Module 5 counselling to suit the client learning resource 1.5.13


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Module 5 counselling to suit the client learning resource 1.5.13

  1. 1. Counselling to Suitthe ClientCHC51712 Diploma of CounsellingModule 5
  2. 2. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2ContentsOverview...................................................................................................................... 3Unit Descriptions ....................................................................................................... 3Learning Outcomes (Essential Skills)............................................................................ 3Content Areas (Essential Knowledge) .......................................................................... 4Module Duration and Workload................................................................................... 5Required underpinning knowledge for this module........................................................... 61. Cognitive behaviour therapy ...............................................................................252. Person-centred therapy......................................................................................293. Behaviour therapy .............................................................................................304. Expressive therapies ..........................................................................................315. Family therapy ..................................................................................................326. Gestalt therapy..................................................................................................337. Narrative therapies ............................................................................................348. Solution focused therapy....................................................................................359. Transactional analysis ........................................................................................38Steps in determining suitability of client for counselling services.......................................461. Obtain information about clients developmental and mental health status.................462. Clarify client suitability for service to be provided.....................................................473. Check for and respond appropriately to risk ............................................................48Steps in applying counselling therapies to address a range of client issues........................501. Use techniques from a range of counselling therapies ..............................................502. Confirm suitability of counselling techniques in specific situations..............................523. Apply counselling techniques to address specific client issues and/or needs ...............53READINGS & RESEARCH...............................................................................................55
  3. 3. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3MODULE 5 Counselling to suit the clientThe two units of competency in this Module are:CHCCSL512A: Determine suitability of client for counselling services andCHCCSL506A: Apply counselling therapies to address a range of client issuesOverviewUnit DescriptionsCHCCSL512A — This unit describes a detailed knowledge of indicators of client’s mentalhealth status required to clarify client’s suitability for counselling services or need for referralin the context of community services work.CHCCSL506A — This unit describes the knowledge and skills relating to using a range ofcounselling therapies to assist clients in dealing with a variety of life issues.Learning Outcomes (Essential Skills)At the end of this module of study you will be able to:1. Observe and question clients appropriately in order to obtain information relating todevelopmental status and actual or potential issues related to community services tobe delivered2. Identify variations from normal developmental or mental health status usingstandard methods and protocols and recognise and refer potentially serious issues inline with organisation requirements3. Identify potential factors responsible for significant variations from normaldevelopmental status and determine an appropriate response in terms of: appropriate referral and reporting in line with organisation requirements provision of appropriate services4. Refer to or seek assistance from an appropriate person or authority in relation tovariations from normal functioning5. Articulate scope of practice and boundaries in relation to response to client status6. Comply with mandatory reporting requirements where appropriate7. Apply high level counselling skills in a range of counselling situations using at leastfive counselling therapies
  4. 4. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 48. Demonstrate the application of counselling techniques and processes from fivecounselling therapies relevant to own work role9. Analyse client information to clarify a range of client needs and issues10. Identify suitability of a range of counselling techniques in identified situations toaddress a range of client needs and issues11. Use counselling techniques appropriately and effectively when assisting clients todeal with a range of issues12. Identify indicators of client issues requiring referral and make appropriate referral13. Maintain confidentiality of client information14. Demonstrate ongoing reflection on and development of capability to meetprofessional standards. In particular, assessment must confirm the ability to: elicit, analyse and interpret feedback reflect on feedback and integrate learning to improve practice effectively use supervision and peer support to maintain self-awareness andpractice skills15. Work with an awareness and sensitivity to conflict, culture and context16. Analyse culturally different viewpoints and take them into account in personaldevelopment and professional practice17. Relate to people from a range of social, cultural and ethnic backgrounds and physicaland mental abilities18. Maintain appropriate documentation in a counselling roleContent Areas (Essential Knowledge)The following areas are the essential knowledge required for this module. These arediscussed in more detail in the following section. Detailed knowledge of aspects of development of the human being throughout thelifespan, including:o physicalo psychologicalo cognitiveo socialo affective Behaviours and reported emotions that may indicate presence of a mental healthissue, including:o suicidal ideation
  5. 5. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 5o hallucinations or delusionso excessive fears or suspiciousness (paranoia)o confused thinkingo indicators or self-harm Knowledge of key factors that may impact on the individual at identified stages ofhuman development and their potential effects Understanding of legal obligations, particularly in relation to child protection andelder abuse issues Appropriate range of referral sources and associated protocols Legislative requirements and provisions relevant to area of service delivery anddelegated responsibility Awareness of own values and attitudes and their potential impact on clients Indicators of significant issues including:o child abuse (including different types of child abuse)o child traffickingo abuse, neglect or harm including self-harmo domestic and family violenceo elder abuse Child protection policy of service State/territory requirements about responding to indications of abuse and reportingprocess Relevant organisation standards, policies and procedures Historical development, terminology and underpinning concepts and principlesrelating to a range of counselling therapies in common use and processes used intheir application Applications, benefits and limitations of at least five common counselling therapies Roles of counsellor and client in relation to a range of counselling therapies andtechniques Indicators of client issues requiring referral Legal and ethical issues relating to working as a counsellor Government legislation, regulations, policies and standardsModule Duration and WorkloadThis module is 4 months in duration. Learning and assessment should be completed withinthis time frame.
