Article 13

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The Process of Counseling


The first part of this handbook examined chronic mental illness from an objective point of view. The symptoms of schizophrenia, major affective disorders and the personality disorders were listed. Case examples were given. This is a view of chronic mental illness "from the outside."

The second part of the handbook took a more subjective point of view. The therapeutic relationship was described from both counselor and client perspectives. It was viewed as a process, which is created, maintained and guided by both parties involved. This is a view of chronic mental illness "from the inside."

Part III of the handbook will begin to examine the processes of counseling. While these are not specific procedures of counseling, i.e. diagnostic assessment, individual, group, or family counseling, (see Part IV), they are common to, and underlie, the specific procedures of counseling.

The processes of counseling in this context refer to the diagnostic or assessment procedure as well. An assessment interview is very similar to a counseling interview. In fact it is an aspect of the counseling process. Counseling begins with the assessment interview, just as assessment is an ongoing, intricate aspect of the counseling process. One is constantly interwoven with the other. The processes of counseling examined in this section, are equally applicable to assessment.

A definition of counseling and its purpose will first be offered. Next, the modalities of counseling will be formulated. They include: supportive, task oriented, educative, and crisis management. These modalities are not a locked-in or rigid set of procedures. Instead, they reflect the basic purpose, methods and goals of a particular type of counseling, e.g. psycho educational family counseling.

Clients are usually screened or selected for a particular modality depending on their needs and abilities. A regressed schizophrenic, for instance, would probably do better in a very structured, supportive, modality, whereas a more organized client would find this restrictive and might require an educational modality.

Lastly, the sub-processes of making contact, engaging the client, facilitating the counseling process and ending the session will be described. Each counseling session is a microcosm of a whole course of counseling. Both have a beginning, middle and ending. And like a course of counseling, each session has its own particular "identity;" it is both separate as well as part of the whole.


What is Counseling?

Counseling does the counselor, initiate a set of processes and procedures with the client, which result in a stable alteration of the client's perception and corresponding interaction of self and environment.

Processes in this context refer to the therapeutic relationship as well as the processes of making contact, engaging the client, facilitating the counseling process, and terminating or ending the session. It is through these processes that the procedures of counseling can operate successfully.

Procedure refers to the methods of counseling. As important as the processes of counseling are, by themselves they cannot create lasting, stable change. Procedures are the technology, the tools a counselor uses to create a stable alteration in the client's perception and behavior. The procedures may be grouped broadly as individual, group and family counseling.

A stable alteration means a positive, beneficial, consistent change over a period of time. In some clients this change may become partially internalized and not require as much ongoing counseling and support. In other clients, especially chronic schizophrenics, this alteration or change may require continued and ongoing treatment with medication, counseling and a support network.

Perception and corresponding interaction refers not only to how the client behaves, but also his point of view, his perception. There are a number of methods to get people to change or to control their behavior. It would not necessarily be correct to call this counseling however. Counseling strives to facilitate a change in how the client perceives himself in relation to his environment. When self-perception is changed, the corresponding interaction also changes.

Self and environment refers to the person of the client as well as his physical and social surroundings. The person of the client can be his physical self, as well as his social, family and occupational selves. The same is true for his environment. As with most people, clients have many different "selves" who respond differently in different contexts or environments.

Counseling then is a set of processes and procedures, which are initiated by the counselor, for the benefit of the client. Counseling is performed with empathy and sensitivity within the process of a safe and reliable relationship. The counselor utilizes various techniques or procedures of counseling to help the client achieve target goals. The general aim of counseling is to help the client develop a stable change in the way he perceives himself and interacts with his environment.


What is the Purpose of Counseling?

The purpose of counseling is to assist the client in gaining a better understanding of his thinking, feelings and behavior, which will enable him to function more successfully in his day to day living.

To assist the client means helping the client help himself. Many times in our effort to be a good counselor, we will do too much for the client. As stated in Part II, when the counselor's need to help the client is too strong, or when he feels sympathy instead of empathy for the client, there can be a tendency to do too much. Doing for the client actually takes away from the client the ability to develop the inner resolve and skills to begin to manage his own life.

Gaining a better understanding in this context refers to more than just an intellectual, factual understanding. In fact most of the understanding that will be gained through counseling is a function of experience. It is not just an understanding, which is taught, but also one that is gained through living. This type of understanding is more basic and fundamental than an intellectual understanding.

Thinking, feelings and behavior refer to the levels of understanding to be gained by the client. At the most basic level is a behavioral understanding. For very chronic or regressed schizophrenics this is a realistic level of achievement. It can best be understood as a "body understanding." Although the client may not intellectually or emotionally grasp some of the principles introduced in counseling, through patient repetition, his "body learns" more appropriate or beneficial ways of behaving.

