MAP605_Advanced Counselling Skills I

Process Counseling 45 3.9 References 1. Kramer, Geoffrey P., Douglas A. Bernstein, and Vicky Phares. Introduction to Clinical Psychology. 7th edition. Upper Saddle River, NJ: Pearson Prentice Hall, 2009. 117-118. 2. ^Kramer, Geoffrey P., Douglas A. Bernstein, and Vicky Phares. Introduction to Clinical Psychology. 7th edition. Upper Saddle River, NJ: Pearson Prentice Hall, 2009. 117-118. 3. ^ Kramer, Geoffrey P., Douglas A. Bernstein, and Vicky Phares. Introduction to Clinical Psychology. 7th edition. Upper Saddle River, NJ: Pearson Prentice Hall, 2009. 117-118. 4. ^ Hilsenroth MJ and Cromer TD (2007). Clinical interventions related to alliance during the initial interview and psychological assessment. Psychotherapy: Theory, Research, Practice, Training, 44, 205-218. 5. ^ Kokotovic AM and Tracey TT (1987). Premature termination at a university counseling center. Journal of Counseling Psychology, 34, 80-82. 6. https://www.ncbi.nlm.nih.gov/books/NBK304189/ 7. Kaplan and sadocks synopsis of psychiatry 8. The First Interview, Third Edition, JamesMorrison  CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 4 SELECTION OF COUNSELING THERAPY, TERMINATION AND FOLLOW-UP Structure: 4.0 Learning Objectives 4.1 Introduction 4.2 Selecting the Therapeutic Approach 4.3 Short-term Behavioural Approaches 4.4 Types of Termination 4.5 Summary 4.6 Key Words/Abbreviations 4.7 Learning Activity 4.8 Unit End Questions (MCQ and Descriptive) 4.9 References 4.0 Learning Objectives After studying this unit, you will be able to:  Explain and evaluate selection of therapies, termination and follow-up 4.1 Introduction Counseling interventions have been defined in professional literature as a unique interrelationship between a client and a counselor, which aims to create a change and a growth in CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 47 three main areas: Personal development, social adjustment, and professional development. During the counseling process, the counselor has the responsibility to contribute to the process of change, concerning his or her client’s personal development (Bordin, 1968). Interventions have been used to address serious personal problems, including alcoholism, compulsive gambling, drug abuse, compulsive eating and other eating disorders, self harm and being the victim of abuse. 4.2 Selecting the Therapeutic Approach No psychotherapeutic method exists today that is applicable to all patients or germane to the operations of all therapists. Techniques by which transformations come about the accord with the skill of the therapist who applies them and with the facility of the patient to accept and utilize the preferred interventions. Since psychotherapy is a learning process, the techniques to which a patient is exposed will work best if they coordinate with his or her unique methods of learning. Some persons learn best through cognitive operations, finding out the reasons that underlie their problems and acquiring an understanding of their self-defeating behavior and its origins. Such persons are attracted to insight methods. Others learn by following suggestions of authoritative persons or those they respect. Some learn through action and doing, i.e., achieving positive reinforcements in their environment for adaptive behavior; some through experiencing a corrective emotional experience with their therapist or with another human being who is used as a substitute therapist; others through example (modeling) and philosophical precepts (identification), which provide them with modes of thinking and behavior. Some learn best when subjected to psychological shock, attack, or confrontation that challenges their habitual defenses. These and additional kinds of learning usually act in combination with each individual. What is challenging for a therapist is discerning the form of learning that each patient can best utilize and then working to adopt techniques that are best suited for the patient’s learning propensities. An important area of research is a way of detecting a patient’s optimal modes of learning. If we can pinpoint these, we may then more precisely determine the best means of therapeutic operation. Different counselors have different approaches to the way they counsel. These differences stem from a variety of considerations, including their education, their practice experience, their personal style and their belief systems. CU IDOL SELF LEARNING MATERIAL (SLM)

48 Advanced Counseling Skills - I One approach therapists use to decide how to work with a specific client is called evidence- based practice (EBP). EBP suggests three types of information that can help decide on the appropriate psychotherapy: 1. Client characteristics, 2. Research evidence, and 3. Therapist’s clinical expertise EBP has been recommended by the American and Canadian psychological associations and is also used in the field of medicine, where it originated. The principles of the EBP were designed to help clinicians; it’s also useful for counselor deciding the appropriate therapeutic model to meet the client’s needs. A therapeutic approach can be simply defined as a theory by which a psychologist or counselor frames how they view human relationships and the issues that occur for people throughout their lives. One way to think of a therapeutic approach is that it is the lens that a therapist looks through when they are considering and addressing their client’s problem. It is not at all uncommon for a trained professional counselor to be educated in a number of different theories. In fact, many therapists utilise an integrative approach in which they blend different but complimentary theories in order to work with their client in the most effective way. This flexible approach enables the counseling experience to be tailored to the individual needs and style of each client. Often no single theory works for everyone, so it is helpful for a counselor to be flexible enough to switch to another approach if their preferred one is not working for that particular client. 4.3 Short-term Behavioural Approaches Short-term approaches often have sessions that occur on a weekly or fortnightly basis, for around four to twelve weeks, although occasionally sessions can occur more frequently or they can be extended beyond the initial 12-week period. CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 49 Approaches that are intended to last only a few months are generally more focused on addressing symptoms and helping clients find ways to relieve those symptoms, rather than delving into the cause. For example, if a person has lost their job and they are experiencing anxiety about looking for and starting a new job, then short-term treatment would involve addressing those feelings of anxiety, when they occur, what the person is thinking when they occur and alternative thoughts that can create new feelings that are more positive. Short-term counseling treatment is usually cognitively focused, meaning that it is interested in the connection between thoughts, behaviours and experiences. Behavioural counselors will first help the client to recognise and define the behaviours and thinking patterns associated with the problem. Once defined, the counselor will then provide tools and strategies to help the client respond differently to the problem and behave/think in an alternative way. These kinds of processes help the client take control over their lives and reposition their experiences as positive ones. There are many different types of therapy that fall into this broad-based category, for example, Cognitive Behavioural Therapy. Most counselors working with this approach utilise and apply a range of different models, depending on the needs of the client. Long Term Psychodynamic Approaches Long-term approaches are often called “ psychodynamic ” approaches. This approach to therapy focuses on looking at a person’s childhood experiences, upbringing, and relationship history so as to consider how this personal history affects and creates the adult personality. Broadly speaking, psychodynamic therapists believe that the problems one faces as an adult develops as a result of life experiences. A counselor who uses a psychodynamic approach may take a very detailed history of the family dynamics of the client’s childhood – who was the dominant parent, was there conflict, was it a family of relaxed rules, etc – along with other aspects of childhood, for example peer relationships, introvert/extrovert as a child, coping with academics etc. History plays a crucial part in psychodynamic treatment because history is considered to be the indicator of how personality develops, which in turn affects our experiences with other people. Based on history CU IDOL SELF LEARNING MATERIAL (SLM)

50 Advanced Counseling Skills - I collected, a counselor using this approach will then be able to develop an idea of how the issues began. Once the underlying causes of the problem are recognised, healing can begin. A few Questions that can help the counselor identify the appropriate therapeutic approach 1. Is this a relatively new problem that is contained within a specific set of circumstances? 2. Is it most important to achieve immediate relief for the symptoms of discomfort that the client is experiencing? 3. Do you need to solve the problem with a minimum amount of time commitment? 4. Is this a recurring problem in the client’s life? 5. Has the larger underlying problem that is causing symptoms been identified? 6. Is the client willing and able to make a long-term commitment to counseling? Different Approaches to Psychotherapy Approaches to psychotherapy Focus 1 Psychoanalysis and psychodynamic therapies. Focuses on changing problematic behaviors, feelings, and thoughts by discovering their unconscious meanings and motivations. Psychoanalytically oriented therapies are characterized by a close working partnership between therapist and patient. Patients learn about themselves by exploring their interactions in the therapeutic relationship. 2 Behavior therapy This approach focuses on learning’s role in developing both normal and abnormal behaviors. 3 Cognitive therapy. Cognitive therapy emphasizes what people think rather than what they do. 4 Humanistic therapy Emphasis on people’s capacity to make rational choices and develop to their maximum potential. Concern and respect for others are also important themes. 5 Integrative or holistic therapy. Blend elements from different approaches and tailor their treatment according to each client’s needs. CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 51 Termination Termination is the final stage of counseling and marks the close of the relationship. Termination is the counselor and the client ending the therapeutic alliance. The termination stage can be as important as the initial stage in that it is the last interaction many clients will have with the counselor. If the termination leaves on a sour note, then the client may look back on the time as a waste of effort and resources. If the termination goes well, then this has a multiplying effect, as the former client sees that their time was well spent and this will be one more person who is helping reduce the stigma of mental health. The Difference between Termination and Abandonment Termination is typically used when referring to the ending of the psychotherapy relationship. It may occur as an anticipated and well-articulated treatment plan that indicates the next phase of the psychotherapy process or it may occur precipitously or by surprise. Abandonment is a term that implies that the psychotherapist either ended the psychotherapy process in an inappropriate manner that does not adequately address the client’s ongoing treatment needs or the psychotherapist did not make necessary arrangements for the client’s treatment during the course of treatment (Younggren & Gottlieb, 2008). 4.4 Types of Termination Forced-termination: Forced-termination is termination of the counseling relationship before the goals of therapy has been fully accomplished. Clients typically feel anger towards the counselor, perceiving the end of the counseling relationship as abandonment. This may occur even if the counselor makes termination a topic of conversation throughout counseling sessions. It is most likely to occur if one does not mention termination until very close to the intended departure from the relationship. Clients may feel anxious at the thought of having to handle things on their own without the support they have found in the counseling relationship. Other reactions from clients might include sadness at losing a relationship upon which they have come to depend, or indifference at the end of the relationship. These emotions are oftentimes easier or more comfortable to express that anger or separation anxiety. It is important to keep in mind that how other relationships in the client’s past have ended may very likely affect his or her reaction to the CU IDOL SELF LEARNING MATERIAL (SLM)