  6. 6. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 6Required underpinning knowledge for this moduleThe following points cover the required knowledge set out in the competencies for thismodule.Detailed knowledge of aspects of development of the human beingthroughout the lifespan and knowledge of key factors that mayimpact on the individual at identified stages of human developmentand their potential effectsStages of development may relate to: Stages of physical development Stages of psychosocial development Stages of cognitive development Psychosexual stages Stages of moral development Stages of ego developmentThese stages have been described by a number of authors, notably:Psychosocial development – EriksonCognitive development – PiagetPsychosexual stages – FreudStages of moral development – KohlbergStages of ego development - LoevingerThis module is titled ‘Counselling to suit the client’. Our clients are all unique. As mentionedin a previous module there are over 7 billion people on planet earth and each one isdifferent. These individuals have personality and physical features that differentiate thembut in addition each is at a particular stage of development as well. We are not of coursestatic in who we are throughout our lifespan. So if you thought that working with peoplewas complex because there are just so many different individuals, add to this the complexityof human development across their lifespans!Fortunately each of us has particular patterns that we follow in our development which arecommon for all human beings. Even though this varies for each of us to some extent, thesepatterns of development help us to know how to support our clients at their particular stageof life in counselling.It is important therefore for us to review some of these developmental stages and the keyfeatures of these stages.The changes that occur for us are along a number of different facets. These include: physical psychological
  7. 7. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 7 affective cognitive socialLet’s look at each of them in turn.PhysicalThe physical changes over our lifespan are quite remarkable. Womb development: During our first nine months in the womb we grow from asingle fertilised ‘egg’ cell to a fully functioning baby with 5 senses and thinking,emotions and so forth. Most of us who have had children have marvelled at thegrowth of babies in the womb. The excitement of birth provides for us a moment intime when we consider the miracle of life. Probably the most important information isthat a great deal of our humanity is established very early and for most of theduration of formation in the womb we are putting on weight. By 6 weeks afterfertilisation the foetus has arm and leg buds, eye spots and a heart starting to form.Most women are just coming to the conclusion that they are pregnant at this stage.By 10 weeks a baby has eyes, brain, fingers, legs etc. Infancy: From birth to 2 years of age, the human body quadruples in weight andgrows approximately 14 inches in length, reaching half the height of an adult. Thefive senses including sight, hearing, touch, taste and smell as well as language skills,and muscle control all develop rapidly during this time. Early Childhood: From age 2 to 6, the human body grows taller and slimmer, andbecomes more proportionate. (If babies simply grew in the same proportion toadulthood, they would look possibly a lot cuter but not be able to do as manythings!) Large muscles become stronger, and skills are learned primarily throughplay. School age: From the age of 7 to 11, our physical growth slows down. The bodydevelops increased control over fine muscle movements. In a sense this is when ourmind starts to grow in terms of curiosity and building a map of our world. Puberty: Around the age 10 until 19, human beings move through a significantphysical change. This period of development is characterised by emotional andcognitive shifts and the physical maturation of the reproductive system. Early adulthood: From age 20 to 35, the human body is in peak physical health andstrength. The challenges of making an income, finding partners, establishinghousing, creating and nurturing new life, require peak human health and strength. Adulthood: Ages 35 to 65 span middle adulthood. This developmental period involvesphysical changes such as wrinkles, menopause and a gradual dulling of the senses,including eyesight and hearing. Late adulthood: From 65 onward, the body continues to change with dryer, thinnerskin, thinner hair, and bone and muscle loss. Late adulthood is also characterised bya slowing of brain function, more physical signs of aging (deeper wrinkles), furtherdecline in visual functions, chronic disorders (such as arthritis) and a further decline
  8. 8. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 8in hearing. These symptoms are prevalent in both sexes, however women generallyhave a life expectancy of six years longer than their male counterparts.Psychological/SocialProbably the most pertinent information in terms of developmental changes for counsellorsis the psychological changes that occur for human beings. In our Module 4 we looked at anumber of theorists including Erik Erikson. Erikson developed a theory of psycho-socialstages roughly in line with Freud’s psycho-sexual stages. Erikson’s views however have beenmore widely upheld and are still seen as incredibly valid when thinking about thepsychological development of human beings. The following eight stages are listed below:1. Hope: Trust vs. Mistrust (Oral-sensory. Birth- 2 years)In this stage the infant dependent particularly on his/her mother will develop or not developtrust. Erikson links this to the capacity for hope that we experience as human beings. If yourclient has little hope for themselves or their lives it may be that in their first two years of lifethat they were not able to develop trust in their caregiver or themselves. Neglect, disruptionto connection to main caregivers or harsh treatment may contribute to this lack of hope andtrust in other people as well.2. Will: Autonomy vs. Shame & Doubt (Muscular-Anal. 2-4 years)In our very early development we are learning to do a few things for ourselves like play,explore and feed ourselves. In our attempts to do this we can be encouraged ordiscouraged. We are learning that we are a separate entity from our parents and caregivers.We are developing will. This is often quite a hard stage for parents to manage as the youngchild will play with the notion of resistance including saying ‘no’ a lot and running awayinstead of coming when called and other equally frustrating behaviour. If parents are notready for this change in their offspring they may react with strong counter-resistance,thereby stunting confidence in this essential stage of life. Parents who won’t let littlechildren try and fail themselves and who ‘take over’ at this stage (or those who have atemper tantrum larger than the child’s) may hinder the child’s capacity for autonomy andunknowingly instil shame and doubt. If however this challenging stage is met withencouragement and containment so that the young child is not harmed through theirexperimentation with exploration of the world then the child should learn autonomy. Theywill learn, ‘I can do some things quite well myself!’ This is obviously a very important lessonto learn. Adults who have not developed this capacity may well believe themselves to beincompetent and not try new things. They may also see themselves as victims.3. Purpose: Initiative vs. Guilt (Locomotor-Genital. Preschool. 4-5 years)This next stage builds on the one before with more confidence for the young child ininitiating play and social relationships. Children start to play cooperatively, not just alongsideeach other. This essential learning to interact cooperatively and socially (often learned withsiblings as well as at preschool) lets that young child understand that they can make friendsand initiate experiences that provide good feedback. If they are resisted or put down theytend to use cognition to determine the reasons for this. It may well include ‘I have done
  9. 9. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 9something wrong’ to ask to play right now. If mummy and daddy are always busy andannoyed when the child initiates social interaction with them, then the child can feel guiltand lose the capacity to initiate social relationships and become passive recipients of others’interest.4. Competence: Industry vs. Inferiority (Latency. 5-12 years)In this stage children are learning to master primary schooling and developmental hurdlessuch as copying adult tasks including tying shoes, dressing, making sandwiches, washingup, helping around the home with chores as well as academic learning and sportingactivities. Will they feel that they are competent and hard working? Will they learn that hardwork has a payoff with reward? If there are no role models or children are forced to do allthings without support then hard work and consistency may not be something that the childlearns. Instead they may feel inferior in their capacity to do things and as a result not try.They may also feel overwhelmed by responsibility. As adults they may require that their ownchildren do for them what they themselves feel incompetent to do. This can of courseimpact full circle.5. Fidelity: Identity vs. Role Confusion (Adolescence. 13-19 years)In adolescence young people are learning more about who they are. They need support andpositive feedback about the changes in their body and in all aspects of their development.Youth without this can feel confused about who they are. If young people are not validatedin their uniqueness but dominated by adults or systems so that they cannot flourish in theirunique identity, they may try extremely hard to enter a social group where all aspects ofidentity are already established. For example ‘emo’ culture has dress codes, behaviourcodes, and music preference codes etc. Young people who have not found that who theyare is ‘sufficient’ and ‘good enough’ and ‘acceptable’ can find themselves only able to feel asense of fidelity (authenticity) by identifying with a group and group standard. This can ofcourse be quite dangerous if the group has adopted risky behaviours.6. Love: Intimacy vs. Isolation (Young adulthood. 20-40 years)Love appears to be the strongest drive in human beings judging by the proportion of songlyrics dedicated to the topic! Biology and psychological needs drive us to find intimacy. If wefail at this or are failed in this by others we can feel isolated and worse than this we canbelieve we are meant to be ‘alone’. Intimacy allows us to partner safely and provides a placeof safety for our children. Happiness in adulthood is strongly linked to the capacity to beintimate with at least one other human being. People who find themselves isolated may wellconnect to animals, workplaces, job roles or even inanimate objects in order to find a way ofconnecting.7. Care: Generativity vs. Stagnation (Middle adulthood 40-64 years)Our sense of wellbeing and care comes from the ability to generate new ideas, interests,friends and experiences. If we are not able to move into new growth during middleadulthood we can stagnate, feel trapped and depressed in our lives. While the challenges ofadapting to new situations can sometimes be overwhelming, its importance for this age
  10. 10. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 0group cannot be underestimated. Assisting middle adults to master new challenges throughcreative strategies is part of the role of the counsellor for this age group.8. Wisdom: Ego Integrity vs. Despair (Late adulthood 65-death)Old age is a time to review life and consider the things that have been accomplished. It is atime of contribution as well and it is important that those over 65 or retired still feel like theyare contributing and have contributed in their life to others in order to have a sense ofintegrity. We want to ensure we are able to pass on the wisdom we have accumulated andto know that it has a place. Without this we may despair. Assisting elderly people tocontribute and find ways to do this will provide a sense of peace and ensure that life has notbeen lived without meaning.Ego DevelopmentJane Loevinger developed a theory of ego development based on Erikson’s psychosocialmodel and integrated the ideas of Harry Stack Sullivan where ‘the ego’ was theorised tomature and evolve through stages across the lifespan as a result of a dynamic interactionbetween the inner self and the outer environment. She saw personality as a whole.Pre-social stage (E1)Babies cannot differentiate themselves from the world and focus on gratifying immediateneeds. Their ego is therefore in Loevinger’s view ‘delusional’.Impulsive stage (E2)In the next stage of ego development a small child asserts his/her growing sense of ‘self’and sees the world as relating to him/her and how it affects them. The small child is focusedon the moment and if someone or thing meets their needs they are ‘good’ and when theydon’t they are ‘bad’.Self-Protective stage (E3)This stage is characterised by the start of self control of impulses. This also incorporates‘blame’ which is usually attributed to other people or circumstances. Morality is a matter ofanticipating rewards and punishments. Children at this stage crave unchanging order ofrightness and wrongness.Conformist stage (E4)The next stage occurs around school age where children start to see themselves and othersas conforming to socially approved norms. Rightness and wrongness apply to everyone atthe same time in the same way. Behaviour is not judged by intentions. Children may beginto reject ‘outsiders’.Self-aware stage (E5)The next stage is self-awareness and is a transitional stage towards adulthood. The capacityto imagine multiple possibilities in situations is now occurring. Conforming however is stillquite strong.