Emotional understanding is probably where most chronically mentally ill clients can achieve substantial gains. This refers to achieving a more positive feeling about them. It focuses on attaining a sense of self-acceptance and developing self- esteem. This means accepting they do have a chronic mental illness, that this illness probably will put certain constraints on their lives, but it does not mean they are any less of a person and that they are entitled to seeking happy and productive lives to the best of their abilities.

Thinking or intellectual understanding refers to achieving some insight into their selves, their lives and their illness. However, intellectual understanding by itself is not enough. There are, on occasions, some very bright clients who may get a quick intellectual understanding of their problems, the counseling process, even the counselor. When it comes to applying these insights to making emotional and behavioral changes however, they have limited ability to do so.

Function more successfully in day-to-day living refers both to feeling better and performing better in those areas of living, which have been limiting. As previously mentioned, each person is composed of several different "selves." Some of these selves include: male, female, husband, wife, son, daughter, brother, sister, wager earner, home keeper, boss, employee, lover, disciplinarian, vacationer, etc.

Each of these selves has a kind of identity, which is connected to the type of activity that is performed. For instance, a person may think, feel and behave very differently at work than he does on vacation. This is because his work self is quite different than his vacationer self. A person may also have a better feeling about one self than another. Usually, people feel better about the self, which is successful in that area of their life, and worse about the self, which is, regarded a failure.

Chronically mentally ill clients are no exception. In those areas of their lives in which they feel unable, inexperienced or incapable, their self-esteem generally suffers. Counseling can help the client identify those areas in which he can perform better, increase that performance and his self-esteem in the process. In those areas in which the client is realistically limited, counseling can help him accept those limitations while developing a more positive self-concept.


The Modalities of Counseling

The processes and procedures of counseling comprise of several different levels. These levels proceed from the general to the more specific. The upper levels represent the philosophy, and general approaches to counseling. The lower levels represent the technology of counseling. Each level is connected to, or interdependent on the ones above and below it. They can be illustrated as follows:

Definition and Purpose of Counseling
________________________________________

Modalities of Counseling
____________________________

Process
___________________

Procedure
_______________

Technique

The definition and purpose of counseling guide and form the general overview of counseling. This is the philosophy of counseling. All other processes and procedures are subordinate.

The modalities of counseling will begin to give definition to certain basic types of counseling. Each modality, i.e. supportive, task oriented, educative, or crisis management represents a general purpose, method and goal specific to that modality. The purpose, methods and goals of supportive counseling for instance are quite different from that of educative or task oriented.

Counseling process is more specific than the modalities of counseling. Counseling process refers to the flow and movement of counseling within the counseling procedure. This movement can be divided into the sub-processes of making contact, engaging the client, facilitating the counseling process and termination. Counseling procedures refer to the specific types or forms of counseling. These are the diagnostic or assessment procedure, individual, group and family counseling. They include the individual parts of counseling; specific questions to be asked, kinds and amounts of information to be solicited as well as the various techniques of counseling.

The final level is the technique of counseling. This refers to when and how to utilize specific counseling techniques including: clarification, reflection, interpretation and confrontation. Both counseling procedure and the techniques of counseling are covered in Part IV in The Procedures of Counseling.

Counseling Modalities

Counseling modality or mode, is a term used here to describe a basic type of counseling. As mentioned earlier, analytical counseling, usually associated with psychoanalysis, is a specific mode of counseling. It is a modality, which is effective with a certain kind of client, and not effective with others.

Behavioral counseling is a modality which is designed and utilized for a specific population of clients because it is more effective with the particular abilities, strengths, weaknesses and capacities of that particular population.

A counseling modality is defined by its purpose, methods and goals. These are the why, how and what questions to be asked when considering which modality to utilize.

1. Purpose refers to why this particular counseling mode is being utilized. Why a supportive counseling modality, for instance, and not a problem solving mode? Why this particular client? These questions are designed to help the counselor choose which mode of counseling is most appropriate for which clients.
2. Methods refer to how this particular modality can meet the specific needs of this particular client. How can supportive counseling meet the needs of a chronic schizophrenic more appropriately than problem solving? How will the counselor conduct a particular mode of counseling to match and meet the needs and abilities of the client?
3. Goals refer to what is to be accomplished. What is the expected outcome of this particular modality of counseling? What goals are reasonable for this mode of counseling?

Supportive Modality

A counseling modality is usually selected by the counselor with the client depending upon that client's needs and abilities. Although the counselor may already have some idea of the needs of the client depending upon his past history and the nature of the referral, the process of collaboratively selecting a modality is important to begin to build rapport and trust.


Purpose

The first modality of counseling is supportive. The purpose of supportive counseling is essentially just that; to support.

The supportive mode of counseling is the least intrusive, invasive, or demanding. There are really no expectations of the client to change, improve or gain insight. The purpose of supportive counseling is to maintain the status quo. It is similar to the holding environment of the counseling relationship. It is designed to provide safety and security.

The main types of client appropriate for this modality are the chronic and/or regressed schizophrenics. This is because these clients have a significant need for reliable, safe, external support due to the lack of internal structure and organization.