52 Advanced Counseling Skills - I end of the counseling relationship. Unresolved issues surrounding past relationships can be played out in the termination process, but if the counselor handles the process ethically, sensitively, and honestly, the counselor is in a position to provide the client a healthy end to a productive relationship that they can look back on positively and feel comfortable with. Counselors may also experience many emotions when forced-termination occurs. Guilt is one of the common emotions counselors feel when they initiate the termination stage. Forced- termination means that the counseling relationship is ending prematurely. After spending an ample amount of time encouraging the client to be trusting, open and honest, one must now abruptly sever that connection. This can lead counselors feeling that they are abandoning their clients just as good progress could have been made, and can lead to a sense of feeling responsible for whatever might happen to the client as a result of the end of the relationship. For many counselors, a sense of frustration exists at not having “finished the job” or achieved the goals set out by the counselor and client. Counselors-in-training often struggle with a sense of omnipotence, or the feeling that they are the only one who can understand or help the client. It is natural to feel a sense of impotence, or the feeling that the relationship was not at all helpful to the client and that the client will be helped more effectively by a different therapist. When working with a client for only a short period of time, it can be difficult to see if any progress was made, especially if the client is not communicating any improvements to the counselor. At such times, it is important for counselors to work to become comfortable with that feeling of “not knowing.” It may not be for some time that a client himself realizes if and how a counselor has been of help. And as a counselor, you may never know. Counselors may feel a sense of loss and sadness at not being able to see their clients anymore, and other may feel a sense of relief. This relief often leads to guilt about being glad to move on from the counseling situation. It is very important to acknowledge your own feelings as you proceed through the termination stage of counseling. Client-initiated termination: Client-Initiated Termination can occur in a number of situations. A client may initiate termination when it is determined that the goals that he or she set out to accomplish have been adequately met, or when he or she feels that problematic symptoms have been reduced or eliminated. If the counselor agrees that goals have been met and the timing for termination is appropriate, termination can be a comfortable, pleasing experience for all CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 53 involved. There may be a sense of loss at not seeing the client on a regular basis, but this is often outweighed by a sense of happiness in knowing that the relationship was positive and productive and helped the client make progress. In some cases, clients may initiate termination of the relationship if they do not feel comfortable with the counselor or do not feel that they are ready to fully engage in the counseling process. At such times, counselors may often feel a sense of insecurity in their ability to effectively connect with and counsel clients, guilt about “losing a client”, and relief at not being in a relationship that they were uncomfortable with. In this case, it is very important for counselors to process their own feelings about the end of the relationship and how it might affect future interactions with clients. Counselor-initiated termination: Counselor-Initiated Termination occurs when the counselor notices that the client has made progress toward achieving goals, notes a reduction in or elimination of symptoms, sees that the client has gained enough insight to deal with future recurring symptoms and has resolved transference issues, and determines that the client has the ability to work, enjoy life and play. Once it is established by the counselor that there is little left to continue working on in therapy, it is time to introduce termination to the client. Counselor- initiated termination is also an ethical duty as a counselor if the counselor determines “an inability to provide professional service” to the client. In such a case, it is the responsibility of the counselor to make appropriate referrals and to obtain the professional training that would enable him/her to work with similar clients effectively in the future. Sometimes, clients will resist the termination process. After all, they have enjoyed success, in part, due to a relationship with their counselor. Ending that relationship can be frightening. The client may insist that more time is needed to work on the issue(s). A plethora of problems may suddenly arise, and sessions may be missed in an attempt to draw out the process or avoid termination. The client may become suddenly angry at the mention of termination in order to create distance between client and counselor, and, in some cases, the client may prematurely end therapy of his or her own volition. Counselors may also resist the process. If goals have successfully been achieved, it is but natural that the counselor may want to maintain that relationship. As a counselor, you are receiving positive feedback, feeling needed and appreciated, all of which provides confidence and a sense of self-worth. Letting go of that to allow your client to function independently can be CU IDOL SELF LEARNING MATERIAL (SLM)

54 Advanced Counseling Skills - I difficult. It is important to recognize the positive work one does as a counselor, but this should not lead to maintaining a relationship that is no longer serving the client. It is important to remember that not all clients will exhibit the emotions outlined as “typical.” One must understand clients’ reactions to termination in relation to their overall experience in the counseling relationship, taking care to acknowledge cultural and historical influences. Natural Termination: The purpose of counseling is to make people better. It has many specific objectives, but generally, overall, the goal is to have enhanced coping and be in happier state than what she/he was at the onset of the process. A good counselor will be able to identify when a person is better and ready to move on. There is no absolute rule on time with the natural termination - it happens when the client and the counselor come to a consensus. The question of termination can be approached by the counselor, which is counselor-initiated termination. This would likely be done when the counselor feels the client no longer has sufficient reason to stay in counseling. It should never been done at the spur of the moment, and adequate time should be given to ensure open discussion. Some clients will be resistant to leave the therapeutic relationship due to this being their first positive relationship or because they have a feeling of being lost or abandoned. These concerns should not be discouraged or argued. Arguing with a client will just leave them embittered, and progress that had been made will be jeopardized. Counselor’s should attempt to explore these feelings and thoughts and to show to the client that they have accomplished what they have set out to do. Termination can be approached by the client, which is referred as client-initiated termination. Likely, the client may feel they are no longer getting anything useful from the therapist or the initial situation that brought them in is resolved. For example, a client may seek out a counselor following the death of someone. As the client improves, they may feel they no longer need the counselor and attempt to terminate. Strategies for Ethical Termination 1. Address Termination Issues from the Outset. Include in the Informed Consent Discussions and Agreement CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 55 The process of informed consent is intended to share all relevant information with clients so that they can make decisions about participation in the treatment services being offered (Barnett, 2015). Knowing from the outset how treatment will end can be a vital piece of information for clients in making their decisions about participation in the proposed course of treatment (Davis & Younggren, 2009). For example, if the length of treatment is open-ended and will be determined by progress made toward treatment goals, this is a very different circumstance than the case where treatment is limited to a specific number of sessions (at times based on limitations on the client’s insurance coverage or in the instance of brief or time-limited psychotherapy). When psychotherapy is provided by a trainee it is a crucial concern as trainees typically have an end date to their time at each setting. Clients have the right to know from the outset if their psychotherapist will be there for them for the next five months or for the next five weeks. Any factors that may have a significant impact on the course of a client’s proposed treatment should be openly discussed as part of informed consent. This enables them to make informed decisions about participation and helps to prepare them for what is to come, helping them to participate more fully in the process, and thus, hopefully to benefit more fully from the experience. 2. Reach Agreement on the Goals of Treatment and the Criteria for Successful Completion of Treatment The ending of each client’s psychotherapy will hopefully occur when all treatment goals have been achieved. But, in order to know when treatment should end, there must first be an agreement on the goals of treatment. While treatment goals may be modified over the course of treatment as clients make progress and life circumstances change, failure to have an open discussion of goals from the outset and failure to reach agreement on what these goals impacts the nature, focus, and scope of the treatment offered as well as when and how this treatment will end (Davis, 2008). CU IDOL SELF LEARNING MATERIAL (SLM)

