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  1. 1. Counselling: Definition, scope, application, relation to health and diseases Dr Khem R Sharma AP, School of Public Health & Community Medicine, BP Koirala Institute of Health Sciences
  2. 2. Background  Communication strategies can enhance learning and bring about change in the desired direction for the person who receives the communication, which may be at various levels: a) Cognitive level - increase in knowledge; b) Affective - changing existing patterns of behaviour and attitudes; c) Psychomotor - acquiring new skills.  Counselling is such a process that enables an individual to know him/herself and his/her present and possible future situations in order to make substantial contributions to the society and to solve his/her own problems through a face to face relationship with a counsellor.
  3. 3. Introduction  “Counselling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.” (ACA)  Counselling - face to face communication by an expert, which helps the person to make decisions or solve problems and act on them.  Specific to the need, issue and circumstances of each individual; Interactive, mutually respectful collaborative process.  Goal directed, acceptable in social and cultural contexts and aims to bring about changes in attitude and behavior of the concerned individual.
  4. 4. Elements of Counseling  The counselling environment is a place to facilitate counseling.  The counsellor is professionally capable of extending help.  The counsellee seeks help and lets himself/herself be subject to counseling.
  5. 5. Major Goals of Counselling  Behaviour Change  Enhancing coping skills  Promote decision making  Improving relationships  Facilitate client's potential
  6. 6. Objectives of Counselling  1. Achievement of Positive Mental Health: When a person is able to relate positively and meaningfully with others around them and leads a fulfilling life.  2. Problem Resolution: Individual is assisted in finding solutions to difficult situations/problems in their lives by themselves.  3. Counselling for Decision-making: Develop individuals capable of making the right and timely decisions independently that is crucial for success in life.
  7. 7. Objectives….contd.  4. Improving Personal Effectiveness: Effective person is able to control impulses, think in creative ways and has the competence to recognize, define and solve problems.  5. Help Change: Counselling helps individual make alterations in attitudes, perceptions or personality to bring about changes for development.  6. Behaviour Modification: Removal of undesirable behaviour or self- harming behaviour and learning desirable behaviour is essential for attaining effectiveness and good adjustment in life.  All these objectives are interdependent and overlapping.
  8. 8. COUNSELLING TECHNIQUES I. DIRECTIVE COUNSELLING (PRESCRIPTIVE COUNSELLING)  Authoritarian or psychoanalytic approach advocated by E.G. Williamson, a professor at University of Minnesota.  The counsellor plays a prominent and leading role by suggesting all possible solutions.  The counsellor gives direct advice, suggestions & explanations to the counsellee, and through repeated explanation convinces the counsellee regarding the suitability of the suggested solution.  Limitations: - The counsellee may face difficulty in implementing and practising the identified solution as the counsellor may not have considered all the issues and the influences on the counsellee. - The counsellee may become totally dependent on others for finding solutions to any problem.
  9. 9. II. NON-DIRECTIVE COUNSELLING  client-centered approach for solving emotional/personal problems of individuals.  Limitations: - time consuming as many sessions may be required to convince the individual to utilise their inner resources for solving problems. - Very much relient on the ability & initiative of the patient. III. ECLECTIC COUNSELLING  The counsellor may start with directive approach but when the situation demands, he may incorporate non-directive technique.  Whatever be the technique used by the counsellor, counselling process requires honesty, sincerity and openness of the counsellee. COUNSELLING TECHNIQUES…
  10. 10. Steps of counselling  G- Greet client in a friendly, helpful, and respectful manner  A- ask clients about themselves, their needs and concerns  T- about different options, methods and coping mechanisms  H- help the client to make decision to choose a method s/he prefers.  E- Explain to client on how to use the method  R- Return: Schedule and carry out return visits and follow-up of client
  11. 11. Stages of Counseling Process 1) Rapport and Relationship Building 2) Assessment & analysis of the problem 3) Goal-setting 4) Counselling Interventions 5) Termination and follow-up
  12. 12. 1) Rapport and Relationship Building  Establishing a rapport by being genuine and extend warm welcome to the client.  Give introduction, orient the client and assure confidentiality of the issue.  Outline the counselling process to the client regarding content, duration, testing options and procedures, facilitated by good atmosphere, adequate privacy, comfortable seating arrangement.  Establishing eye contact with the client .
  13. 13. 2) Assessment & analysis of the problem  Define and focus specifically on the problem.  Identify and asses the gravity of the client’s problem.  Assess the impact of the problem on the client’s life.  Exploring the resources and support available to the client.