  11. 11. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 1Conscientious stage (E6)This is seen as the adult stage where internalisation of rules is completed and exceptionsand contingencies are recognised. Goals and ideals are acknowledged and a sense ofresponsibility and guilt at hurting others is understood rather than life being about breakingconventions or rules. Choices are very much part of the thinking of the adult at theconscientious stage.Individualistic stage (E7)Loevinger feels that adults who move beyond the conscientious stage must become moretolerant of themselves and others. They must be able to understand and accept the humandilemma of lack of perfection but do so in growth. Individualistic egos are broadminded andrespect people’s needs for autonomy and choice.Autonomous stage (E8)The next stage is where people are free from the oppressive demands of the conscience andare able to synthesise ideas. This person can understand that interdependence is inevitable.There is a high toleration for ambiguity and conceptual complexity and an ability to embracecomplexity.Integrated stage (E9)At this stage people can understand that inner conflicts are unavoidable and to make peacewith them. It is also where a fully worked out identity is achieved and being reconciled to adestiny. People are empathetic towards themselves and others.AffectiveDevelopment of emotion or ‘affect’ is an interesting study. It is tied to development ofthought. As we have mature explanations for events and situations our emotions are not soraw. The overwhelming emotions of a child who bursts into tears, has temper tantrums andanger outbursts need to be tempered as adulthood approaches. Adolescence is a time ofsignificant turbulence of emotions due to hormonal changes. The ‘child’ and ‘adult’ arefighting for dominance in physiology and thinking and emotion moves on these waves ofchange.Where we see ‘childlike’ emotional responses in adults we may be sure that as a child thisperson experienced some trauma or lack of support or discipline in their family of originwhich stunted their emotional growth. Other disturbances including developmental disorderslike ADD and Autism also contribute to disturbance of emotional development and make itmuch harder to cope with emotions.In adulthood people may be emotionally damaged through traumatic events or too muchstress to their nervous systems resulting in disorders of thought and emotion.Emotional maturity in adults is a sought-after capacity — that is being able to consider otherpeople’s feelings and thinking and being able to experience compassion and think logically.Adults who mature emotionally are able to achieve and contribute and ultimately experience
  12. 12. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 2greater personal satisfaction in life. For counsellors, helping the ‘little child’ within an adult toheal is a great gift. Helping that ‘hurt’ part of us to grow, heal and develop will bringharmony and capacity for an enhanced human experience. The work of counselling is agreat privilege.CognitiveThe development of cognition has possibly been best mapped by educational theorist JeanPiaget. Piaget studied the way children develop thinking. This observation is particularlyhelpful for us in counselling.The first stage he called Sensori-motor and saw that the way young children from 0-2understand their world is from movement and touch. It is important for children to be ableto use their bodies and move and touch things in order to learn. He felt that small childrenin the first year of life failed to understand that when an object is taken away it is still there.When mum or dad moves out of sight they may well fear that they are really alone. Whilecounsellors rarely ‘counsel’ babies, we are called upon to help young parents to support littlechildren. Encouraging parents to allow their children to move freely and to provide a richsensory environment is critical to cognitive development.The second period of thinking he called ‘Pre-Operations’ and was observed as a stage ofdevelopment from 2-7 years of age. Piaget noticed that children of this age are ego-centricand are only able to see things from their own point of view. Bad things happening aroundor to a child from 2-7 may be interpreted as ‘something bad that I have done’. Parentsbreaking up may be thought of as ‘I was a bad boy/girl and they left’. While this ego-centricthinking may not be able to be corrected at this stage it will be important later on to askquestions to understand the attribution that the child has given to negative events aroundthem. It is important to explain at this stage in simple language the meaning of events toreassure them that bad things are not their fault.For example: ‘Mum and dad have been angry with each other and we decided to spendtime apart so that we are happy and have more happy times with you kids.We love you and it is not your fault. Sometimes grown-ups do fight andget cranky, but we have to stop fighting as it doesn’t make anyone happy.That’s a good idea isn’t it, because we all need to be happy’.Death is also something that should be explained to a small child in simple language ratherthan not talked aboutt. If a sibling dies for example the language and explanation that weuse is critical. There will be a couple of concerns for children in understanding grieving anddeath. This includes a sense of place — where is that person now? Also a sense of safety isimportant — is the child or person safe now? Why did this bad thing happen? Is this myfault? Will we get better? By locating a place for the deceased person this provides a senseof connection — adults benefit from this as well. By providing safety in concept for theperson who has died provides reassurance about death for the child that if they were to diethey would be safe too. Clearly stating that this is not anyone’s fault is important as well.