56 Advanced Counseling Skills - I 3. Consider and Prepare for Possible Psychotherapist-Initiated Interruptions to Treatment. Have a Professional Will. Psychotherapy can end for a variety of reasons. As is highlighted above, the most desired reason for ending treatment is that the client has achieved the upon agreed goals of treatment. But, psychotherapy may end for a variety of reasons, both client and psychotherapist initiated. To meet ethical obligations, psychotherapists may need to end a client’s treatment if the client is not benefitting from treatment, if an inappropriate multiple relationship develops or is discovered, or if the psychotherapist no longer possesses the competence necessary to meet the client’s treatment needs (APA, 2010). Psychotherapists may also terminate treatment “when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship” (APA, 2010, Standard 10.10). Psychotherapists may also need to abruptly end or interrupt a client’s ongoing treatment due to psychotherapist factors such as illness, disability, retirement, and even death. In keeping with our focus on each client’s best interests, psychotherapists should plan for these eventualities and make needed advance arrangements to help ensure that clients are not abandoned during the course of treatment. While some possible interruptions to treatment may be anticipated and planned for (e.g., vacation, taking time off after giving birth or adopting a child, and retirement), others such as illness and death tend not to be anticipated and can be doubly challenging for clients when they occur: the unplanned interruption in their treatment and the impact of the loss of their psychotherapist. It is recommended that each psychotherapist make advance arrangements with one or more colleagues to step in and offer assistance to clients when any of these events occur. Psychotherapists should each have a professional will in which a colleague is identified who has access to client contact information and records, and who will contact clients in the case of CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 57 psychotherapist death or other incapacitation, assessing ongoing treatment needs and assisting with crisis intervention and referrals to other clinicians (Pope & Vasquez, 2005). 4. Be Mindful of Client and Other-Initiated Interruptions to Treatment Clients may initiate termination for a variety of reasons. These may include limitations in finances, feeling dissatisfied with the psychotherapist or with how treatment is proceeding, losing one’s job, loss of or changes in their insurance coverage, or moving from the local area. While each of these cannot be anticipated from the outset of treatment, open discussions with clients about their progress in treatment and any issues that may impact their ability to continue should be explored at least periodically. To fulfill counselor obligations to clients, even when they initiate termination, counselors should ensure a reasonable good faith effort to help address any ongoing treatment needs. While counselors are not required to meet client treatment needs indefinitely, and doing so in some of these situations is not practical, offering assistance in connecting with alternative treatment resources is important to do whenever possible. When clients discontinue treatment, for any reason, before the agreed goals of treatment have been achieved, it is recommended that the client be contacted (either verbally or in writing) to make recommendations for addressing any ongoing treatment needs, offering options and alternatives, and offering assistance in procuring them. Sample letters that may be sent to clients to address these issues may be found in Barnett, MacGlashan, and Clarke (2000) and in Vasquez, Bingham, and Barnett (2009). 5. Be Clear on What Abandonment Is and Is Not (e.g., the Client’s Role in Treatment Discontinuation, the Psychotherapist’s Role) Abandonment occurs when the psychotherapist does not meet a client’s ongoing treatment needs appropriately. Abandonment may occur when treatment endings are mismanaged as well as when clients’ ongoing treatment needs are not adequately addressed. The latter may include failure to make needed coverage arrangements during periods of anticipated absence such as vacations, attending a conference, or other times when client access to the psychotherapist may be limited. CU IDOL SELF LEARNING MATERIAL (SLM)

58 Advanced Counseling Skills - I Charges of abandonment may even arise from not being sufficiently accessible between regularly scheduled treatment sessions. It is vital that reasonable expectations be established from the outset, with clients being provided with information on how to access the psychotherapist between sessions, when it is or is not appropriate to contact the psychotherapist, and the preferred means of contact. Realistic expectations should be established for the psychotherapist’s responsiveness and when others should be contacted, such as calling 100 in emergency situations. It is not abandonment when a client drops out of treatment precipitously or when the client does not fulfill treatment obligations. Nor is it abandonment if the client cooperates with treatment recommendations and the treatment is ended appropriately, after discussion, with notice, and with referrals being made; and in fact, these actions may not be necessary in situations where the psychotherapist is threatened or assaulted. As Younggren, Fisher, Foote, and Hjelt (2011) emphasize, clients have obligations as articulated in the informed consent agreement and/or treatment contract. When continued treatment is not possible or not indicated based on client actions and responses, ending the treatment is not seen as abandonment. Of course, documenting all such situations, discussions, consultations with colleagues, actions taken, and efforts to contact clients, should occur on an ongoing basis. 6. Have Ongoing Discussions with Clients about Progress in Treatment toward Termination Plan and prepare for termination. If possible, treatment endings should not come as a surprise. Work collaboratively with clients toward successful treatment endings. Termination should be considered a process and not an event. It should be seen as a phase of each client’s treatment that is worked toward together on an ongoing basis. It is recommended that termination be conceptualized as a consolidation phase of treatment that helps prepare the client to build on the gains made in treatment and to move forward positively after treatment ends (Barnett & Coffman, 2015). This important phase of treatment may be conceptualized from a range of perspectives and it may stimulate a number of important CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 59 themes and issues that are important to work through and address before treatment ends (Hardy & Woodhouse, 2008). Guidelines for effectively moving your clients toward termination  Remind clients of the approaching ending of the sessions. This should be done at least 2- 3 sessions prior to the final one. This provides an opportunity to ask clients to talk about relationships that have ended in their past, how they have ended, and how that might affect the end of this counseling relationship. One can also ask clients what they would like to focus on during their remaining time with you. A question to ask prior to the final one, which may help to prepare clients for the reality at the end, is “If this were our last meeting, how would that be for you?”  If the counselor and client are not limited to a certain number of sessions, one can space out the last few meetings. This is a good way to wean the client of the relationship and foster in them a sense of confidence in their ability to handle things without seeing you on a weekly basis before the relationship abruptly ends.  Review the progress that the counselor and the client have made during sessions. Very often, clients will forget the advances they have made, or neglect to give themselves credit for their accomplishments. Doing this with them can instill confidence and provide them with a positive perspective on what counseling helped them to do. Ask clients what they learned, what they intend to do with what they have learned, what they found helpful about their sessions and how they felt about their participation in the process.  Allow clients to talk about their feelings surrounding termination. They may likely have many emotions to work through and time should be spent acknowledging and processing them.  Be aware of your own (counselor) feelings surrounding the termination process. It is normal to feel many emotions when ending a relationship with your clients. Acknowledge your feelings, your ambivalence about termination, etc. Always keep in mind that your ultimate goal as a counselor is to “put yourself out of business.” If you are CU IDOL SELF LEARNING MATERIAL (SLM)

60 Advanced Counseling Skills - I good at what you do, people will not need to continue to see you for help. They will have the tools to help themselves.  If possible, have an open-door policy. Once termination has ended, clients may want to return a few months or years later to refocus or to “check-in”. This is often impossible in the training setting, but something to keep in mind for your professional career.  Review the tools and skills that clients have acquired through the counseling process. These tools will be critical in helping clients be self-sufficient in handling problems that might have previously brought them to counseling. If there are additional resources that you feel the client would benefit from for continued personal growth, make appropriate referrals and make your client aware of them. Considerations for a Planned Termination of the Counseling Relationship 1. An examination of whether the client’s initial problem or symptoms have been reduced or eliminated 2. An assessment of the clients coping ability and degree of understanding of self and others 3. A determination of whether the client can relate better to others and is able to love and be loved 4. An examination of whether the client has acquired abilities to plan and work productively and an evaluation of whether the client can better play and enjoy life 4.5 Summary Follow-up counseling is a stage of treatment that comes after successful completion of therapy (post termination). Prior to discharging the patient, it is advisable to ask whether he or she would object to receiving an occasional letter from the therapist asking regarding one’s progress. Most patients are delighted to cooperate and consider the therapist’s gesture a mark of interest in their development. Follow-up letters, briefly inquiring into how things have been progressing, may be sent to the patient yearly, preferably for at least 5 years. This enables the therapist to maintain a good check on what has been happening over a considerable period of time. The CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 61 patient’s replies to the follow-up inquiry may be entered in the case record, and, if necessary, a brief notation may be made of the contents. Follow-up is an essential practice where one wishes to determine the efficacy of one’s clinical activities. It is an important aspect of outcome research. In doing follow-up we must remember that a single contact may not tell us too much. A person does not live in a vacuum after completing psychotherapy, and many inter current events can temporarily augment, detract from, or destroy the benefits of treatment. Thus an individual who has achieved a good result and has left therapy in a satisfactorily improved state may be subject to catastrophes that are beyond one’s power to avoid or resolve. One may be in a state of depression at the time of follow-up but can later rally and pull oneself out of despair. This may not be evident unless provision is made for further contacts. Personal interviews are far more useful for a follow-up than communication by mail, although practical considerations, such as changes in domicile to a remote area, may pose problems. Sometimes follow-ups are done over the telephone maybe much more satisfactory than by mail. However, patients tend to be more guarded here than in private interviews even where they have had a good relationship with their therapists. Ideally, appraisals of the patient by other persons with whom the patient is living or working can be helpful, but this may be difficult to arrange. A simple statement of “feeling better” or “worse” means little unless areas of improvement or decline are delineated. Unless the case record has detailed categories of problems and deficits existing at the start of treatment estimates of change may be inaccurate. Researchers who have had no personal contact with a patient are especially handicapped, but even the primary therapist may without recorded backup be prejudiced by optimistic hunches. 4.6 Key Words/Abbreviations  Termination: The final stage of counseling and marks the close of the relationship. ● Follow-up: Counselors check in with clients after termination or have their clients check in with the counselors to review progress. CU IDOL SELF LEARNING MATERIAL (SLM)

