy mobilisation 204 Epston, David 114-15, 173, 175 equality 350 equipment for counselling 320 Erickson, Milton 115 ethical behaviour see codes of ethical conduct ethics/ethical perspectives 333, 339-47 ethical issues of suicide 268-9 of internet counselling 314-16 see also confidentiality; legal considerations ethrfeity 270, 327, 328, 335 euthanasia 272 exception-oriented questions 178-80 excuses 68 exercise 214-17, 219-22, 241, 287 existentialist (humanistic) counseling 111-13 expectations 9-10, 118, 169-72, 265, 295, 370 experiences 333 'Ah- ha' experiences see Gestalt Therapy counsellor's own experiences 136-7 differences in 84 -9 dynamic counselling experience 92 expectations/agenda differences 136-7 identifying positive responses to negative experiences 180-1 past and childhood 110 somatic 85, 202 of trauma 334 experiential counselling skills 127, 211- 17 experiential gmuawork 348 experiential learning 28 experiments (experiential exercises) 212- 17 expletives 89 exploration 129-2, 157, 179, 197, 277 externalising 129, 173-7, 244, 248 externalising interviews 175-7 eye contact 40, 313, 336 eyestrain 320 face-to-face counselling 4, 284 5, 318 chair arrangement 30 versus telephone counselling 263, 284-5, 289-92, 294, 303 versus telephone counselling and internet 305, 308-9 facial expressions 37, 39 failure, feelings of 193, 359 families 271, 331, 341 therapy for see Milan Model of Family Therapy family therapy 235, 341, 352 feedback 93,152 5, 213, 235, 352 appropnate/inappropr ate statements 155, 159 giving 153-4 positive 302-3 via transitional questions 74 feeling (kinaesthetic) mode of awareness 84, 86 feelings 31-2, 36, 76, 217 avoiding 51-2 of being 'stuck' 196, 200, 202, 206, 217 counsellor's own feelings 137, 325, 355 emoticons and acronyms 312-13 experiencing 52 expressing 163-4 'gut' feelings 51, 197, 290 of hopelessness and helplessness 247-8, 254, 358 'I feci...' statements see T' or i feelstatements negative 152 ’normal'feelings of grief 253 opposites in 184-5, 187 potential misunderstandings 307 reflection of 51-8, 59-64 responses to reflection 55-6 of self-worth 343 suppressed 112 words expressing 53, 54-5 see also emotions; reflection of content/feelings; somatic experiencesfirst meeting 34 'meeting' callers 288 'fishing' skills 285 flexibility 309 forgiveness 186 foundation skills 28-33 also under individual skills 'free association' 110 Freud, Sigmund 109-11 friendship 185, 351 frustration 11,2, 246-7, 296, 298 versus anger 247 Geldard, David 2, 5 Geldard, Kathryn 2, 5 gender/gender roles 270, 328, 330, 331-2 genograms 293-4 Gestalt awareness circle 202-6 Gestalt Therapy 28-9, 112-13, 127, 202 awareness circle 202-6 emotional arousal 231 exploring polarities 129, 184-8 guru questions 75 heightening awareness 73-4 'here and now' experience 112, 128 9, 140,150-9, 292 introjects 20 use of the empty chair 237-8, 246 Glasse, William. 114 goal-oriented questions 76-7 see also scaling questions goals 207-9 see also counselling: purpose and goals grief helping people with grief 252-3 maladaptive 257 persons troubled by 96-7, 252-7 stages of 253-6 Grinder, John 113 ground rules 311-12 grounding 367 group counselling 305 groupwork 348 see also support groups guilt (grief stage) 255 guru questions 75 guru strategy 217 handwritten records/notes 322-3 hang ups (telephone counselling) 289 hearing 38 hearing mode 85-6 helping people to change 7,113, 125-6, 130, 167, 238-44 to focus on present 151-2 with grief 252-3 to integrate polarities 188 using verbal, non-verbal and relationship skills 2 'here and now' experience 112, 128-9,140, 150-9, 213, 292 hoax callers 296 hope 120-1 hostility 185 humanistic counselling 111-13 humour, sense of 17, 372 'I ‘ or 'I feel...' statements 112, 154- 5, 209, 242 iceberg model 184-6 id 110 idealisation (grief stage) 256 ideas 110, 231 preconceived 137 see also 'free association' identifiers 322 identity 311 cultural issues with 328 personal identity 328, 343-4 illness people troubled by 3, 272 psychiatric 272 as reason for depression 245 imaginary space-bubble 367-8 imagination 71, 294 use of the empty chair 237-8, 246 immediacy 48,152,156,158 inappropriate responses, use of 47 8 individuality 47, 297 individual