  13. 13. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 3Explaining that grief is something that we feel but we can recover from is importantlearning.For example: ‘We are all really sad because Jeremy died. We miss him, that’s why wecry sometimes. Jeremy got so sick that the doctors couldn’t get him bettereven though they tried very hard. They were very kind to Jeremy.Grandma is looking after him now and he is safe with her in heaven. That’sgood news isn’t it. One day when we are very old we will get to see himagain but right now we have some pictures. You have been a very goodbrother. Mum and dad are sad right now but we will be happy again in awhile. We have a lovely family, one of our children is with us and one ofour children is in heaven with grandma. We’ll get used to this althoughright now we do feel sad because we can’t see Jeremy now or play withhim.’Small children will want to go over the story many times to get it fixed in their mind. It isimportant also to allow smaller children to draw their representations of such events so thatthey can get a sense of order. A child at this stage who has experienced death at close handmay well worry if they get sick that they might die too. Reassuring them that they arestrong and it’s not the same kind of sickness if they get sick, and also that the deceasedperson is safe now provides comfort and security. While these explanations may seemcommon sense it is amazing how many times small children are no given explanations andare left to their own devices. They may pick up snippets of information and come up withsome very wrong conclusions.Piaget then observed 7-11 year olds and described this stage of thought capacity as‘Concrete Operations’. Children are able to think more logically but they need the object inorder to think. In continuing our story we may be able to ask an older child where they feelsomeone is when they have died, or why they think mum and dad have split up. A child ofthis age will be able to explain logically what they think about the situation, they will be ableto describe feelings. In asking questions you can then help shape thinking positively.For example an older child may say:‘Jeremy died because he had a bad heart and it didn’t work very well. Thedoctors didn’t help and now mum and dad are sad and won’t ever behappy’.You might be able to confirm the first part but help shape the second.‘The doctors worked very hard, they cared for Jeremy but his heart wasjust too sick, it just couldn’t keep up the work of pumping anymore. Mumand dad are very sad now, and probably will be for a good while but theywill feel better in the future. They don’t want to be so sad, but they can’thelp it right now.’
  14. 14. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 4Piaget saw that older children and adolescents at around the age of 11 started to move to anew stage of thinking which he called ‘Formal Operations’. He observed that the thinkingcontinued to be logical however the person no longer needed to have a physicalrepresentation in order to think. Conceptual thinking was now possible. Questions withoutanswers were possible. Death could be perceived for example as abstract.The examples of family separation and death have been used here to help illustrate theapplication of Piaget’s theory of cognitive development particularly for counsellinginterventions. Our understanding of the client’s capacity to think will assist us in the supportwe provide. For older youth and adults more open ended questioning to fathom theirmeanings and struggles for meaning is appropriate. Commiserating about the dilemmas inlife will be more appropriate than having ‘pat answers’ and ‘simple black and whiteexplanations’. Adults can handle unanswered questions although it is important that in theend we do have ‘mental solutions’ to difficult issues.Our job as counsellors is to assist people to recognise their own culpability in situations andthen forgive themselves if this is appropriate or recognise when something is not their fault.We aim to help them move away from the black and white thinking about breaking rulestowards considering the multiple factors involved in any situation — there are many shadesof grey. Possibilities ultimately provide hope, whereas black and white thinking, sticking toright and wrong or good and bad leads to dead-end thoughts for adults. It’s where we startas children but as adults we need to move beyond this to cope with our world.An example of this is when adults are racially prejudiced. This may work in a limitedenvironment however it cannot work if we are to interact with people freely and start totravel outside our own backyard!Moral developmentKohlberg described six stages of moral development which can be roughly grouped intothree levels of two stages relating to Piaget’s notion of cognitive development. He felt thatstages couldn’t be skipped but that each step is necessary for the next to be successfullybuilt.Level 1 (Pre-Conventional)1. Obedience and punishment orientation(How can I avoid punishment?)2. Self-interest orientation(Whats in it for me?)(Paying for a benefit)Level 2 (Conventional)3. Interpersonal accord and conformity
  15. 15. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 5(Social norms)(The good boy/good girl attitude)4. Authority and social-order maintaining orientation(Law and order morality)Level 3 (Post-Conventional)5. Social contract orientation6. Universal ethical principles(Principled conscience)The understanding gained in each stage is retained in later stages, but may be regarded bythose in later stages as simplistic, lacking in sufficient attention to detail.Behaviours and reported emotions that may indicate presence of amental health issueAs previously mentioned there are situations where we can recognise disorders in thoughtand emotion.These include: suicidal ideation hallucinations or delusions excessive fears or suspiciousness (paranoia) confused thinking indicators or self-harmAs counsellors if we recognise any of the above they are indicators for referral to a morefully trained mental health practitioner including a psychologist, medical doctor orpsychiatrist. This is not to say that we cannot provide support and care but the importanceof referral cannot be more highly stressed.Awareness of own values and attitudes and their potential impact onclientsEnglish writer Douglas Adams once wrote: ‘The most misleading assumptions are the onesyou don’t even know you’re making.’ He may not have been a counsellor, but this isnevertheless an astute observation. Many of the things we ‘know’ about the world aremerely assumptions that are so deeply ingrained that we’re not aware of ever havinglearned them and we may never question them. As a counsellor, you will encounter clientsfrom a host of backgrounds and cultures that might be different from your own. Some of theassumptions you don’t even know you are making may conflict with some of theassumptions your client does not even know he or she is making. In other words, ourperceptions about the world might clash with those of our client.