62 Advanced Counseling Skills - I ● Therapeutic approach: The lens through which a counselor addresses their clients' problems. ● Transference: When a person in therapy may apply certain feelings or emotions toward the therapist. ● Resistance: Refers to any opposition to the therapeutic process. ● Evidence-based Practice (EBP): The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preference. 4.7 Learning Activity 1. Discuss five ways a counselor may help a client avoid resisting termination ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- 4.8 Unit End Questions (MCQ and Descriptive) A. Descriptive Types Questions 1. Discuss the various approaches one can use to choose the appropriate counseling model? 2. Elaborate and discuss integrated approaches as therapeutic models used in counseling? 3. Define termination and discuss the different types of termination. 4. What is the importance of follow-up sessions in counseling after termination? 5. What are the Strategies for Ethical Termination? B. Multiple Choice Questions 1. EBP has been recommended by the __________ and __________ psychological associations. (a) American & Canadian (b) Indian & American (c) British & Korean (d) Korean & Canadian CU IDOL SELF LEARNING MATERIAL (SLM)

Selection of Counseling Therapy, Termination and Follow-up 63 2. Short-term approaches often have sessions that occur on a __________ basis. (a) monthly (b) Quarterly (c) Half- yearly (d) Weekly/fortnightly 3. Long-term approaches are often called __________ approaches. (a) Psychodynamic (b) Humanistic (c) Existential (d) Behaviouristic 4. Humanistic therapy focuses on __________. (a) People’s capacity to make rational choices and develop to their maximum potential. (b) What people think rather than what they do. (c) Learning’s role in developing both normal and abnormal behaviors. (d) On changing problematic behaviors, feelings, and thoughts by discovering their unconscious meanings and motivations. 5. Forced-termination is __________. (a) Termination when it is determined that the goals that client set out to accomplish has been adequately met, or when he or she feels that problematic symptoms have been reduced or eliminated. (b) Termination of the counseling relationship before the goals of therapy has been fully accomplished. (c) Termination when the counselor notices that the client has made progress toward achieving goals, notes a reduction in or elimination of symptoms, sees that the client has gained enough insight to deal with future recurring symptoms. (d) When goals have been met. Answers 1. (a), 2. (d), 3. (a), 4. (a), 5. (b) CU IDOL SELF LEARNING MATERIAL (SLM)

64 Advanced Counseling Skills - I 4.9 References 1. Ellis, A. (1987). The evolution of rational-emotive therapy (RET) and cognitive behaviour therapy (CBT). In: J.K. Zeig (Ed.). The Evolution of Psychotherapy. New York: Brunner/hazel. 2. Miller, W.R., Zweben, A., DiClemente, C.C., and Rychtarik, R.G. (1992). Motivation enhancement therapy manual: A clinical research guide for therapist treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series, 2. DHHS Pub. No. (ADM) 92-18894. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off. 3. Miller, W.R., and Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: Guilford Press. 4. Techniques of psychotherapy, wolberg  CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 5 ETHICS IN COUNSELING Structure: 5.0 Learning Objectives 5.1 Introduction 5.2 Ethics Defined 5.3 Ethical Codes 5.4 Purpose of the Code of Ethics 5.5 Limitations of Ethical Codes 5.6 Other Guidelines for Acting Ethically 5.7 Summary 5.8 Key Words/Abbreviations 5.9 Learning Activity 5.10 Unit End Questions (MCQ and Descriptive) 5.11 References 5.0 Learning Objectives After studying this unit, you will be able to:  Explain and analyze the ethics of a Counselor, Need for ethical standards. CU IDOL SELF LEARNING MATERIAL (SLM)

66 Advanced Counseling Skills - I 5.1 Introduction Ethics are moral principles and a code of conduct that should be adhered by any individual or group. The word ethics is derived from a Greek word ethos meaning custom, habit. In counseling ethics lay the foundation of the nature and course of actions taken by the counselor. One is expected to sincerely comply with the code of conduct. 5.2 Ethics Defined Ethics is generally defined as a philosophical discipline that is concerned with human conduct and moral decision making. Unethical behaviour can take many forms such as:  Physical intimacy  Titillation of gossip  Opportunity to advance one’s carer The most prevalent forms of unethical behaviour in counseling include:  Violation of confidentiality  Exceeding ones level of competence  Negligent practice  Claiming expertise one doesn’t possess  Creating dependency on the client  Sexual activity with the client  Dual relationships  Plagiarism  Improper advertising CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 67 5.3 Ethical Codes Guidelines counselors should adhere by, and have been listed by organizations like American psychological association and American counselor association. Dimensions to ethical decision making include: 1. Virtue ethics: Beyond obligatory ethics and are obligatory 2. Principle ethics: Overt ethical considerations 5.4 Purpose of the Code of Ethics 1. Maintain public trust and credibility of the profession. 2. Facilitate greater professionalism in facilities management. 3. Define ethical behaviour to protect against improper conduct by its members. 4. Provide a commitment to the Association and its members. 5. Help control internal disagreement and bickering, thus promoting stability within the profession. 6. Designed to provide some guidelines for the professional behaviour of members. One of the primary reasons is that “without a code of established ethics, a group of people with similar interests cannot be considered a professional organisation” (Allen, 1986). 7. Facilitate the profession to regulate itself and function autonomously. 8. Help control internal disagreement and bickering, thus promoting stability within the profession. The function of a Code of Ethics lies in: 1. It being an enabling documents: A framework for organising and evaluating alternative courses of action in novel situations. 2. Source of public evaluation: As a visible pronouncement of a profession’s self proclaimed role and values. It can function as a basis for the public’s expectations and evaluation of professional accountability. CU IDOL SELF LEARNING MATERIAL (SLM)

68 Advanced Counseling Skills - I 3. Professional socialisation: Helps to foster pride in the profession and strengthen identity and allegiance. 4. Enhance the profession’s reputation and public trust: A profession’s status and autonomy are linked to the public’s perceptions about its motives and quality of performance. A code helps to reassure the public that professionals are deserving of its confidence and respect. 5. Deterrent to unethical behaviour: A code may function as a deterrent to unethical behaviour as well as promoting ethical conduct by an affirmative duty for the professional to report errant colleagues. 6. Support system: May constitute a legitimate source of support for professionals against erosion of their power or improper demands on their skills by outsiders. 7. Adjudication: Codes may serve as a basis for adjudicating disputes among members of the profession or between members and outsiders. 5.5 Limitations of Ethical Codes Many researchers’ have noted that ethical codes are too idealistic and general, they seldom answer specific questions. Many a times, these documents don’t address foreseeable professional dilemmas. In contrast, they provide guidelines, based on experiences and values emphasizing on how counselors should behave. Some of the frequently discussed limitations are:  Some issues cannot be resolved by a code of ethics.  Enforcing ethical codes is difficult.  Ethical codes are not proactive documents for helping counselors decide what one should do in new situations.  Ethical codes don’t address every possible situation.  Ethical codes don’t address cross-cultural issues. CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 69 Ethics Counselors should Abide by 1. Confidentiality: Welfel (2002) summarized the concept of confidentiality: The term confidentiality refers to the ethical duty to keep client identity and disclosures secret. It is a moral obligation rooted in the ethics code, the ethical principles, and the virtues that the profession attempts to foster. Client confidentiality is the requirement that therapists, psychiatrists, psychologists, and most other mental health professionals state to protect their client’s privacy by not revealing the contents of therapy. Confidentiality includes not simply the contents of therapy, however typically the very fact that a client is in therapy. For instance, it’s common that therapists won’t acknowledge their clients if they run into them outside of therapy in an attempt to safeguard client confidentiality. Other ways in which confidentiality is protected include:  Not leaving revealing data on voicemail or text.  Not acknowledging to outside parties that a client has an appointment.  Not discussing the contents of therapy with a 3rd party without the specific permission of the client.  For authorized mental health professionals, confidentiality is protected by state laws and also the insurance movability and responsibleness Act (HIPAA). Therapists who break confidentiality will get in trouble with state licensing boards. They will even be sued by their clients in some cases.  Some individuals operating in mental health, like phone crisis counselors or life coaches, aren’t authorized by their state. These individuals might not be lawfully needed to safeguard client confidentiality. Nevertheless, most agree to not reveal distinguishing information concerning their clients anyway. Exceptions to Confidentiality Rules Licensed mental health professionals will break confidentiality in some circumstances. One amongst the foremost common eventualities is when a client could be a threat to him/herself or CU IDOL SELF LEARNING MATERIAL (SLM)