Higher functioning or more organized clients can also utilize this modality when the purpose of counseling is primarily supportive. The Family Support Group for relatives of chronic schizophrenics for example utilizes a supportive modality.


Method

Supportive counseling can be carried out individually or within a group setting, which is the preferred procedure. This is because groups tend to provide more safety.

Most groups provide a predictable, consistent, ongoing format where there are activities to be performed. This can include art, sewing, crafts, even simple work, preferably something that will keep the clients' hands and minds occupied.

The group is usually open and ongoing. This means, in contrast to therapy groups, membership is open. It is not a requirement to attend so many sessions per week or month, and clients are not restricted to enter the group only when one has left.

Ongoing means the group will be long-term. Since personal counseling issues are not discussed, the counselor's role as a therapist is minimal. The strength and value of a supportive group is its continuing, ongoing nature. Because it is consistent, reliable and supportive by definition, clients can draw from the group's nature to help provide safety and consistency in their own internal world.

The counselor's role in supportive counseling is generally more active, structured, non-directive and reflective than with other modalities. While these counseling approaches are described in greater detail under Facilitating the Counseling Process, it is worthwhile to give a brief description of them here:

1. Activity refers to the counselor's level of physical and emotional involvement. This includes: modeling useful behavior, at times demonstrating how to perform specific activities, as well as how much emotional energy is required.
   
   Of all the counseling modalities, the supportive mode requires more activity from the counselor. This again is because most clients who will utilize supportive counseling are the least structured internally, and more passive in their behavior.
2. Structure refers to the predictability, consistency safety of the group, and how educative the counselor is. This includes setting limits and boundaries for individual and group behavior.
   
   The more there is clear, consistent and predictable structure to the counseling process, the more safety is experienced by the clients. Educative refers to the amount and type of information the counselor provides.
3. Non-directive refers to the amount of control of the tempo and direction of the counseling process the counselor provides.
   
   In a supportive mode of counseling, the counselor tends to relax his control over tempo and direction of the counseling process. With a clear and predictable structure, the counselor can "go with the flow."
4. Reflective refers to an indirect, low-key approach to facilitating the counseling process.

Goals

As already stated the general goal of supportive counseling is to support, or to maintain optimal functioning for the individual client involved. This can include:

1. Preventing relapse. Possibly the most important goal of supportive counseling with chronically mentally ill clients especially chronic schizophrenics, is to prevent psychotic decompensation leading to re-hospitalization.
2. Provide safety, structure and reliability. It would be difficult to understate just how important a regular, consistent, structured activity such as supportive counseling can be to clients. For many it fills and empty void always present inside them.
3. Provide an opportunity to socialize, to feel belonged and part of a group. Possibly one of the most agonizing aspects of chronic mental illness is the isolation, shame and rejection felt by clients and their families.
4. Although not always a direct goal of supportive group counseling, the acquisition of new skills and the discovery of latent abilities is many times its result. In some cases this leads to higher and more productive functioning at home and/or the possibility of gainful employment.

Task Oriented Modality

The next modality of counseling to be discussed is the task-oriented mode. Task oriented counseling is developed from behavioral psychology, which focuses on modifying particular behaviors, rather than on in depth understanding of how and why they are formed.

It is found this modality is particularly effective for those clients whose insight into their thinking, feeling and behavior is limited. Instead of trying to help the client understand how or why he thinks, feels or behaves in a particular way, specific behaviors are identified and targeted for change.


Purpose

The purpose of task-oriented counseling is to identify and progressively modify specific behaviors. The focus is on the specific behavior.

While insight and understanding of the reasons for the behavior are always welcomed, even hoped for, they are not the focus. In fact, the counselor must keep one eye open for clients wanting to change the focus, from modifying behavior to talking about modifying behavior.

The types of client appropriate for this modality can range from stabilized schizophrenics to the fairly high functioning. It seems to be particularly effective for clients with behavioral problems or personality disorders.

This is because personality disordered clients have problems which are specific to their behavior. Since many or most of them do not have a biochemical related illness such as schizophrenia or major affective disorder, their problems are not significantly affected by medication and are particularly resistant to change. They appear to respond best to a specific behavioral modality.

It is also important to remember the division between these particular modalities is artificial. There is probably no such thing as a completely supportive, task oriented, educational, or crisis resolution mode of counseling. They should be viewed as a particular color of counseling that can be successfully blended with other colors.


Method

Task oriented counseling is generally done individually. This is particularly the case when counseling a behaviorally or personality disordered client.

This is because a single client with a prominent personality disorder can require significant amounts of focus and energy from the counselor. There are many times, tenacious transference reactions, which complicate and detract from the focus of the counseling process, which must be repeatedly dealt with.

The counseling sessions will usually be very specific; in the focus, in the number of sessions, and in the problems which the counselor will contract with the client. From this clear format, specific tasks will be assigned to the client that is designed to modify a specific portion of his behavior.