differences 85 issues 329 inequality 319 questions creating 66-7 'inevitability' 148 information 355 demographic information 322 factual information 323 gained prior to counselling 137 gathering 311-12 known and unknown see Johari window iack during telephone counselling 284 personal information 3-4, 315, 320 question and answer styie of gathering 337 sensitive and private 66, 95 withholding 342 see also disclosure (of information) information seeking 72-3 informed consent 315, 341, 352 initial contact see first meeting insight 131-2, 368 integrative counselling approach 108-15, 124-32, 196, 202 challenging self destructive beliefs 166-8 desirable counsellor qualities 12-17 integration of polarities 188 questions in 65 reasons for use 124-5 interaction 351 international Society for Mental Health Online 315 internet (online) counselling 305-16 interpreters 336-7 interrogation 66, 77,158, 167 intervention 235, 268 -9, 279, 324, 370 crisis intervention 258-67, 295 legal intervention 342 practical intervention 265-6 interviews 314 externalising interviews 175-7 intimidation 336 introjects 20 intrusiveness 66, 137, 288, 320 invitations to continue 38, 93 to experiment partici pat on 212 for friendship and closeness 351 to talk 35-6, 72 irrationality 114, 240 irrational beliefs 166 isolation 271, 369 Johan window 130-2 influence of counselling on 131—2 joining 72, 266, 311 12 counselling stage 137-8 listening and 34-41 kinaesthetic mode of awareness 84, 86 language 173 anxious person versus person troubled by anxiety 174 matching 84-9 translation issues and 336 7 use of 173-4, 332 lead in words 62 -3 learning processes 28, 30-2, 33 didactic learning 350 legal considerations 326, 335 counsellor obligations 346 legal requirements 315, 342 regarding suicide 268 listening 8, 66, 68, 203, 266, 289- 90, 301, 312, 337 actively see active listening with interest 36-41 joining and 34-41 loss 273 of counselling relationship 96-7 of energy 92 people troubled by 3 persons troubled by 252-7 types of 252 see also grief lost relationships 247, 252, 260 love hate opposites 184' 5 maintenance (readiness to change stage) 232, 234 maladaptive behaviour 153,166 maladaptive grief 257 mandatory reporting 342, 346 Maori people 334 matching language and metaphor 84-9 non-verbal behaviour 38-9 persons seeking help 86-7 meaningful relationships 252 medical crises 259 meditation 287, 372 messages 37-8,40,284 metaphor 314 'bundle' metaphor 141 for counselling 14-15 'doorway' metaphor for crises 261-2 extending 88 illustrating personality opposites see iceberg model matching 87-8 'peeling the onion' see 'peeling the onion' metaphor Index 385rrdcro-skiUs 28-33,120, 264, 289-90, 308-9, 311, 315, 337 for grieving people 253 for people considering suicide 275 Mi i lan Model of Family 'I herapy 75-6 minimal responses 31, 37-8, 44-6, 138, 290 miracle questions 76 misunderstandings 307, 312 modelling 32-3, 152 appropriate behaviour 89, 343 mood 355 moral values 343 motivation 249-50 for change 230-1 recognising 231 reduction of see ambivalence Miotivat onal Interviewing 314 versus counselling strategies 233 goals 230-3 process 233-4 see also addiction movement 37, 39 Narrative Therapy 28 -9. 122,129, 173, 314 the problem is the problem., not themselves 114-15 questions in 65 natural counselling skills 29 natural disasters 259 natural helpers 330 needs 68, 267, 291-2, 298, 320-1, 344, 346 negativity 120, 234, 359 denying negative emotions 185-6 negative feelings 152 posit ve responses to negative experiences 180-1 see also positivity negotiation 252, 335 Neuro Linguistic Programming (NLP) 84, 89, 113, 129 non judgemental approach 15-16, 19-21 non-verbal behaviour 32, 35, 37, 151, 213, 335, 353 matching 38-9, 89 non-verbal messages 284, 290 normalising 129, 146-9, 264 norms 331-2, 336, 337 note-taking 323 -6 during telephone counselling 293-4 see also re cords/re core keeping nuisance callers 296-7 objectivity 243, 352 observation 32, 213 with audio- or DVD-recording and analysis 353 in counselling rooms 351 direct observation 351-3 during first meeting 34-5 learning through 32-3 through a one-way mirror 352 using closed circuit TV 352- 3 office equipment 320 one-way mirrors 352 Online Therapy