70 Advanced Counseling Skills - I others, within which case an expert should inform the person in peril or inform somebody who will keep the client safe. In these circumstances, therapists typically obtain hospitalization for his or her clients. It is vital to notice that an expert won’t automatically break confidentiality if a client reports thoughts concerning suicide. Typically, a client has to state an intent to act on those thoughts and have a particular suicide plan before hospitalization is taken into account. An individual won’t be hospitalized against their will for merely seeking help. Most therapists are happy to review any confidentiality issues before beginning therapy. An expert may additionally be required to interrupt client confidentiality if they believe a baby or disabled person is being abused. As a mandated communicator, they need a responsibility to report their suspicions to authorities. In rare cases, therapists will be forced to testify against their clients through a subpoena. However, its way more tough to force an expert to testify that it’s to force a non- licensed psychological state professional. Laws governing therapists are abundant stricter concerning confidentiality. 2. Respecting privacy and maintaining confidentiality: Respecting clients’ privacy and confidentiality are basic necessities for keeping trust and respecting client autonomy. The skilled management of confidentiality concerns the protection of personally classifiable and sensitive information from unauthorised revelation. Revelation could also be authorised by client consent or the law. Any disclosures of client confidences ought to be undertaken in ways in which best defend the client’s trust and respect client autonomy. Communications created on the premise of client consent don’t constitute a breach of confidentiality. Client consent is the ethically preferred means of resolving any dilemmas over confidentiality. Exceptional circumstances might stop the professional from seeking client consent to a breach of confidence because of the urgency and seriousness of matters, as an example, preventing the client inflicting serious hurt to self or others. In such circumstances the practitioner has a moral responsibility to act in ways in (which) which balance the client’s right to confidentiality against the necessity to communicate with others. Practitioners ought to expect to be ethically answerable for any breach of confidentiality. CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 71 3. Beneficence: Is a commitment promoting the client’s well-being. The principle of beneficence means that acting within the best interests of the client based on skilled assessment. It directs attention to operating strictly within one’s limits of competence and providing services on the basis of adequate training or expertise. Making certain that the client’s best interests are achieved requires systematic monitoring of practice and outcomes by the simplest offered means that. It’s vital that analysis and systematic reflection inform practice. There’s an obligation to use regular and on- going supervision to boost the standard of the services provided and to attempt to change the observed by continued skilled development. An obligation to act within the best interests of a client could become paramount once working with clients whose capability is diminished due to immaturity, lack of understanding, extreme distress, serious disturbance or alternative significant personal constraints. 4. Non-maleficence: Non maleficence is a commitment to avoiding harm to the client. Non-maleficence involves: avoiding sexual, financial, and emotional or the other kind of client exploitation; avoiding incompetence or malpractice; not providing services once unfit to try due to ill health, personal circumstances or intoxication. The professional has an associate moral responsibility to attempt to mitigate any harm caused to a client even once the damage is inescapable or unplanned. Holding acceptable insurance could assist in restitution. Practitioners have personal and skilled responsibility to challenge, wherever acceptable, the incompetence or malpractice of others; and to contribute to any investigation and/or adjudication concerning skilled practice that falls below that of a reasonably competent professional person and/or risks bringing discredit upon the profession. 5. Sexual and dual Relationships: Counselors ought to never have interaction in an exceedingly sexual manner with a client. The greatest range of malpractice suits and complaints to skilled organizations involve client- counselor sexual relationships. The counselor is in a position of power over the client by virtue of the profession. This suggests it’s perpetually the counselor’s responsibility to prevent these relationships. A counselor who has sexual feelings for a client may have to refer the client to CU IDOL SELF LEARNING MATERIAL (SLM)

72 Advanced Counseling Skills - I another counselor. Moral standards even recommend that the counselor mustn’t have an interaction in a sexual relationship with a former client because of that earlier relationship. As a matter of fact in relation to friendships or different relationships with clients there are no clear-cut moral pointers regarding the subject matter with those that you have already got some relationship with. However, the counselor should use caution in counseling people with whom he or she has different relationships, like members of the family, friends, and coworkers. the other relationship with the client would possibly impair the counselor’s judgment and objectiveness and will have an effect on the ability to provide services. The counselors need to decide if the relationship will cause damage to the client. The counselor could plan to refer the client to a different counselor or continue see the client, however establish guidelines to prevent moral problems. 6. Self-respect: Fostering the practitioner’s self knowledge and self care. The principle of self-respect means the professional appropriately applies all the above principles as entitlements for self. This includes seeking counseling or therapy and alternative opportunities for personal development as required. There’s an ethical responsibility to use supervision for appropriate personal and skilled support and development, and to seek training and other opportunities for continuing professional development. Guarding against monetary liabilities arising from work undertaken sometimes needs obtaining appropriate insurance. The principle of self-respect encourages active engagement in life-enhancing activities and relationships that are independent of relationships in counseling or psychotherapy. 7. Training: In order to practice as a counselor, you must be trained suitably. All states require that counselors be authorized. Additionally to the present training, counselors should follow state guidelines for continuing education and training. This training is meant to keep counselors informed about new developments within the field, likewise make sure that the information obtained during a educational program is refreshed. As counselors directly apply this information to the treatment of clients, it’s vital that continued education be obtained. Misguided or inappropriate application of counseling techniques may be harmful to clients. CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 73 8. Autonomy: Refers to respect for the client’s right to be independent. This principle emphasises the importance of developing a client’s ability to be self-directing inside medical care and all aspects of life. Practitioners who respect their clients’ autonomy: ensure accuracy in any advertising or information given prior to of services offered; look for freely given and adequately informed consent; emphasise the worth of voluntary participation within the services being offered; interact in specific contracting prior to of any commitment by the client; shield privacy; shield confidentiality; normally create any disclosures of confidential information conditional on the consent of the person concerned; and inform the client prior to of foreseeable conflicts of interest or as soon as doable after such conflicts become apparent. The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends. 9. Counter transference: Signs of counter transference in therapy will embody a variety of behaviors, including excessive self-disclosure on the part of the therapist or an inappropriate interest in irrelevant details from the lifetime of the person in treatment. A therapist who acts on their feelings toward the person being treated or that person’s scenario or engages in behavior not appropriate to the treatment method might not be effectively managing counter transference. A person in therapy who suspects a therapist of harmful counter transference may bring conveyance up in a session if it’s safe to do so. Making the therapist conscious of the issue may be enough to unravel the matter, however obtaining a second opinion may additionally be of profit in some cases. If the difficulty doesn’t resolve, finding a replacement therapist is also a doable resolution. Grossly unethical behaviors are typically best reported to a licensing board or some higher authority. Another ethical issue that’s seldom mentioned is counter transference. Counter transference is where the counselor projects feelings and attitudes that distort the way he or she perceives a client. Perceptions of a client are influenced by the counselor’s own experiences. Counter transference might end in the counselor being overprotective, treating the client too cautiously, and seeing herself in the client, developing romantic or sexual feelings for the client, giving recommendations rather than therapy or developing a social relationship with the client. Counter transference isn’t all bad and may make the counselor feel more empathetic of the client and more CU IDOL SELF LEARNING MATERIAL (SLM)

74 Advanced Counseling Skills - I aware of their feelings. When it becomes problematic, though, the counselor should manage feelings through consultation, supervision, or personal therapy. 10. Informed Consent: Informed consent in counseling and psychotherapy refers to the process by which clients or prospective clients receive information about the proposed treatment and subsequently decide whether to provide consent for the counselor or therapist to proceed with the treatment. Historically, informed consent requirements were applied to surgery and other medical procedures; later these requirements were expanded to include counseling and related activities. Currently, informed consent is mandated by the ethical codes that govern most counselors and psychotherapists. There is significant variability, however, in the beliefs and practices of professionals regarding informed consent, including its content, timing, method, and effect. Content of Informed Consent Procedures The information counselors and psychotherapists include during the informed consent process is very sensitive. Ethical codes and legal regulations typically offer little guidance regarding the specific topics to cover or particular details to address. In the absence of unambiguous guidelines, counselors and psychotherapists have developed and employed a wide variety of approaches to informed consent. A number of topics have traditionally been included in the informed consent process. Prospective clients are generally informed about the nature of the counseling or therapy being proposed. This includes what the therapeutic approach is called, how it usually works, what activities it may involve, and how long it may last. They are also typically informed about the effectiveness of the proposed treatment, as well as potential risks and alternative treatments. Of course, the pragmatics of the treatment arrangement is also usually covered: how appointments are scheduled, where and how often sessions will take place, payment arrangements and responsibilities, and emergency contact information. Finally, informed consent procedures have customarily included confidentiality policies, including situations in which the counselor or therapist may need to break confidentiality without the permission of the client (e.g., when the therapist becomes aware of a legal duty to warn a third party of potential danger). CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 75 In addition to these essentials, a number of additional topics may merit inclusion in the present-day informed consent process. Recently, numerous authors have identified contemporary issues in the counseling or therapy field about which the client may have a right to be informed. For example, the increasing involvement of insurance companies, managed care organizations, and other third-party payers has had a widespread and well-documented influence on the counseling and psychotherapy professions, and some members of these professions believe this topic merits inclusion in their informed consent procedures. Similarly, therapy manuals (or empirically supported therapies, or best practices guidelines) have resulted in many clients in recent years receiving treatment that is to some extent predetermined or preplanned according to a diagnostic category or presenting problem. Informing prospective clients about their use by a counselor or therapist may be another relatively new addition to the informed consent procedure. Timing of Informed Consent When should counselors and therapists obtain informed consent? Ethical codes and legal regulations generally suggest that informed consent be obtained as early as possible in the therapeutic relationship. The rationale behind this suggestion is: Clients should have the opportunity to choose whether to proceed with counseling or therapy before finding themselves immersed in it. However, counseling and psychotherapy are fundamentally different from other practices that utilize informed consent procedures. Counseling and psychotherapy are unique in two important ways: They unfold gradually over time in ways that cannot always be accurately predicted at the outset, and they necessarily differ from client to client. For these reasons, a standardized informed consent procedure cannot be offered to all clients at the outset. Of course, some basic information can and should be provided at the very beginning, including confidentiality and payment policies. However, discussion about more substantive issues, such as treatment orientation, duration, goals, and activities may need to be delayed until the therapist has learned enough about the client to provide personalized information. Thus, many authors on informed consent promote a “process” model rather than an “event” model, such that informed consent represents not a distinct occurrence, but an ongoing and recurrent element of counseling and psychotherapy. CU IDOL SELF LEARNING MATERIAL (SLM)