  14. 14. 3) Goal setting  Following the identification and assessing the magnitude of the problem, goals need to be set with time frames.  Examples : pretest counselling of HIV/AIDS 1.To get the test done. 2. If not undergone test, encourage them and ask them to come when they are prepared. 3.Prepare the client for any type of test result i.e negative/positive.
  15. 15. 4) Counselling intervention  The counselling process is then initiated using the appropriate techniques as required.  Key factors during HIV post test counselling:- • Cross check the result with the client . • Provide result to the client in person. • Ask the client to summarize what was discussed last time
  16. 16. 5) Termination and follow-up  Adequate exchange of knowledge, skills and emotions leads to a determination of providing solutions to the problem by the client.  It does not end there but the set goals and timeline are adhered to  Eg: STI counselling does not end with the diagnosis of the client’s status. • Ask the client to come with his/her partner. • Counsel their family members to accept them and help them to live comfortable life.
  17. 17. MICRO SKILLS OF A COUNSELLOR I. Listen Actively - how to listen actively ?????  Sit comfortably and accept the clients as they are.  Listen intently to what the clients say and how they say it.  Notice the tone of the voice, facial expression and gestures.  Keep silent occasionally to provide the client time to think & ask questions.  Look directly at the client when they speak, not on the notes or windows.
  18. 18.  Ensure they are continually involved in the conversation by either “nodding head, saying then” etc.  Overall, 10 % of the communication we perform are represented by words, 30 % are represented by sounds we make (by minimum verbal) and 60 % are represented by body language ( eg- eye contact, body posture etc.)  Once the counsellor recognizes the client’s feeling let him/her know in clear and simple words that they have been understood which is know as “reflecting feeling”. MICRO SKILLS OF A COUNSELLOR
  19. 19. MICRO SKILLS OF A COUNSELLOR II. Questioning  Ask questions to understand clearly the clients’ problem or worries and to help the client go deeper into his/her own awareness or insight.  One question should be asked at a time, looking at the person  Ask questions that serve the purpose - not irrelevant ones or too many questions.  Be brief and clear and use questions centered around the concerns of the client, that enable them to talk about their feelings and behaviours (open ended questions).  Use question to explore and understand issues and not to collect juicy material for gossip.
  20. 20. SN Open ended questions Closed ended questions Leading questions 1 Response more than one Limits the response of client in one word answer Unknowingly suggests answer to the client 2 Invites the client to continue talking and helps in what direction counsellor wants to take conversation Did not give opportunity to think about what they are saying Questions are usually judgemental. 3 Simple yes/no cannot answer the question Answer- very brief and do not provide much information 4 Ex- 1. what difficulties do you experience in practicing safe sex? 2. When did you think would be right time to disclose your test to your spouse? Ex- 1. Do you practice safe sex? 2. Should I disclose your test result to your spouse? Ex-1. You do practice safe sex , don’t you ? 2. Do you think that your wife will abandon you if she knows about your HIV status? MICRO SKILLS OF A COUNSELLOR…contd
  21. 21. MICRO SKILLS OF A COUNSELLOR…contd III. Using silence  Give the client time to think about what to say next.  Provide space to experience feeling.  Allow clients to proceed at their own pace.  Give the client freedom to choose whether or not to continue.
  22. 22. MICRO SKILLS OF A COUNSELLOR…contd IV. Non-verbal behaviour  It is not what is said but how it is said that is important.  Majority of expression – non verbal  When a person’s body language is not similar to what they are saying, it results in verbal confusion/mis-interpretation.  Effective counsellor is sensitive to nonverbal communication .  Examples : gestures, facial expression, posture, eye contact, tapping fingers, change in voice pitch and fluency of voice.
  23. 23. MICRO SKILLS OF A COUNSELLOR…contd V. Accurate Empathy  Empathy - recognition and understanding of clients thoughts and emotions.  It is characterized by ability to put oneself into another's shoes - experience the view point of another within oneself. VI. Paraphrasing  Counsellor repeats in his/her own words what client has said to show that they have understood.  They summarize the clients thoughts and feelings in a few words that captures the whole gist of what the client is trying to express.