The counselor's role in task-oriented counseling is usually more passive, structured, directive and concretive.

1. Passive in this context does not mean weak, submissive and compliant. It does mean calm, non-resistive, and when appropriate, yielding. It is a quiet strength. Of all populations, the personality disordered client requires more "therapeutic martial art."
   
   In contrast with schizophrenics, the personality-disordered client usually has a great deal of energy. Though the counselor will feel just as drained after a session, it is usually from deflecting the energy aimed at him rather than boosting low energy.
2. Structure in this context refers to setting clear limits and boundaries to appropriate behavior; specifically within the counseling session, and generally outside counseling. It also includes providing an organized, time limited and goal specific plan or agenda around which counseling will revolve.
   
   Again, in contrast to schizophrenics, personality disordered clients are usually cognitively organized. Emotionally, and behaviorally they lack structure and control. Clear, concise structure from the beginning of counseling is required.
   
   This includes appropriate behavior during the session, how long and how often the sessions will be, as well as how often the client may contact the counselor outside of the session and for what reasons. Often, the counselor will need to give alternative sources of support, such as a crisis center to handle in-between session "crises."
3. Directive refers to the amount of control of tempo and direction of the counseling process the counselor provides. It is at the other end of the continuum as non-directive.
   
   In a task-oriented mode of counseling, the counselor maintains considerable control over how fast and in what direction the counseling process unfolds. He provides a clear aim, specific methods and agreed-upon goals. This will guide the session so that specific behaviors can be tried out, monitored and corrected.
4. Confrontive, which is along the other end of the continuum as reflective, refers to the amount of focus and intensity the counselor provides. Confrontive does not mean intimidation. It means, "bringing the picture" into immediate clarity.
   
   Confrontation is frequently used in a task-oriented modality in order to keep the counseling on purpose. Without bringing counseling back to task with focus and at times intensity, with personality-disordered clients, it drifts and/or bogs down.

Goals

The goal of task-oriented counseling is to change behavior. Many times this basic goal is quite formidable. This is usually because the client himself may be minimally invested in changing his behavior and/or is highly defensive about his behavior.

Many times it is family, friends or co-workers who bring the client to counseling out of their discomfort or concern. The client may not recognize or be actively concerned about the effect his behaviors are having on others.

When the client does appear for counseling on his own he may have some difficulty accepting, emotionally, that it is he who is in need of examining and changing his behavior. Therefore, the goals of task-oriented counseling must be basic and modest. These goals may include:

1. Help the client identify and accept his need for change. This means, helping the client understand it is his responsibility to begin to change behaviors, which are hurting himself and/or others in his immediate social environment.
   
   This includes helping the client shift his perspective from feeling blamed, to accepting responsibility. One of the most formidable yet necessary tasks of the counselor with clients in general, and personality disordered clients specifically, is to let go of blame (whether it is from self or others) and accept responsibility.
2. Help the client identify and prioritize which specific behaviors can be changed. This is where skilful confrontation in providing focus and intensity is most needed. Often the client will identify those behaviors, which are either too global or diffuse to change, or those, which are minor, and of low priority.
3. Help the client begin to change; small, specific behaviors at first. This will give the client a feeling of success that change is possible, and it is very much to his advantage to change.

It is often (usually) necessary to contract with clients which specific behaviors will be worked on in counseling, how they will be changed and over what period of time. Written and signed contracts between counselor and client, clearly spelling treatment objective, methods and goals are usually quite helpful.

Educative Modality

The educative modality of counseling is quite flexible. It can be utilized for a variety of populations in a number of ways.

It can be used in combination with a supportive modality, at a basic level with chronic schizophrenics to educate them about their illness, the need for medication, how family and others relate to them, and how they can better relate to family and friends.

It can be used at a higher level with more stabilized clients to help them learn interpersonal skills, increase their ability to accept their illness, and to develop a positive self-concept and self-esteem.

It can also be used with families of the chronically mentally- ill. Psycho educational family therapy is the method of choice in helping families understands and more successfully relate to their chronically mentally ill family member.


Purpose

The educational modality of counseling has two main purposes: 1) to impart information and 2) to increase awareness.

The first purpose is quite straightforward. The provision of information is central to educational counseling. Whether it is information about the cause(s), course and treatment of mental illness, the need for medication, or the effects of highly expressed emotions within the family, providing corrective information is central and essential.

The second purpose is (hopefully) a result of the client's participation in achieving the first purpose. It is a purpose of process.

During the course of providing information about chronic mental illness the opportunity is for the client to increase his awareness. Whether the client is the family or the CMI, the opportunity is the same.

To increase awareness means the client is to gain some level of insight into his personal relationship with chronic mental illness. This can include his thoughts, feelings, behaviors, attitudes, perceptions, and reactions, in relation to his, or another's mental illness and/or emotional problems.