76 Advanced Counseling Skills - I Whether informed consent is viewed as a process or an event, at times it may need to be delayed as a result of client variables. If the client is in an acute crisis state or is temporarily unable to adequately comprehend the information to be provided, it may be clinically and professionally wise to delay informed consent until a more appropriate point in time. How should counselors and psychotherapists obtain informed consent? Historically, two methods—written and oral—have been utilized. Written informed consent procedures feature the advantage of enabling clients to read over information at their own pace, as well as the opportunity for the counselor or therapist to keep a hard copy of a signed form in the file as proof that informed consent was obtained. Oral informed consent procedures allow for more flexibility and customization of information for particular clients. They also facilitate discussion between the client and the counselor or psychotherapist. In practice, a combination of written and oral informed consent procedures may be ideal. Numerous standardized written informed consent forms have been made available, and they can be adapted by counselors or psychotherapists working in particular contexts or with particular types of clients. However, these forms, or others originally designed by counselors or therapists for their own practices, should not stand alone. Instead, clients should be given the opportunity to ask questions during the informed consent process, and the counselor or psychotherapist should provide answers to the fullest extent possible. Counselors and psychotherapists can combine the written and oral approaches by supplementing a standard information form with a written list of questions that clients may choose to ask. Whether written, oral, or both, the method by which counselors and psychotherapists obtain informed consent should be consistent with professional ethical codes, applicable laws, and the Health Insurance Portability and Accountability Act (HIPAA). 5.6 Other Guidelines for Acting Ethically  Personal and professional honesty: counselors should function openly with themselves and with those whom they work with. Hidden agendas and unacknowledged hamper relationships and place counselors on shaky ethical ground. CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 77  Acting in the best interest of the clients: many a times a counselor may impose their values on the client and ignore the need of the client. They may also fail to recognize an emergency and readily accept the idea that the client’s best interest is served by doing nothing.  Act without malice or personal gain: not all clients are easy to deal with; with these individuals the counselors must be careful. Counselors must avoid relationships with likable clients on either personal or professional basis.  Can counselors justify their action: one must be able to have a logical premise of their actions that should also be updated with the changing perspectives in the field. 5.7 Summary Counselors are like any other professions and have an established code of ethics to guide them in the practice of helping others. In making any decision counselors may live in personal values as well as ethical standards and legal proceedings. They can consult other professional colleagues and principles in case it is a necessity that counselors become well informed in the area of a fixed situation for the sake of their own well-being and that of the clients. Counselors should not only have an academic good knowledge of ethics but they must also have a working knowledge and be able to assist the developmental level they and their colleagues are operating on. Counselors should also be well informed about the state and national legislation and legal decisions. Counselors are liable not only for civil but also criminal malpractice suits if they violate the client rights or societal rules. An easy way for counselors to protect themselves legally is to follow the ethical standards of the professional organisations with which they are affiliated and operate according to recognised normal practice. Ethical standards and legal codes reflect current conditions and ever evolving documents. They do not cover all situations but they offer help beyond the counselor’s personal beliefs and values. CU IDOL SELF LEARNING MATERIAL (SLM)

78 Advanced Counseling Skills - I 5.8 Key Words/Abbreviations  Ethics: Professional values foundational to the profession. ● Confidentiality: Confidentiality is a part of the ethical guidelines of psychologists and means that information between a patient and a therapist cannot be shared with anyone. ● American Counseling Association (ACA): The American Counseling Association is the world’s largest organization representing professional counselors in various practice settings. ● Codes: Guide of principles designed to help professionals conduct business honestly and with integrity. ● Health Insurance Portability and Accountability Act (HIPAA): Created primarily to modernize the flow of healthcare information, stipulate how Personally Identifiable Information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage. 5.9 Learning Activity 1. Obtain copies of early ethical codes for the ACA. Compare these guidelines to the most recently published ACA “Code of Ethics.” What differences do you notice? Discuss your observations with your class members. ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- 2. Obtain as many copies as you can of counseling laws in states where councillors are licensed. Check the NBCC Web site and APA code of ethics in carrying out the assignment. Compare these laws for similarities and differences. What areas do you think the laws need to address that are not being covered? ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- CU IDOL SELF LEARNING MATERIAL (SLM)

Ethics in Counseling 79 5.10 Unit End Questions (MCQ and Descriptive) A. Descriptive Types Questions 1. In your own words, define the term ethics. 2. Discuss the ethical considerations counselors must abide by. 3. State the limitations of Ethical Codes. 4. What is the function of ethical codes. B. Multiple Choice Questions 1. Beneficence refers to __________ well being. (a) Client (b) counselor (c) client relatives (d) therapist well being 2. Non maleficence is commitment to avoid __________ to the client. (a) harm (b) emotional support (c) well being (d) pain 3. A combination of __________ and __________ informed procedures may be ideal. (a) Audio and video recordings (b) written and oral (c) video and written (d) written and audio 4. The full form of ACA is __________ (a) American counseling Association (b) American Counselors Association (c) Association of American Counselors (d) American counselors association CU IDOL SELF LEARNING MATERIAL (SLM)

80 Advanced Counseling Skills - I 5. The principle of _______ means the professional appropriately applies the ethical principles as entitlements for self. (a) Self respect (b) self care (c) self knowledge (d) self respect Answers 1. (a), 2. (a), 3. (b), 4. (a), 5. (d) 5.11 References 1. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073. 2. Beahrs, J.O., and Gutheil, T.G. (2001). Informed consent in psychotherapy. American Journal of Psychiatry, 158, 4-10. 3. Counseling a comprehensive profession, Samuel Gladding, 2012.  CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 6 GROUP COUNSELING Structure: 6.0 Learning Objectives 6.1 Introduction 6.2 History of Groups 6.3 The Principles of Group Therapy 6.4 The Role of Groups in Counseling 6.5 Myths and Realities of Groups 6.6 Theoretical Approaches 6.7 Types of Groups 6.8 Drawbacks of Groups 6.9 Summary 6.10 Key words/Abbreviations 6.11 Learning Activity 6.12 Unit End Questions (MCQ and Descriptive) 6.13 References 6.0 Learning Objectives After studying this unit, you will be able to:  Explain and analyze the development of group counseling along with the techniques and barriers in group counseling. CU IDOL SELF LEARNING MATERIAL (SLM)

82 Advanced Counseling Skills - I 6.1 Introduction Counseling is considered as a direct one-on-one relationship between the client and the counselor it is viewed as an individualistic approach. With several changes taking place in society many traditional concepts and meanings no longer hold. There have been tremendous societal pressures and demands such that the one-on-one relationship has become uneconomical and wasteful and may appear to lack social sensitivity and commitment. In the field of counseling, the available trained personnel and the demand for competent assistance are alarmingly unrelated. In this context group currently has been thought of as a practical solution. Face-to-face interaction between the counselee and the Counselor has been considered as Counseling in which the counselor helps to resolve the Counselors problems There are practical situations in which the counselee directly involves members of his family or of members of his group. In such a situation individual counseling may not be effective. Group counseling, therefore, becomes a practical means of helping resolve problems by harnessing the social process of group dynamics, social facilitation and so on. Group counseling could be looked upon as an extension of individual counseling in which the communication between members is encouraged and will lead to an understanding and evaluation of each other’s point of you. Simply explained, Group therapy is a form of psychotherapy that involves one or more therapists working with several people at the same time. Group therapy is widely available in a variety of settings including private therapeutic practices, hospitals, mental health clinics, and community centers. Group therapy is sometimes used alone, but it is also commonly integrated into a comprehensive treatment plan that also includes individual therapy and medication. 6.2 History of Groups Groups have a long and distinguished history in the service of counseling. Joseph Hersey Pratt a Boston Physician is generally credited with starting the first psychotherapy counseling CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 83 group in 1905. Pratt’s group members were tubercular outpatients at Massachusetts General Hospital who found the time they regularly spent together informative, supportive and therapeutic. Although this group was successful, the spread of groups to other settings and the development of different types of groups were uneven and sporadic until the 1970s. Table 6.1: Contributors in the Group Therapy Movement Expert Contribution 1. Jacob L Moreno Introduced the term group psychotherapy 2. Fritz Perl Gestalt approach to groups attracted new interest in the field by stressing the importance of awareness and obtaining congruence within oneself 3. W Edwards Conceptualised and implemented the idea of quality work groups to improve Deming the processes and products people produced and to build morale among workers and businesses 4. William Schutz Emphasized a humanistic aspect to T-groups that focused on personal growth as and Jack Gibb a legitimate goal 5. Carl Rogers Devised the basic encounter group in the 1960s that became the model for growth-oriented group approaches Besides influential individuals, a number of types of groups, some of which have just been mentioned, developed before groups were classified as they are today. Chronologically psychodrama was the first, followed by T-groups, encounter groups, group marathons and self- help support groups. Kurt Lewin, whose field therapy concepts in the 1930s and 1940s became the basis for the Tavistock small study groups in Great Britain and the T-group movement in the United States. Table 6.2: Group Type Group Type Description 1. Psychodrama  Originator of psychodrama: Jacob L Moreno a Viennese psychiatrist.  Employed for decades with mental patients at Saint Elizabeth Hospital in Washington DC, was initially used with ordinary citizens in Vienna, Austria, at the beginning of the 20th century.  Members in enact unrehearsed role-plays, with the group leader serving as the director. Other group members are actors in the protagonist’s play, give feedback to the protagonist as members of the audience, or do both. CU IDOL SELF LEARNING MATERIAL (SLM)

