Lecture 3- Counselling Process and the Skills

Beginning (The Initial Interview)

There is no one place to begin the initial interview, but the most
important thing to begin your counselling or therapy with is to start with
building Rapport.
Rapport:
 Rapport is crucial.
 How you build rapport with your patient depends completely on
you.
 Rapport building is the process that begins with the first time you
meet your patient, but goes on till it is required in the process.
 You are your best judge, therefore, observe yourself throughout the
process, and help yourself building rapport with your patient.
 Start by trying to make the patient comfortable.
 Set aside your own agendas and focus on the patient,
including listening to the patient’s story and presenting
issues.
 This type of behavior in which there is a genuine interest
in and accepting of a patient is known as rapport.
 Two most important micro skills for rapport building-
basic attending behavior and client-observation skills.
 A counselor needs to tune in to what the patient is thinking
and feeling and how he or she is behaving.
 In this process, counselor’s sensitivity to the metaphors
generated by the patient may help to convey understanding
of the patient’s unique way of knowing and at the same
time contribute to the development of a shared language
and collaborative bond between the two.
 For instance, a patient may describe herself as being
treated by others as “yesterday’s leftovers.” Here, the
metaphor gives both the patient and the counselor
 information about the thinking and behavior going on in
the patient as she seeks to be seen “as the blue plate
special.”
 Regardless, establishing and maintaining rapport is vital
for the disclosure of information, the initiation of change,
and the ultimate success of counselling.
 Inviting patients to focus on reasons for seeking help is
one way in which counselors may initiate rapport. Such
invitations to talk are called ‘door openers’. The contrast
of which is called ‘door closer’ which is- judgment or
evaluative responses.
 Appropriate door openers- inquiries and observations such
as “what brings you to see me?” “What would you like to
talk about?” and “You look like you are in a lot of pain.
Tell me about it.” These unstructured, open-ended
invitations allow patients to take the initiative to talk. In
such situations, patients are most likely to talk about
priority topics.
 The amount of talking that patients engage in and the
insight and benefits derived from the initial interview can
be enhanced by the counselor who appropriately conveys
empathy, encouragement, support, caring, attentiveness,
acceptance, and genuineness. Out of all of these qualities,
empathy is the most important.
Empathy

 Empathy is the counselor’s ability to enter the patient’s phenomenal

world to experience the patient’s world as if it were your own without
ever losing the ‘as if’ quality.
 Empathy involves 2 specific skills: perception and communication.
 Empathy is inbuilt in us; we need to put a light on it.
 It is difficult to be empathic towards people, however, it is possible.
  We all come with our own biases, preconceived notions, and myths,
which make our perception. However, an effective counselor perceives
the cultural frame of reference from which his or her patient operates,
including the patient’s perceptual and cognitive process.
 This type of sensitivity, if it bridges the gap between the counselor and
patient, is known as ‘culturally sensitive empathy’ and is a quality
counselors may cultivate.
 Nevertheless, a counselor who can accurately perceive what it is like to
be the patient but cannot communicate that experience is a limited helper.
Such a counselor may be aware of the patient dynamics, but no one,
including the patient, knows of the counselor’s awareness.
 The ability to communicate clearly plays a vital role in any counseling
relationship.
 In the initial interview, counselors must be able to convey primary
empathy.
 primary empathy is the ability to respond in such a way that it is apparent
to both patients and counselor that the counselor has understood the
patient’s major themes.
 Primary empathy is conveyed through nonverbal communication and
various verbal responses. For example, the counselor leaning forward and
speaking in a soft, understanding voice.
 Advanced empathy is a process of helping a patient explore themes,
issues, and emotions new to his or her awareness.
 This second level of empathy is usually inappropriate for an initial
interview because it examines too much material too quickly.

Verbal and Nonverbal Behavior

 Whatever its form, empathy may be fostered by attentiveness, that is, the
amount of verbal and nonverbal behavior shown to the patient.
 Verbal behaviors include communications that show a desire to
comprehend or discuss what is important to the patient.
 These behaviors include probing, requesting clarification, restating, and
summarising feelings. This indicates that the counselor is focusing on the
person of the patient.
 Equally important are the counselor’s nonverbal behaviors.
  Physically attending behaviors such as smiling, leaning forward, making
eye contact, gesturing, and nodding one’s head are effective nonverbal
ways of conveying to patients that the counselor is interested in and open
to them.
 5 nonverbal skills in initial attending (SOLER):
S- S is the reminder to face the patient squarely, that is, the counselor
shows interest and involvement in the patient.
O- O is the reminder to adopt an Open posture, free from crossed arms
and legs and showing nondefensiveness.
L- L reminds the counselor to lean toward the client. However, leaning
too far forward and being too close may be frightening, whereas leaning
too far away indicates disinterest. The counselor needs to find a middle
distance that is comfortable for both parties.
E- E represents Eye contact. Good eye contact with most patients is a sign
that the counselor is attuned to the patient. For other patients, less eye
contact or even no eye contact is appropriate.
R- R is the reminder to the counselor to Relax. A counselor needs to be
comfortable.

Unhelpful Behavior(Verbal):

 Interrupting
 Advice giving
 Preaching
 Blaming
 Extensive questioning
 Demanding
 Patronizing attitude
 Over interpretation
 Using jargons
 Straying from the topic
 Overanalyzing
 Talking about self too much
 Minimizing or disbelieving

Unhelpful Behavior(nonVerbal):
  Looking away
 Sitting far away or turned away
 Frowning
 Tight mouth
 Shaking pointed finger
 Distracting gestures
 Yawning
 Closing eyes
 Unpleasant tone of voice
 Rate of speech too slow or too fast
 Acting rushed
 fidgeting

Beginning (Exploration and the Identification of Goals)

 Help the patient explore specific areas and begin to identify goals that the
patient wants to achieve.
 Establishing goals is crucial in providing direction at any stage of
counseling.
 Exploring and ultimately identifying goals often occurs when a patient is
given the opportunity to talk about situations, or to tell personal stories.
 The counselor reinforces the patient’s focus on self by providing
structure, actively listening (hearing both content and feelings), and
helping identify and clarify goals.
 Effective Goals are:
1. Mutually agreed on by the patient and counselor- Without mutual
agreement neither party will invest much energy in working on the
goals.
2. Specific- If goals are too broad, they will never be met.
3. Relevant- there are many possible goals for the patients to work on,
but only those that are relevant to changing should be pursued.
4. Achievement and success oriented- counsleing goals need to be
realistic and have both intrinsic and extrinsic payoffs for patients.
5. Quantifiable and measurable- it is important that both patient and
counselor know when goals are achieved. When goals are defined
quantitatively, achievement is most easily recognised and measured.
6. Behavioral and observable- this relates to the previous one: an
effective goal is one that can be seen when achieved.
7. Understandable and can be restated clearly- it is vital that patient and
counselor communicate clearly about goals. One way to assess how
well this process is achieved is through restating goals in one’s own
words.