The aim of increasing awareness is to increase acceptance; of one's self, others, and of the nature of chronic mental illness. With increased acceptance come increased self-esteem and a more positive self-concept.


Method

Educational counseling is generally done in groups, families and groups of families. This is for several reasons: 1) it is more economical of time, energy and resources, 2) it is often very helpful for clients to hear from others with similar problems to gather information, compare situations, try new approaches, and 3) it can form an emotional bond and cohesion between clients which is very healing.

Similar to the supportive modality, educative counseling is usually open. Since the purpose is education, a closed membership is not required to protect the confidentiality of the client.

Similar to the task oriented modality, educational counseling is usually time-limited. There are a specific number of meetings or sessions to present the topic of education and discuss it.

There are situations however when educational counseling may be ongoing. This is usually the case when it is used in combination with a supportive modality. While the presentation of information may be a focus, the supportive process of the group may require an ongoing format.

The counselor's role in educational counseling is usually more flexible than with supportive and task oriented modalities. He will often vacillate between two poles of a continuum depending upon how the session or meeting is progressing and the particular needs of the client(s) at that time.

1. Active - passive. The counselor will usually be quite active as facilitator, especially at the beginning of the process to "get the ball rolling." This can include setting ground rules for the meeting, outlining the information presented, encouraging and facilitating individual and group interaction.
   
   As the process of the meeting or session begins to become more active and self-generating, the counselor will allow his participation to become increasingly passive. This does not mean to relinquish control. It does mean to guide interaction without being the focus of the interaction.
2. Structured - open ended. The educative modality of counseling is both structured and open-ended. It is structured in that the counselor usually has an organized, often time-limited, and goal-specific plan for the counseling sessions or meetings. Especially with psycho educational family counseling, there is specific information to be introduced.
   
   Educational counseling is often open-ended in process. This means, within the structure of presenting ideas and concepts, how that information is accepted, understood and utilized may require considerable flexibility.
3. Directive - non-directive. This continuum is probably in greatest flux with most counseling modalities. It also requires more empathy from the counselor when and when not to be directive.
   
   It is up to the counselor to "play each meeting by ear" to decide when and how much tempo and direction are needed. Essentially, the counselor needs to be directive to keep the counseling on track and moving, and non-directive when it is progressing well on it's own.
4. Confrontive - reflective. As a general rule, the counselor usually remains fairly reflective with the educational modality. Since it is information, which is primarily being offered, examining behaviors with focus and intensity is usually not required.
   
   The exception to this is when the educational modality is used with family counseling. At times, patterns of behavioral dysfunction within the family may need to be confronted.

Goals

The goals of the educational mode of counseling are to increase both understanding and tolerance of chronic mental illness and the chronically mentally ill. These will include:

1. Provide new information regarding chronic mental illness. Very often, many problems are created and supported from lack of accurate information. As mentioned in Part one, mental illness still tends to be misunderstood and therefore viewed with suspicion and fear. Providing accurate information regarding chronic mental illness will significantly increase both understanding and tolerance.
2. Correcting old information. As is so often the case, new information cannot be accepted and utilized until old information is corrected. Simply providing facts and figures is not enough. A cup must first be emptied before it can be refilled.
3. Reduce guilt, blame and stigma. Again, just providing information may not be enough. Old emotional attitudes, feelings and perceptions, which are attached to the lack of, or misinformation, need to be addressed and dealt with. Emotional relief is the basis of increased tolerance.
4. Replace old dysfunctional behavior with new corrective behavior. The actual, physical demonstration of increased understanding and tolerance is corrective behavior. It is not enough to talk about increased understanding and tolerance; it needs to become real or actualized.
5. The result or end product of a positive change in thinking, feeling and behaving is increased acceptance, a more positive self-concept and self-image.

When accurate information, increased understanding and tolerance have replaced old dysfunctional beliefs, attitudes and behaviors, the result is a positive internal change in self-concept and self-esteem.

Crisis Resolution Modality

Crisis resolution is included as a modality of counseling with the chronically mentally ill because crises of varying degrees are often encountered. These crises can include just about any aspect of living. They can be default of medication leading to psychotic decompensation, just about any variation of relationship problem, and internal feelings of isolation, depression, and desperation.

A crisis is almost always specific to the individual. This is because different individuals have different capacities to tolerate and adapt to the various stresses and strains of daily living. What is a crisis for one person may not be for another.

Generally speaking, chronically mentally ill clients have a lower capacity to tolerate and cope with stress. Since their internal sense of self is usually weaker and more prone to fragmentation, they react more severely (whether it is obviously apparent or not) to upsets and unpredictability than others with a stronger, more cohesive self.

They also (usually) have fewer resources at their command to provide relief or resolution.

A crisis may be defined as danger and opportunity. While the danger may not be identified as a real or external threat to life, limb or property, it may be felt as such. Again this is because the precipitant or stressor may threaten the client's internal sense of safety.