84 Advanced Counseling Skills - I 2. T-Groups  Popular with behaviourists, Gestaltists, affective-oriented group leaders who (T stands for have adopted it as a way of helping clients experience the emotional qualities training) of an event. 3. Encounter  The first T-Group was conducted at the National Training Laboratories (NTL) Groups in Bethel, Maine,in 1946. 4. Group  These groups appeared at a time when neither group counseling nor group Marathons psychotherapy had evolved.  Members of such groups are likely to learn from the experience how one’s behaviour in a group influences others behaviour and vice versa.  T-groups are similar to some forms of family counseling in which the emphasis is on both how the system operates and how an individual within the system functions.  Encounter groups emerged from T- groups in an attempt to focus on the growth of individual group members rather than the group itself.  Intended for “normally functioning “people who wanted to grow, change, and develop (Leiherman,1991).  Frederick Stoller and George Bach pioneered the concept in the 1960s.  An extended, one-session group experience that breaks down defensive barriers that individuals may otherwise use.  It usually lasts for a minimum of 24 hours.  Have been used successfully in working with substance abusers in rehabilitation programs and well-functioning individuals in other group counseling settings. 6.3 The Principles of Group Therapy Irvin D. Yalom outlines the key therapeutic principles that are derived from self-reports from people who are concerned within the group therapy process: 1. The instillation of hope: The group contains members at different stages of the treatment process. Seeing those who are coping or recovering gives hope to those at the beginning of the process. CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 85 2. Universality: Being a part of a group of people who have similar experiences helps people see that what they're going through is universal and that they’re not alone. 3. Imparting information: group members can help one another by sharing information. 4. Altruism: group members will share their strengths and help others within the group, which might boost self-esteem and confidence. 5. The corrective recapitulation of the first family group: The therapy group is sort of a family in some ways. Within the group, every member will explore however childhood experiences contributed to personality and behaviors. They’ll conjointly learn to avoid behaviors that are harmful or unhelpful in reality. 6. Development of socialization techniques: The group setting may be a great spot to apply new behaviors. The setting is safe and supportive, permitting group members to experiment without the fear of failure. 7. Imitative behavior: people can model the behavior of different members of the group or observe and imitate the behavior of the therapist. 8. Interpersonal learning: By interacting with others and receiving feedback from the group and also the therapist, members of the group will gain a greater understanding of themselves. 9. Group cohesiveness: since the group is united in a common goal, members gain a sense of happiness and acceptance. 10. Catharsis: Sharing feelings and experiences with a group of individuals can facilitate relieve pain, guilt, or stress. 11. Existential factors: whereas operating within a group offers support and guidance, group therapy helps members understand that they're accountable for their own lives, actions, and decisions. 6.4 The Role of Groups in Counseling A group is defined as two or more people interacting together to achieve a goal for their mutual benefit. Everyone typically spends some time in group activities each day. Gregariousness CU IDOL SELF LEARNING MATERIAL (SLM)

86 Advanced Counseling Skills - I is part of human nature, and many people and professional skills are learnt through group interactions. It is only natural, then, for councilors to make use of this primary way of human interaction. Group therapy is a style of psychotherapy that involves one or more therapists working with several individuals at the same time. This type of therapy is wide available at a variety of locations including private therapeutic practices, hospitals, mental health clinics, and community centers. Group therapy is sometimes used alone; however it's conjointly unremarkably integrated into a comprehensive treatment plan that additionally includes individual therapy and medicine. Most councellors have to make major decisions about when, where, and with whom to use groups. In some situations groups are not appropriate ways of helping. For instance, a counselor employed by a company would be unwise to use groups to counsel employees with personal problem who are unequal in rank and seniority in the corporate network. Likewise, a school counselor would be foolish to use a group setting as a way of working with children who are all behaviourally disruptive. But a group may be ideal for helping people who are not too disruptive or unequal in status and who have common concerns. In such cases counselors generally schedule a regular time for people to meet in a quiet, uninterrupted setting and interact together. Groups differ in purpose, composition, and length .Basically; however they all involve work, which Gazda describes as “the dynamic interaction between collections of individuals for prevention or remediation of difficulties or for the enhancement of personal growth/enrichment.” Hence, the term “group work “is often used to describe what goes on within groups the ASGW defines group work as “a broad professional practice involving the application of knowledge and skill in group facilitation to assist an independent collection of people to reach their mutual goals, which maybe interpersonal, interpersonal, or work related.” The goals of the group may include the accomplishment of tasks relating to work, education, and personal development, personal and interpersonal problem-solving, remediation of mental and emotional disorders. CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 87 6.5 Myths and Realities of Groups Since the history of groups is uneven, certain misperceptions about groups have sprung up. Some of the reasons for these misperceptions occurred in the 1960s when groups were unregulated and yet a popular part of the culture. It was during that period several inappropriate behaviours and discussion of personal life experiences, which spread after being, passed on by word of mouth. It is the remnants of these stories that make some people skeptical about groups or keep them from joining groups (Gladding). Some prevalent myths about groups are as follows (Childers and Couch):  They are artificial and unreal.  They are second-rate structures for dealing with problems.  They are for people to lose their identity by tearing down psychological defences.  They require people to become emotional spill their guts.  They are touchy-feely, confrontational and hostile; they brainwash participants.  Groups are suited for everyone.  The main goal of a group is for everyone to achieve closeness.  Groups tell people how they should be.  Group pressure forces members to lose their sense of identity. The reality is that none of these myths are true, at least in well-run groups. Indeed the opposite is normally true. Therefore, it is important that individuals who are unsure about groups ask questions before they consider becoming members. Doubts and misperceptions they may have gained to be addressed and their anxiety may be lessened. Therefore they may be able to benefit significantly within a group environment. 6.6 Theoretical Approaches Theoretical approaches to counseling in groups vary as much as individual counseling approaches. In many cases, the theories are the same. For instance, within group work there are CU IDOL SELF LEARNING MATERIAL (SLM)

88 Advanced Counseling Skills - I approaches based on psychoanalytic. Gestalt, person-centered, rational emotive behaviour, cognitive, and behavioural theories. Yet the implementation of any theoretical approach differs when employed with the group because of group dynamics (the interaction of members within the group). In an evaluation of seven major theoretical approaches to groups, Ward analysed the degree to which each approach paid attention to the individual, interpersonal, and group levels of the process. Gestalt and behavioural approaches were strong in focusing on the individual but weak on interpersonal and group-level components of the group process. However, the person-centred approach was strong on the individual level and medium on the interpersonal and group level. Ward pointed out the limiting aspects of each approach and the importance of considering other factors, such as a group task and the membership maturity, in conducting comprehensive group assignments. 6.7 Types of Groups Groups are available in several forms: “there seems to be a group experience tailored to suit the interests and desires are virtually anyone who seeks psychotherapy, personal growth, or just support and companionship from others (Lynn and Frauman).” There are variety of group models appropriate for a variety of situations. Although spirited debates persist, groups ought to be categorized, especially in relation to goals and process (Waldo and Bauman), the following kinds of groups have training standards developed by the Association for Specialists in Group Work (ASGW). 1. Psycho Educational Groups: Psycho educational groups, typically referred to as guidance groups or educational groups are preventive and institutional (Brown, Pence, Paymar, Ritmeester and Shepherd. Their purpose is to teach group participants how to deal with the potential threat (such as AIDS), a developmental live event (such as growing older), or an immediate life crisis (like the death of a favored one). These varieties of groups are typically found in educational settings, like schools, but are more and more being used in other settings such as hospitals, mental health centers, social-service agencies and universities (Jones and Robinson). One of the foremost vital components of the method in such groups revolves around CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 89 group discussions of how members can personalize the knowledge presented within the group context (Ohlsen). In school settings, instructional materials such as unfinished stories, puppet plays, films, audio interviews, and guest speakers are employed in psycho-educational groups. In adult settings, alternative age-appropriate means, using written language or guest lectures, are used. 2. Self-Help/Support Groups: Self-help groups and mutual help groups are similar (Klaw and Humphreys). They take 2 forms: people who are organised by an established, professional helping organisation or individual (support groups) and those that originate spontaneously and stress their autonomy and internal group resources (aid groups in the truest sense). Self-help groups usually develop spontaneously, center on a single topic, and are led by a commoner with very little formal group training however with expertise in the stressful event that brought the group along (Riordon and Beggs, 1987). Support groups, as noted, are similar to self-help groups in their focus on a specific concern or drawback, but established professional helping organisations or people (like Alcoholic Anonymous, Lamplighters or Weight Watchers) organise them (Gladding). Some support groups charge fees; others don’t. The involvement of laypeople as group leader varies. Like self-help groups support groups centre around topics that are physical, emotional, or social. Self-help and support groups partially fill the needs of populations who can best be served through groups and that might otherwise not receive services. They meet in churches, recreation centres, schools, and other community buildings as well as in mental health facilities. Lieberman sees self-help and support groups as healthy for the general public, and Corey thinks such groups are complimentary to other mental health services. Like other group experiences, however, “cohesion is always a vital characteristic for success, “and proper guidelines must be set up to ensure the group will be a positive, not a destructive, event (Riordon and Beggs ). 3. Task/Work Groups: Task/work groups facilitate members apply the principles and processes of group dynamics to improve practices and achieve known work goals. The task/work group specialist is in a position to assist groups such as task forces, committees, planning groups, CU IDOL SELF LEARNING MATERIAL (SLM)