Institute 315 386 Index open questions 70-1, 78 optimism 120-1, 182 options (in decision making) 196-7 organic reasons (for depression) 245 'out there' discussion/answers 68, 140,150 outcomes (counselling) 370 common factors for positive outcomes 119-21 notes 324 positive 118,121, 243 over-involve me nt 369 pa n 292-3 defence mechanisms 110 devaluing 149 emotiona. pain 29, 249-50, 303, 349, 367-8 panic 263 paradoxical intent 75 paraphrasing see reflection of content/feelings parents 148, 185-6, 260 see also child rearing practices parroting 48 'peeling the onion' metaphor 3, 4 perceptions 328-34 of self 138,173-4 of time 332 see also reframing Peris, Frederick (Fritz) 112-13, 211 see also Gestalt Therapy permission 53, 55, 341, 351 see also informed consent personal growth (grief stage) 256 personal information 3-4, 315, 320 personal needs 291-2 personal problems 30-1 personal responsibility 150 personal space 39 personal stress 369 personal therapy 348 personality, human 109 10,18-1 see also polarities, exploring Person-Centred Counselling 11, 28-9, 67, .111-12, 122,127, 230 persons seeking help competence of 122-3 empathy and 367 expectations of crisis intervention 265 expectations/agenda 136-7 factual information given 323 giving time to think 44 greeting 34 helping to focus on present 151-2 identifying 322 internet counselling, suitability of 308-10 inviting to participation in experiment 212 inviting to talk 35--6, 72 matching 86-7 meeting needs 346 observing (during first meeting) 34-5 pace of 140 personal factors 120 as persons of equal value 350 persons with suicidal intentions 340 perspective of 7- 8 putting at ease 34-5, 318 20 reasons for seeking counselling 2-3 respect for under respect rights to records 326 'shopping list' 138 telephone caller's perspective 287 trust in counsellors 119-20 wellbeing 344 see also counsellor-help seeker relationship perspective (of callers) 287 phone counselling see telephone counselling physical burnout symptoms 358-9 physical closeness 39, 351 see also personal space physical exerc.se see exercise physical grief symptoms 255 physical issues 333-4 physical space 336 see also personal space polarities, exploring 129, 184-8, 216, 277 acceptance of polarities witnin self 187-8 as a continuum 187 effect of polarities 199 helping people to integrate polarities 188 polarities model 186-8 positive feedback 302-3 positivity 242 being positive about changes 181-2 positive responses to negative experiences 180-1 statements comparison 243 unconditional positive regard 15-16 see also negativity post-traumatic stress 266-7 posture, mirroring 38-9 power imbalances 67 practice, reflective 368-9 practice counselling sessions 32 prank' callers 288 prayer 287, 372 preconceptions 137 precontemplation (readiness to change stage) 232- 3 prejudices, awareness of 327, 328 preparation counselling stage 136-7 for internet counselling 311 psychological 207 for telephone counselling 285-7 presenting issues 309- 10 pressure/pressuring 141, 196 primary counselling skills 134 centrality to counselling process 136 privacy 4, 315, 318, 320-1, 342 see also confidentiality problem callers 295-301 problem, solving 111, 249-50 approaches 130 responsibility for 196 short-term 8 solving caller's problems 292 3problems arising from developmental crises 146-9 clarification 140 devaluing 149 externalising 173-5 financial problems 273 how it has troubled the person 176-7 name of problems as statement beginners 174-6 own problems, influence when telephone counselling 285-6 particular problems, dealing with 177, 230-5. 237-79 problem- free times 178-9 relationship problems 272- 3 'shopping list' 138 storying 114-15 using genuine problems 30-1 professional ethics see ethics/ ethical perspectives professional issues 318-37. 