The opportunity available during crises is the possibility that resolution of the crisis may increase the client's internal strength and ability to tolerate stress more successfully. It may also create a beneficial change in his external environment. This can include greater understanding and tolerance from others in his immediate social environment.


Purpose

The purpose of crisis resolution is to decrease the danger and increase opportunity. The types of danger may include:

1. Physical danger. This of course is the most urgent and imperative form of danger. It includes the possibility of eminent danger to self or other. It necessitates immediate action.
   
   The most extreme cases of physical danger are suicide and/or homicide. It can also include self-mutilation, or physical harm to others.
2. Mental danger. This includes the danger of psychotic decompensation. Losing one's grip on reality is often a frightening and disturbing possibility. For chronically mentally ill clients, especially those with chronic schizophrenia or affective psychosis, it is too often a reality.
   
   Mental danger can also come in the form of intrusive, obsessive, or disturbing thoughts. The client with obsessive-compulsive personality disorder is often in crisis because of thoughts and fantasies he cannot control.
3. Emotional danger. This is usually the sense of being overwhelmed and out of control of one's feelings. These are most often the clients who call a crisis hotline. While in some cases, emotional dyscontrol can lead to physical or mental danger; it is often an indication of feeling helpless and/or hopeless.
   
   Emotional danger is usually a client's reaction to a mix of situational stress and emotional vulnerability. When the severity of the emotional reaction seems disproportionate to the stress caused by the situation, there is a good chance the client may be highly vulnerable.

Decreasing physical, mental and/or emotional danger usually requires specific and immediate action on the part of the counselor. As will be discussed, it many times requires the counselor to take control of the situation providing clear direction and specific action.

Increasing opportunity means to utilize the crisis situation not only to provide resolution to the immediate crisis, but when possible, to gain some level of personal understanding and empowerment to make internal and/or external change.

One of the unique opportunities a crisis presents to the client and the counselor is that of making some kind of significant change. This is because the nature of crises many times strips the client of his usual defense system.

When this is the case, the client is particularly vulnerable and susceptible. Vulnerability and susceptibility can of course lead to greater danger when it is not dealt with skillfully and appropriately.

When it is handled with appropriate empathy and skill, the resolution of the crisis can lead to lasting internal and external change. This change can be the way the client perceives himself and/or how he interacts with his social environment.


Method

The crisis resolution modality of counseling is almost always done individually. While there are usually others who are affected and involved, the personal nature of crisis requires an individual approach for the person in crisis.

Crisis resolution is often done over the phone. This requires the counselor to project or extend his empathy. This is probably the most taxing kind of counseling. It puts great demands upon the counselor to listen intently with "every pore of his body."

It is often as important to listen for what is not being said, as what is being told. Emotional tone of the voice, the delivery of the content and how "things add up," become essential information for the counselor. He is required to make rapid and essential decisions, at times with very little objective information.

Of all the counseling modalities, the crisis counselor must be the most fluid and flexible in his approach. He requires a good command of his own personality to be able to shift instinctively from one continuum to another, as the situation requires. Although he will most often find himself in the active, open-ended, directive and confrontive role, he must be able to smoothly and spontaneously transition to the other continuum, as the situation requires.

1. Activity in this context refers to how the counselor utilizes or applies his energy and activity. Many times the counselor is quite active gathering information, providing reassurance, clarifying and prioritizing issues. Since the situation may require immediate and concise action, the counselor must have as much and as clear, accurate information as possible.
   
   There are times when the crisis is primarily emotional in nature; the counselor will find himself in a passive, supportive role.
2. The crisis modality of counseling in generally open -ended. While the counselor may be very directive, even confrontive, he must also be open-ended. This is because he is learning about the client as the process of counseling progresses.
   
   While he is making necessary decisions and comparisons based on his experience, he must not allow himself to be judgmental or jump to premature conclusions about what kind of person the client is or the nature of the situation involved. The counselor must be able to "roll with the punches" as new information and impressions are received.
3. Again, the crisis counselor must be flexible. Most of the time, especially when the danger is physical or mental, he will be quite directive. Usually, clients who are experiencing physical or mental danger will be upset, disorganized and chaotic. They may present with an enormous amount of irrelevant or disconnected information. The counselor must be directive enough to screen, organize and prioritize information to come to a decision and plan of action.
   
   When the danger is primarily emotional however, the counselor may find himself in a less directive or non-directive role. In these situations, it may be more appropriate to allow the client to vent. Being too directive may be experienced by the client as intrusive or "uncaring."
4. Similar to the directive non-directive continuum, the counselor needs flexibility in the confrontive -reflective continuum. Empathy for the current needs of the client is required.
   
   When the danger experienced by the client is physical or mental, confrontation in providing focus and intensity is appropriate. The primary need of the client in this situation is clarification and specific direction. Focus and intensity can help separate "the wheat from the chaff" and get directly to the core issues.
   