90 Advanced Counseling Skills - I community organisations, discussion groups, study circles, learning groups and other similar groups to correct or develop their functioning (ASGW). Like other types of groups, task/work groups run best when the following factors are in place:  The aim of the purpose is clear to all participants,  Process (dynamics) and content (information) are balanced,  Time is taken for culture building and learning about each other  Conflict is addressed  Feedback between members is exchanged  Leaders pay attention to the here-and-now, and  Time is taken by leaders and members to reflect on what is happening (Hulse-Killacky, Killacky, and Donigian ) Another type of task/work group that councilors may use is “focus groups” (Kress and Shoffner ). These groups “can be outlined broadly as a technique whereby eight to twelve people discuss a particular topic of interest for 1-2 hours under the direction of a group moderator.” The moderator promotes interaction by asking group members open -ended questions and ideally elicits “a synergistic effect that cannot be obtained through individual interviews.” Themes are delineated in the process and the group facilitator may gain valuable information in the process about group member’s preferences as well as be able to describe, evaluate, and assess programs, such as mental health services. Psychotherapy Groups: Psychotherapy groups, sometimes known as personality reconstruction groups, are set up to help individual group remediate in-depth psychological problems. Because the depth and extent of the psychological disturbance is significant, the goal is to aid each individual to reconstruct major personality dimensions (ASGW). Sometimes there is overlap in group counseling and group psychotherapy, but the emphasis on major reconstruction of personality dimensions usually distinguishes the two. Group psychotherapy often takes place in patient facilities such as psychiatric hospitals or other mental health facilities that are residential in nature, because it may be necessary to keep close control CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 91 over the people involved. Certain types of individuals are poor candidates for outpatient, intensive group psychotherapy. Among them are depressives, incessant talkers, paranoids, schizoid and sociopathic personalities, suicidal and extreme narcissists (Yalom). It may be easier to identify group psychotherapy candidates who should be excluded then choose those who should be included. Regardless, group psychotherapy is an American form of treatment and has provided much of the rational for group counseling. 5. Counseling Groups: Counseling groups, sometime known as interpersonal problem- solving groups, seek “to help group participants to resolve the usual, yet often difficult problems of living through interpersonal support and problem-solving. An additional goal is to help participants develop their existing interpersonal problem-solving competencies so they may be better able to handle future problems. Non-severe career, educational, personal, social and developmental concerns are frequently addressed (ASGW). Distinguishing between a group counseling and a psycho educational group is sometimes difficult to do Table 6.3: Differences between Psychotherapy Groups and Counseling Groups Psychotherapy Groups Counseling Groups Stresses the affective involvement of participants (i) Concentrates more on the cognitive understanding of its members Conducted in a small, intimate settings (ii) More applicable to room-size environments Similarities between Individual and Group Counseling  Both have similar objectives. They aim at helping the counselee achieve self direction, self integration and responsibility.  The counselor attempts in creating an accepting, permissive climate for clients to participate freely.  The techniques Aim at clarifying feelings, restatement of content. The counselor helps the clients to become aware of their feelings and attitudes.  Both provide for privacy and confidentiality of relationship. CU IDOL SELF LEARNING MATERIAL (SLM)

92 Advanced Counseling Skills - I Differences between Individual and Group Counseling Individual Counseling Group Counseling 1. One on one, face to face marked by Physical proximity with other members of the groups, intimacy, warmth, rapport with similar concerns. 2. One on one resolution The counselees receive help and give others help. 3. Meets the needs of several individuals Counselors task is more complex, has more demands to one at a time. satisfy. Factors that Play an Important Role in Group Counseling  Selection of Group Members: A crucial factor, as members of the group should have common goals and are homogenous. A few considerations and leverages such as different age levels, different sexes have been seen desirable. Individual counseling is usually recommended as a preliminary step in the selection of members of a group. This helps prevent individuals withdrawing from the group.  Size of the Group: There has been a difference of opinion on the exact number of members in a group. Some suggest six while some even suggest twelve. What is important to keep in mind is that as the size of the group increases, collateral relationships are often weekend.  Duration of Sessions: With the adults’ sessions ranging from one hour to one hour thirty minutes seems ideal while with children approximately thirty minutes is usually ideal.  Frequency of Sessions: Some recommend weekly sessions while some recommend two sessions a week. Too many sessions may not be productive as the group members may not have the opportunity to ponder over the previous session and prepare further.  Overcoming Resistance: A common problem in group counseling is to get the discussion started. Often counselors resort to one of the most common ice breaking activities wherein the participants share the reason of participating in the group. There may be resistance, which through the process becomes less significant; as if one member ceases to talk the other may step in to sustain the process. A member, who is resistant initially, may find it easier to verbalize feelings after hearing the other group members. CU IDOL SELF LEARNING MATERIAL (SLM)

Group Counseling 93 Stages in Group Counseling Along with pre-planning, effective group counseling leaders recognize five stages in group counseling: 1. Dependency 2. Conflict 3. Cohesion 4. Interdependence 5. Termination. The stages are often called (Tuckman and Jensen, 1977): 1. Forming: The first group stage is “dependency” or forming. At this point, group members are unsure of themselves and seek direction from their leaders. This gives members a chance to explore who they’re within the group and to start establishing trust. 2. Storming: The second stage in group counseling is “conflict,” or storming. It’s going to be overt or covert. The type and amount of conflict that's generated relates to how much jockeying for position goes on within the group. 3. Norming: Stage 3 focuses on “cohesion,” or norming, which may be defined as a spirit of “we-ness.” In it, members become closer psychologically and are more relaxed. Everybody feels enclosed within the included and productive sharing begins to occur. 4. Performing: In the fourth stage, performing, the most work of the group is begun. Interdependence develops. Group members are able to assume a wide variety of constructive roles and work on personal problems. The level of comfort within the group will increase too. This is a prime time of problem resolution. It occupies about five hundredth of a typical group's time. 5. Adjourning: Adjourning deals with termination. Problems with loss in separating from the group are raised. Celebrating the accomplishment of goals is additionally a primary focus among this stage. CU IDOL SELF LEARNING MATERIAL (SLM)

94 Advanced Counseling Skills - I Recognizing group stages gives counselors an opportunity to devise or utilize appropriate leadership interventions. Advantages of Groups The principal advantages of group therapy include:  Group therapy allows individuals to receive the support and encouragement of the other members of the group.  People participating in the group will see that others are going through constant thing, which may facilitate them, to feel less alone.  Group members will function as role models to different members of the observing.  By perceptive somebody successfully managing a haul, different members of the group will see that there's hope for recovery.  As every person progresses, they can, in turn, serve as a role model and support figure for others. This may facilitate foster feelings of success and accomplishment.  Group therapy is often very reasonable. Rather than focusing on only 1 client at a time, the therapist can devote his or her time to a much larger group of people.  Group therapy offers a safe haven.  The setting permits individuals to practice behaviors and actions at intervals the safety and security of the group.  By working in a group, the therapist can see first-hand how every person responds to others and behaves in social situations. Using this information, the therapist will provide valuable feedback to each client.  Some researchers in the field regularly write comprehensive reviews on select group activities that help practitioners become better informed.  Some recent findings about groups revealed the following:  Group Counseling can be used to help ninth and 10th grade students learn social problem-solving behaviours that help them in career decision preparation (Hutchson, Freeman and Quick). CU IDOL SELF LEARNING MATERIAL (SLM)