  24. 24. Attributes of an Effective Counselor  Communication Skills: Effective counselors should have excellent communication skills with a natural ability to listen and be able clearly explain their ideas and thoughts to others.  Acceptance: Being nonjudgmental and accepting are important attributes in any of the helping professions with warmth and understanding  Empathy: the ability to feel what another person is feeling. Compassion and empathy help your clients feel understood and heard.  Problem-Solving Skills: must have excellent problem-solving skills to be able to help their clients identify and make changes to negative thought patterns and other harmful behaviors that might be contributing to their issues
  25. 25. Attributes of an Effective Counselor…  Rapport-Building Skills: must possess a strong set of interpersonal skills to gain the client’s trust focusing on their clients without distractions.  Flexibility: ability to adapt and change the way you respond to meet your clients' needs without a rigid predetermined approach  Self-Awareness: Self-awareness is the ability to look within and identify your own unmet psychological needs and desires and prevent it from affecting or conflicting with those of your clients.  Multicultural Competency: relate to and understand clients regardless of their race, ethnicity, religious or political beliefs or socioeconomic background
  26. 26. TYPES OF COUNSELING I. INDIVIDUAL COUNSELING:  Personal opportunity to receive support and experience growth during challenging times in life.  Individual counseling can help deal with many personal topics in life such as anger, depression, anxiety, substance abuse, marriage and relationship challenges, parenting problems, school difficulties, career changes etc. II. COUPLES COUNSELING:  Every couple experiences ups and downs in their levels of closeness and harmony over time which can range from basic concerns of stagnation to serious expressions of aggressive behavior.  Marriage/couples counseling can help resolve conflicts and heal wounds by decreasing animosity and reestablish realistic expectations and goals.
  27. 27. TYPES OF COUNSELING…contd III. FAMILY COUNSELING:  Family counseling is often sought due to life changes or stress negatively affecting one or all areas of family closeness, family structure (rules and roles) or communication style.  Common issues addressed in family counseling are concerns around parenting, sibling conflict, loss of family members, new members entering the family, dealing with a major move or a general change affecting the family system. IV. GROUP COUNSELING:  Group counseling allows one to find out that they are not alone in their type of life challenge, but with a group of peers which increases one’s understanding of the struggles around the topic and also the variety of the possible solutions available.  Typically, groups have up to eight participants, one or two group leaders, and revolve around a common topic like: anger management, self-esteem, divorce, domestic violence, recovery from abuse and trauma, and substance abuse and recovery.
  28. 28. Scope of counselling  Scope of counselling is very vast as it is required to solve a variety of physical/Mental and social problems.  In medical sciences counselling is a major part of the management strategy, with inherent differences in the content and context.  Counseling includes, but is not limited to, psychotherapy, diagnosis, evaluation; administration of assessments, tests and appraisals; referral; and the establishment of counseling plans for the treatment of individuals, couples, groups and families with emotional, mental, addiction and physical disorders.
  29. 29. Scope of counselling…contd  Work Stress:  Work environment has become a leading cause of stress for the working population owing to unrealistic pressures and deadlines set up by the CEO’s, which is ultimately carried home, hampering their personal life too.  Often individuals need the help of counselors to get a clear perspective and overcome their challenges to handle their professional and personal life.  Depression & Anxiety: A common disorder that necessitates the role of counseling, which forms a part of its management.  Grief Counselling: Greif and Bereavement are situations where most people find themselves unable to cope with their loss. counseling is needed to guide the person through this difficult period.
  30. 30. Scope of counselling…contd  Pregnancy & post-pregnancy: Before and after the introduction of a new member in the family the situation can become stressful.  Chronic Diseases: Counselling is an integral part of its management  Behavioural Issues: Identification of the reason behind behavioral issues and helping the person to find coping mechanism to overcome it.  Family & Relationships: Solving problems in family and relationships requires a professional approach with implementation of various techniques of counselling
  31. 31. Scope of counselling…contd  Marriage/Divorce counselling  Guidance and career counseling  Rehabilitation counseling  Mental health counseling  Substance abuse counseling  Educational Counseling  Counselling is also necessary in different areas like Juvenile delinquency, Gender-identity, sexuality, Disadvantaged groups etc.
  32. 32. Evaluation of Counselling  the process of finding the effectiveness of counselling.  It is an attempt to find out to what degree the objectives of guidance and counselling has been attained.  Tools have been developed to assess the output of counselling  The trans-theoretical (stages of change) model assesses patients’ motivation for change so that the physician can select the optimal counseling approach.
  33. 33. Evaluation of Counselling  The five A’s (ask, advise, assess, assist, arrange) technique has been associated with reduced smoking and alcohol use as well as modest weight loss.  The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) technique has been associated with reductions in alcohol-related risk behavior  For patients ambivalent about change, motivational interviewing is more likely to be successful.  The BATHE (background, affect, troubles, handling, and empathy) strategy is useful for patients with psychiatric conditions and psychosocial issues.
  34. 34. Counselling Vs health education Counselling Health education 1 Confidential Not confidential 2 One to one process or a small group. For a group of people 3 Focused, specific and goal directed Generalized 4 Facilitates change in attitude and motivates behavior change Information is provided to increase the knowledge 5 Problem oriented Content oriented 6 Based on needs of client Based on public health needs.