   In dealing with the client's emotional danger, at times confrontation will lead to intimidation or conflict. The counselor needs a good sense of timing, must have a good assurance of the issue at hand, and a willingness to let go if confrontation is not furthering the process.

Goals

The primary goal of the crisis resolution modality of counseling is to resolve the immediate crisis. This may include:

1. Preventing physical harm to the client or others. This is always the overriding and most important goal. Physical harm can include suicide or homicide, self-mutilation or assault on others, or any variation thereof.
2. Preventing or resolving mental harm to the client. This includes an acute psychotic decompensation or mental breakdown, progressive mental deterioration, or chronic mental conflicts such as acute obsessive rumination.
3. Giving support and/or offering resolution to emotional harm. Many times this includes just giving support and reassurance. Other times it includes helping the client to solve problems regarding conflicts at home or at work. It usually entails listening, helping the client sort out problems and prioritize what is important. It may include giving advice (carefully) and making referrals for ongoing counseling.

The secondary goal of crisis resolution is to help the client make use of this crisis to help prevent others. This is the opportunity available during the crisis and while it is being resolved.

The type and amount of opportunity will depend on the nature of the crisis and the abilities of the client. With chronically mentally ill clients the opportunity may include small gains in understanding and restructuring of their behavior. It may include:

1. Helping the client recognize what his particular vulnerabilities are in relation to the kind of stress, which is precipitating the crisis. This will begin to help him identify "warning signals," i.e. specific thoughts, feelings and behaviors he engages in when he is reaching a crisis point.
2. Helping the client recognize what kinds of situations he is vulnerable to, that tax his abilities to cope with the stress that situation precipitate. This will help him learn to modify his behavior and/or environment to avoid or limit his involvement in these kinds of situations.
3. Helping the client to develop support systems. This may include becoming involved in a support group, counseling, developing supportive friendships or improving relations with family members.

For families, relatives and friends of chronically mentally ill clients, substantial relief, both immediate and long, term is available.

As will be discussed in Part IV, psycho educational family counseling and support groups have proven to be tremendously helpful in providing accurate information, decreasing guilt and shame associated with the stigma of mental illness, restructuring family relationships and providing peer support to families of the chronically mentally ill.

Diagnostic Evaluation

As previously stated, the diagnostic evaluation or assessment is considered a counseling procedure. While assessment or gathering needed information is certainly a primary focus of the first interview, it is a procedure of counseling as the counselor will continually request new, more in-depth information as counseling progresses.

Counseling and assessment are continually interwoven. As the counselor gains more information, both objective and subjective, he defines and re-defines his approach and methods. As his approach and methods focus on key areas of client dysfunction, the counselor gathers new and more relevant information.

The assessment interview per se, is concerned with how to collect and organize data into a format that will make it easily accessible and presentable. The format presented is similar to those used widely in medical, psychiatric and social service agencies in the United States. It is found to be relevant and useful in the Singapore context.

It is designed to gather and record the essential data needed to gain a good idea of the dynamics of the client involved, to make a provisional assessment or diagnosis, and to form a treatment plan. The format presented is flexible and every section need not be followed or utilized, depending on the needs and scope of the agency.

Information presented during the assessment interview may not follow the prescribed form. It may require taking notes while interviewing the client and later organizing them into the assessment form.

Identifying data is the basic demographic information needed to identify this particular client. It includes age, race, martial status, referral source and reason for referral.

Presenting problem refers to the initial problem or complaint the client comes to the agency or counselor with. While it may not be the same problem(s) the client leaves the interview with, it is the initial, presenting problem.

It may also be that the client, especially when concerning chronic mental illness, is a family member who is distressed, but whose focus will be on CMI family member. Never the less, this format can be utilized when assessing a client directly or via a family member. Some of the information the counselor will need may include:

1. What is the client's understanding of the problem? Is it a problem with his thinking, feelings or behavior?
2. Why is the client seeking help at this time? Especially if the problem has been ongoing, what has changed? What is the precipitating event?
3. Why this agency? What are the client's expectations? What is hoped for? How realistic are their expectations? What can be provided?

History of the Problem.
When the counselor has some idea of what the problem is, he needs to begin to get a history of how long the problem has been going on, how it has developed over time. Whether this is the first time this problem has arisen, or whether the client has dealt with this before. And if so, what was done at that time. It is important to begin to fit the problem into some kind of personal context.

1. How long has this been a problem? Has it ever happened before? When? What was done then? How did that work?
2. What part of the client's life is being affected, i.e. physical health, emotional stability, thought process, relationships, family, marriage, financial. When did the problem begin to affect this part of the client's life?
3. Intensity. How badly is the client feeling at this time? What has he thought about? Listen for suicidal ideas, thoughts of violence or losing control.