339-56, 358-72 projection 156-7 protagonists 214 15 Provocative Therapy 75 psychoanalytic method, criticisms 110-11 Psychoanalytic Psychotherapy 109-11 psychoeducation 305 psychological cues 239 psychological grief symptoms 255 Psychotherapy and Counselling Federation of Australia (PACFA) 29, 348 questions 137-8, 213 to ask prior to internet counselling 310 cheerleading 182 direct questioning 311, 337 exception oriented 178-80 for externalising interviews - problem extent 176-7 dentifying irrat ona. beliefs 114 silence and 337 for specific purposes 72-7 use and abuse of 65-78 race 328 rapport 14-15, 335 Rational Emotive Behav.our Therapy (REBT) 114, 128-9, 314 ABCDE model 166 questions in 65 rationalisation 68, 157 readiness to change 231-3 readjustment (grief stage) 256 Reality Therapy see Choice Theory real time chat 306, 307 recharging 368 records/record keeping audio- or DVD-recording and analysis 353 confidential records, access to 340 of counselling sessions 322-6 details of problems, issues, dilemma 323-4 legal aspects 326 need for 340 see also reporting/report writing referrals 314 versus dealing with 'here and now' 292 ethical issues 346 people who need 247 reflection of content/feelings 31. 42-9, 51-64, 78, 80, 111, 138, 165, 247-8, 311-12 counsellor responses 64 minimal responses use with see minimal responses versus parroting 48 prefacing reflection statements 62-3 ' reflective listening 66, 68 reflective practice 368 9 reframing 129, 189-95 registration (of counsellors) 315, 348 regular (frequent) callers 297-9 relapse (readiness to change stage) 232-3, 234 relationships absent 260 building 111, 115, 284-5 counselling relationships 3-6. 11-17,108,119, 343-4, 350-1 dependency on 94-5 issues related to 252, 329 loss of 96-7, 247 normalising changes in 147-9 one-way versus two way 369 personal 359 person to-person 11, 67, 324, 334, 343-4 relationship crises 260 safe and trusting 211, 249-50, 264, 288, 318, 327, 337 unsatisfactory/lost 3 see also counsellor-help seeker relationship relaxat on 239, 287, 367-8 exercise for 219-22, 241 facilitating 219-22 reporting/report writing 322- 6 mandatory reporting 342, 346 verbatim reports 353-6 see also records/record keeping repressed anger 186 research 118-19, 124-5 resistance 110, 202 dealing with 158 examp/e 157-8 rolling with 235 resolution 82, 91 resources 115, 314-15 inner resources 122 respect 4, 122. 161, 329, 333, 342 for all callers 288 lack of 300 for person's pace 140 for person's process 141-2 for persons seek ng help 122-3, 140, 343 restructuring (thoughts) 140-1 review (counselling process) 350 rights to privacy 342 to records 326 risk 256, 260-1 suicide risk assessment 270-4 Rogers, Carl counselling practice research 118-19 counselling skills (Rogerian) 59, 84, 112 Person-Centred Counselling see Person'Centred Counselling role-playing 31,112-13,175-7, 209, 211, 214-15, 244 roles, normalising changes in 147-9 safety issues 56, 321 see also emergencies, response to scaling questions 77 seeing mode 85-6 self dialoguing between parts of 216 polarities within 187-8 self-destructive beliefs (SDBs) 241-2 alternatives 171 challenging 128-9,166-72 persons with suicidal intentions see suicide/suicidal intent ons statements comparison 276 self-disclosure 3-4, 14, 31 self-discovery 130-2 see also Johari window self-efficacy 235 self-esteem 93, 122, 359 self-examination 162 self-harming behaviour 142, 340 self-help 305 self-promotion 347 self-reliance 8, 9 self-sufficiency 95. Ill self-talk 85,241,372 self-worth 343 seminars 341-2 sensitivity 14-15, 96, 122,140 separation 252 sequential learning 33 service(s) advertising 347 inappropriate use of 296 sessions see counselling sex callers 300-1 shaking hands 336 shock (grief stage) 254 short responses 62 'should', 'must', 'ought' and 'have to' beliefs 168-9 sickness 245 silence, use of 41, 290, 337 skills additional skills for promoting change 146-59,161-82, 184-200, 202- 22 also under individual skill addressing thoughts and behaviours 290-1 comb ning to facilitate change 134-42 computer literacy 309 dunng confrontation 96 for experiments 213 facilitating change 2 foundation skills 28-33 micro-skills see micro-skills relevance to counselling process stages 136 Index 387Rogerian skills 59. 8-4 skills models match 29 solution-focused 293 for telephone counselling 285 upgrading 349-50 see also micro-skills social norms 40 social system 331 socioeconomic status 328 Solution Focused Counselling 122, 128, 173. 196. 