  16. 16. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 6For example, you might take it as self-evident that women share the same fundamentalrights as men, while your client has very different attitudes. Keep in mind that he or sheprobably feels just as strongly about their values as you do about yours. Try to be awarethat your values are just that: your own, not theirs. What is ordinary to you might beshocking to them and vice versa. No matter how strenuously you may object to theirattitudes or values, remember that their values are a product of the circumstances of theirupbringing, just as yours are.Remember that as counsellors our role is to help clients, not to judge them or to foist ourvalues upon them.Indicators of significant issuesThese include: child abuse (including different types of child abuse) child trafficking abuse, neglect or harm including self-harm domestic and family violence elder abuseSignificant issues of harm for people need us to be clear in our responsibilities of care andespecially of reporting to the right authorities.For example each state has different requirements in terms of reporting children at risk inAustralia. The following table provides information about these requirements for counsellingand other health care professionals. (Source: Australian Institute ofFamily Studies updated June 2012)State/territory requirements about responding to indications ofabuse and reporting and procedures processTable 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/RegulationsACT A person who is: a doctor;a dentist; a nurse; anenrolled nurse; a midwife;a teacher at a school; aperson providing educationto a child or young personwho is registered, orprovisionally registered, forhome education under theEducation Act 2004; aA belief, onreasonablegrounds, that achild or youngperson hasexperienced or isexperiencingsexual abuse ornon-accidentalphysical injury; and Physicalabuse SexualabuseSection 356 ofthe Children andYoung PeopleAct 2008 (ACT)
  17. 17. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 7Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulationspolice officer; a personemployed to counselchildren or young people ata school; a person caringfor a child at a child carecentre; a personcoordinating or monitoringhome-based care for afamily day care schemeproprietor; a public servantwho, in the course ofemployment as a publicservant, works with, orprovides servicespersonally to, children andyoung people or families;the public advocate; anofficial visitor; a personwho, in the course of thepersons employment, hascontact with or providesservices to children, youngpeople and their familiesand is prescribed byregulationthe belief arisesfrom informationobtained by theperson during thecourse of, orbecause of, thepersons work(whether paid orunpaid)NSW A person who, in thecourse of his or herprofessional work or otherpaid employment delivershealth care, welfare,education, childrensservices, residentialservices or lawenforcement, wholly orpartly, to children; and aperson who holds amanagement position in anorganisation, the duties ofwhich include directresponsibility for, or directsupervision of, theprovision of health care,welfare, education,childrens services,Reasonablegrounds to suspectthat a child is atrisk of significantharm; and thosegrounds ariseduring the courseof or from thepersons work Physical abuse Sexual abuse Emotional/psychologicalabuse Neglect Exposure tofamily violenceSections 23 and27 of theChildren andYoung Persons(Care andProtection) Act1998 (NSW)
  18. 18. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 8Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulationsresidential services or lawenforcement, wholly orpartly, to childrenNT Any person withreasonable groundsA belief onreasonablegrounds that a childhas been or islikely to be a victimof a sexual offence;or otherwise hassuffered or is likelyto suffer harm orexploitation Physical abuse Sexual abuse Emotional /psychologicalabuse Neglect Exposure tophysicalviolence (e.g.,a childwitnessingviolencebetweenparents athome)Sections 15 and26 of the Careand Protection ofChildren Act2007 (NT)Registered healthprofessionalsReasonablegrounds to believea child aged 14 or15 years has beenor is likely to be avictim of a sexualoffence and theage differencebetween the childand offender isgreater than 2years. Sexual abuse Section 26 of theCare andProtection ofChildren Act2007 (NT)QLD An authorised officer,employee of theDepartment of ChildSafety, a personemployed in adepartmental careservice or licensed careserviceAwareness orreasonablesuspicion ofharm caused to achild placedin the careof an entityconducting adepartmental care Physical abuse Sexual abuseor exploitation Emotional /psychologicalabuse NeglectSection 148 ofthe ChildProtection Act1999 (Qld)
  19. 19. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 1 9Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulationsservice or alicenseeA doctor or registerednurseAwareness orreasonablesuspicion duringthe practice of hisor her profession ofharm or risk ofharm Physical abuse Sexual abuseor exploitation Emotional /psychologicalabuse NeglectSections 191-192 and 158 ofthe Public HealthAct 2005(Qld)The staff of theCommission for Childrenand Young People andChild GuardianA child who is inneed of protectionunder s10 ofthe Child ProtectionAct(i.e., hassuffered or is atunacceptable riskof suffering harmand does not havea parent able andwilling to protectthem) Physical abuse Sexual abuseor exploitation Emotional /psychologicalabuse NeglectSection 20 of theCommission forChildren YoungPeople and ChildGuardian Act2000 (Qld)SA Doctors; pharmacists;registered or enrollednurses; dentists;psychologists; policeofficers; communitycorrections officers; socialworkers; teachers; familyday care providers;employees/volunteers in agovernment department,agency or instrumentality,or a local government ornon-government agencythat provides health,welfare, education,sporting or recreational,child care or residentialservices wholly or partly forchildren; ministers ofreligion (with the exceptionReasonablegrounds that a childhas been or isbeing abused orneglected; and thesuspicion is formedin the course of thepersons work(whether paid orvoluntary) orcarrying out officialduties Physical abuse Sexual abuse Emotional /psychologicalabuse NeglectSection 11 of theChildrensProtection Act1993 (SA)