Psychiatric History.
A clear and accurate psychiatric history is needed, especially when the client is chronically mentally ill. This will begin to give the counselor an ideal of how chronic the problem has been, what action has been taken in the past. Some questions to ask:

1. Is the client currently in treatment with a doctor, psychiatrist, counselor, privately or at a clinic? It is very important that clients do not split their treatment or treatment providers. If they are in treatment, ask whether you may contact the provider. If not, ask why.
2. Is the client currently taking any psychiatric medications? If so, what are they? Who is prescribing them? How long has the client been taking them? Effects? Side effects? If they have recently stopped their medication, ask why? How have they been since stopping their medicine?
3. Has the client ever been hospitalized? If so, where, how long, how many times? What was the discharge plans? Did the client follow the plans? If not, why not? These questions are not meant to insight the client, nor are they asked punitively, - the client may have a very good reason for stopping treatment. It is important for the counselor to know.

Medical History.
Although we are physicians, it is important to get some idea of the client's medical history. Many times chronic medical problems can be a source of intense emotional stress even if they have been silently tolerated for years.

It can also be useful to gain some idea of the medications and/or alcohol taking habits the client may have.

1. Does the client have any medical problems? If so what are they, how long has he had them? What medicines are taken? Any recent change in medicines? Who is the doctor prescribing them? Is the client taking any non-prescribed drugs? If so what, and how long? What use of alcohol?

Social History.
A history of the client's social interactions is especially important when chronic mental illness is involved, as the presenting client may be the family. It is very helpful to gain an understanding of the social environment, which surrounds, and/or is affected by the client. Social history involves both a developmental history and the current situation.

1. Developmental history. This includes information regarding the past personal history of the client. How was the client's childhood? Any developmental arrests? Childhood diseases? Traumatic accidents? How was the environment at home? Supportive? Conflictual? Any deaths, marital separations or other significant losses? How was the client in school? How did he perform scholastically, socially? What kind of work history does the client have?
2. Current Situation. What is the client's social, marital, financial and family situation like at present? How are the client's symptoms affecting these situations? How well does the current situation tolerate these symptoms?

Mental Status Examination.
The mental status examination (MSE) is the counselor's equivalent to the physician's physical examination. It is the direct examination of the client's thinking, feeling and behavior. While some of this information may be obtained second hand, it is never as complete and as accurate as obtaining it directly.

Much of the information may be obtained through observation and casual interaction. Some of it must be asked for directly. The MSE becomes increasingly important when dealing with chronic mental illness as it provides direct evidence of a mental disorder. It is also the primary tool used in forming a differential diagnosis.

The MSE is composed of several different parts and although listed in a specific order here, can be tested in whatever order is most convenient for the counselor.

1. Appearance. This is an overall impression of the client and includes: dress, grooming, hygiene, facial expression and presenting behavior.
2. Arousal. The means the level of alertness the client is at the time of examination.
3. Orientation. This refers to whether the client knows: 1) time: i.e. what day of the month, month of the year, and what year it is; 2) place: where it is he is at, at the time of the interview; 3) person: does the client recognize his name, home, place of birth, or basic identity?
4. Thought Process (form of thought). This refers to the process of thinking, i.e. whether it is goal oriented, and associations are intact, or whether the client displays loosening of associations, rambling, tangential, circumstantial or poverty of thought.
5. Perception. This refers to whether there are current auditory, tactile, somatic or visual hallucinations.
6. Thought Content. This refers to whether the client is displaying any fixed or partial delusions, or delusional ideation.
7. Speech. The refers to the client's rate and flow of speech. Rate is the speed or tempo of the speech, while flow, refers to the evenness and spontaneity of delivery.
8. Affect. This refers to the client's current emotional expression and is composed of several aspects:
• Appropriate or inappropriate to the content of what is being said.
• Type, i.e. flat, expansive, labile or restricted.
• Mood or current emotional state, i.e. depressed, happy, angry, elated, sad, etc.
• Suicidal or homicidal ideation, intent or plan.

Impression.
The impression includes both a subjective statement about the counselor's assessment as well as an objective diagnostic statement. The impression reviews and unifies the various parts of the assessment and leads to a plan.

1. Subjective statement. This is where the counselor draws together his subjective impressions of the client, based upon information acquired through empathy. It is more of a description of the process of how the interview transpired than the specific information gathered.
2. Objective statement. This is a presentation of the facts, or the clinical evidence to support a specific diagnosis. It includes specific symptoms of the disorder by history and the mental status examination. A diagnosis is then drawn from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), which is consistent with the history and symptoms presented.

Plan.
The plan is a statement of action based on the assessment. It has two parts. The first is a general or overall statement concerning the major issues the client is facing. It can include a suggestion for a modality of treatment, i.e. supportive group counseling, individual task oriented counseling, etc.

The second is a contract to be signed with the client. The contract is considered an essential part of the plan because it forms an agreement with the client for counseling around specific problems. This gives the client a specific idea of what the issues of his counseling are as well as a commitment from him, by signing the agreement, to attend counseling.

 
 
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