291, 314 goal-oriented questions in 76 7 questions in 65, 76-7 skills 178-82 solutions, resources and competency thrust 115 somatic experiences 85, 202, 211-12, 217 specificity 73 speech recognition software 322 spincuality 333 stereotyping 186, 335 storying 114-15 strategies, counselling 233, 334-7, 371 different strategies for different, purposes 130 strengths 128, 173, 180, 182 stress 91 2,152, 295, 369 due to life changes 3, 261 from internal conflict 328 of interpersonal counsell ng relationship 359 post traumatic stress 266-7 see also anxiety structured programs 305 suicide/suicidal intentions 340 bringing thoughts into open 275 direct approach 277 persons with su cidal intenlons 268-79, 369 reasons for contemplating 269-70 responding to 268-79 risk factors 270-4 suicide plans and methods 271 triggers - today 278 summarising 80-2, 93, 141, 197, 219, 302-3, 355 super-ego 110 Super- TC [fairy story) 292-3 supervision 340 audio- or DVD-recording and analysis 353 methods 351-6 need for 21-2, 348 51 providing support 358 trainee participation 351 verbatim reports 353-6 supervisors 339 40, 345-6 direct observation 351 experienced 350 perceptive 349 talking through own problems with 286 support groups 235, 305 see also groupwork suppressing 141, 152-3, 186 talking 35 -6. 72, 85,110, 250-1, 368, 372 388 Index technology, counselling and 284- 304, 305-16 telephone counselling 4, 284-304 advantages 294 being prepared for 285-7 boundary setting 294-5 caller expectat ons 265 comfortable closure 301-4 debriefing 295 versus face-tc face 263, 284-5, 289-92, 294, 303 versus face-tc face and internet 305, 308-9 first critical few minutes 285 'fishing' skills 285 hang-ups 289 initial contact and continuing the call 288 macro view of 135, 290 personal response crises 262-3 problem callers 295 -301 skills required 289-94 staying focused 289 tension 39, 196, 219 terminating a session see closure termination of counselling 93,96,
142. 346, 350-1 therapeutic alliance 121-3 thinking 76, 313 cognitive chanqe facilitation 128-30 different ways of 85-6 logical 197 potential misunderstandings 307 processes 113 rational 272 skills addressing 290-1 thought(s) 110, 167, 217 emphasis on 140-1, 202, 248, 314 feeling-thoughts, distinction 51 helping people to change 113, 238-44 implied thoughts 337 restructuring 140-1 'STOP!' 239-40 suicidal thoughts 268, 270 thought-stopping 239, 372 see also Cognitive Behavioural Counselling: thinking time out 239-40 time/timing issues inappropriate timing for telephone counselling 288 perceptions of time 332 time, constraints on 92. 250 -1 time limits for regular callers 298 time to think 44 tiredness 358 -9 touch/touching 84 unwelcome 344 training 341-2, 345-6, 348-56 see also accreditation transcripts 81-2, 353-5 transference 110, 156 transitional questions 74 trauma 3, 273, 334, 368 post-traumatic stress 266-7 triads, learning in 30-2 trust 31, 63. 119-20, 211, -264, 288, 327, 330, 335, 344 tuning in 36 unconditional positive regard 15-16 'unconscious' 110 understanding 38, 288 depression in terms of blocked anger 246-7 unethical behaviour 147, 253, 295, 339, 342 see also dilemma: ethics/ethical perspectives 'unfinished business' 112 uniqueness 84-5, 329 unrealistic expectations 169-72 'life is fair and just' 170 values 272 awareness of 327 counsellor's values, influence of 19-22 moral values 343 owning own value system 21 valuing (the person) 21, 38 verbal behaviour 89, 32, 335 verbal cues 307-8, 311-12 verbalisation 157,159, 170 verbatim reports 353-6 video conferencing 306, 307 video recordings 157 8, 244 violence 237-8, 260 see also abuse: anger virtual settings 306,307 visual contact, advantages 284 visual cues 307-8, 311-12 visual imagery 85 voice 37, 40, 288, 290, 313 vulnerability 31. 294. 321, 344 wariness 288 warmth 14-15,94 249 50,288,318 see also empathy: rapport warnings 92-3, 149, 222, 238. 270, 302 weeping see crying wellbeing 279, 340, 344, 358 White, Michael 114-15 Maps of Narrative Practice 173 whiteboards 320 'why' questions 68 words choices 288-9, 312 'feeling' words 53, 54-5 lead in 62-3 liste n i n g ca reful ly to 289 pace 313 word based therapies 314 working collaboratively 118-23 Gestalt therapist versus integrative counsellors 203 between sessions 91-2 workshops 341-2, 348 written consent 342, 353 see also informed consent 'yes/no' answers 69 Yin Foo. Rebecca 2, 5-6 'you' statements 155