  20. 20. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 0Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulationsof disclosures made in theconfessional); employeesor volunteers in a religiousor spiritual organisationsTAS Registered medicalpractitioners; nurses;dentists, dental therapistsor dental hygienists;registered psychologists;police officers; probationofficers; principals andteachers in any educationalinstitution; persons whoprovide child care or a childcare service for fee orreward; persons concernedin the management of achild care service licensedunder the Child Care Act2001; any other personwho is employed orengaged as an employeefor, of, or in, or who is avolunteer in, a governmentagency that provideshealth, welfare, education,child care or residentialservices wholly or partly forchildren, and anorganisation that receivesany funding from theCrown for the provision ofsuch services; and anyother person of a classdetermined by the Ministerby notice in the Gazette tobe prescribed personsA belief, suspicion,reasonablegrounds orknowledge that: achild has been or isbeing abused orneglected or is anaffected child withinthe meaning of theFamily ViolenceAct 2004; or thereis a reasonablelikelihood of a childbeing killed orabused orneglected by aperson with whomthe child resides Physical abuse Sexual abuse Emotional /psychologicalabuse Neglect Exposure tofamily violenceSections 13 and14 of theChildren, YoungPersons andTheir FamiliesAct 1997 (Tas.)VIC Registered medicalpractitioners, registerednurses, a person registeredas a teacher underthe Education, Trainingand Reform Act 2006 orteachers grantedBelief onreasonablegrounds that a childis in need ofprotection on aground referred toin Section 162(c) or Physical abuse Sexual abuseSections 182(1)a-e, 184 and 162c-d of theChildren, Youthand Families Act2005 (Vic.)
  21. 21. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 1Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulationspermission to teach underthat Act, principals ofgovernment or non-government schools, andmembers of the policeforce162(d), formed inthe course ofpractising his or heroffice, position oremploymentWA Court personnel; familycounsellors; familydispute resolutionpractitioners, arbitratorsor legal practitionersrepresenting the childsinterestsReasonablegrounds forsuspecting that achild has been:abused, or is at riskof being abused; illtreated, or is at riskof being ill treated;or exposed orsubjected tobehaviour thatpsychologicallyharms the child. Physical abuse Sexual abuse Emotional/psychologicalabuse NeglectSection 160 ofthe WesternAustralia FamilyCourt Act 1997(WA)Licensed providers ofchild care or outside-school-hours careservicesAllegations ofabuse, neglect orassault, includingsexual assault, ofan enrolled childduring a caresession Physical abuse Sexual abuse NeglectRegulation 20 ofthe Child CareServicesRegulations2006Regulation 19 ofthe Child CareServices (FamilyDay Care)Regulations2006Regulation 20 ofthe Child CareServices(Outside SchoolHours FamilyDay Care)Regulations2006Regulation 21 ofthe Child CareServices
  22. 22. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 2Table 1: Mandatory reporting requirements across Australia*Who is mandated tonotify?What is to benotified?Maltreatmenttypes for which itis mandatory toreportRelevantsections of theAct/Regulations(Outside SchoolHours Care)Regulations2006Doctors; nurses andmidwives; teachers; andpolice officersBelief onreasonablegrounds that childsexual abuse hasoccurred or isoccurring Sexual abuse Section 124B ofthe Children andCommunityServices Act2004Note: * Section 67ZA of the Family Law Act 1975 (Cth) applies to all states and territories.Child protection policy of service and relevant organisationstandards, policiesIf in doubt about whether an issue or your position requires that you make a report,remember it is not wrong to report an issue of concern to the Child Protective Agency inyour state or territory. However it may be wrong NOT to report. In other words yourlegislative responsibilities in the area of Child Safety means that it may be useful to think ofhow you go about reporting an issue rather than whether you should in the first place. Yourorganisation may have associated protocols where you need to discuss an issue first withyour senior. It may be that your organisation requires them to make the report. Be carefulhowever that if your senior doesn’t appear to be following through you may still be liable.Not all managers have made themselves aware of legislation.Elder abuseAt the present time there is no Australian legislation which protects older people from abuseand neglect in the home however general legislation with respect to Physical Abusereportable to the police is in place. There needs to be more exploration of this subject in thefuture.Historical development, terminology and underpinning concepts andprinciples relating to a range of counselling therapies in common useand processes used in their applicationAny therapy has at its base, a model of the mind and a methodology for addressing anyproblems it may develop. Not any one of them is more ‘right’ than another; it is probablymore accurate to say that all of them are right some of the time. Understanding thetheoretical and historical foundations upon which therapeutic techniques are based provides
  23. 23. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 3a context and a framework for working with those techniques. It also helps you toaccurately and efficiently communicate information to other therapists.In Module 4 we looked at a range of therapies and models and the historical context forthese. As you continue to learn about new ways of working with clients it will be importantto connect these back to the possible base model that they relate to. In this way we canalso judge the possible effectiveness and appropriateness of the therapy for the client weare working with.Applications, benefits and limitations of common counsellingtherapiesThere are three main pathways for counsellors to use in the task of supporting change inpeople’s lives for the better;1. through the mind (thoughts)2. through the emotions (feelings) and3. through the body (behaviour).Depending on the therapist’s own philosophical and experiential preferences they maychoose one of these ‘gateways’ over others. Some therapists are purists and stick with theone way of working with clients as they are convinced of the benefits and feel comfortablewith this way of working. Others choose strategies that seem to fit the client best and mixand match techniques and models to suit the moment and the purpose of the intervention.Those that forge new therapeutic models of working with people tend to be purists as theybelieve in the therapy that they have discovered or pioneered and are most convincing intheir discourse on its use. They will often gather research to prove that their model andtherapy is the ‘better’ one compared to previously used strategies.Strangely enough, new therapies are often vehemently argued against by those using pre-existing therapies as they have much to gain from holding their popular position. Anexample of this is Eye Movement Desensitisation and Reprocessing (EMDR). This therapyutilises the body as the gateway to change emotions, thoughts and behaviour through usingeye movement as the name suggests. At first the author of EMDR, Francine Shapiro, metwith scorn and ridicule but gradually as the evidence has been gathered through researchand successful outcomes it has had more acceptance in mental health circles.However we choose to work with our clients we need to understand that all three of theaforementioned ‘gateways’ need to be impacted in a therapeutic intervention for lastingchange to occur. If we work though helping a client to change their negative thoughts it willof course impact their emotions and hopefully this in turn will impact behaviour. We maychoose simply to work through changing client’s behaviours which will impact thoughts andemotions as well or we may use an emotionally based therapy which will lubricate thoughts
  24. 24. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 4and modify behaviour in turn. Possibly however it makes the most sense to work on all threeat the same time!Some who consider ‘spiritual’ or ‘intuitive’ practices wonder how this would fit into thisoverview. Quite simply, unless the counsellor is sensitive to others in the first place, nomatter what strategy or therapy they choose, they may never be able to be an effectivecounsellor. We shouldn’t forget about the simple act of caring for our clients and being ‘intune’ with them. You just have to imagine for yourself going to see a counsellor who isinsensitive to you. You won’t be tempted to go back to see them and, regardless of anyevidence on the effectiveness of the therapy they use, if you do not see that counsellorthere will be no effectiveness!Some common modern therapies include but are not limited to:1. Cognitive behaviour therapy2. Person-centred therapy3. Behaviour therapy4. Expressive therapies5. Family therapy6. Gestalt therapy7. Narrative therapies8. Solution focused therapy9. Transactional analysisEach one of these therapies has a particular scope of use. None of them is adequate to treatevery problem a client may present; however by acquiring competency in several of thesetherapies you will be able to address most of the problems you will encounter. Let’s take anoverview of each of these therapies.emotionsbehaviourthoughts
  25. 25. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 51. Cognitive behaviour therapyCognitive Behaviour Therapy or CBT combines the strategies and tenets of CognitiveTherapy and Behaviour Therapy. It has become one of the most well-known and utilisedtherapies in counselling practice today. It stresses the importance of changing people’scognitions (thoughts) through bringing to their awareness the negative impact of unhelpfulor irrational thoughts on emotions and behaviours and then assists the client to changethese through practice of new behaviours particularly new thought behaviours. CBT has alarge range of strategies that fit under this umbrella. One of the important things to note isthat it deals with the present and the future, not so much the past. It is action-centred. It isalso fairly balanced in its emphasis on shared responsibility for outcomes between thecounsellor and the client.Therapy Orientation Movement Responsibility DurationCBT Present & future Action/goalorientatedCognitiveBehaviouralShared Short termCBT includes a range of other therapies including Rational Emotive Behaviour Therapy(REBT), Cognitive Therapy (CT), Rational Behaviour Therapy (RBT), Rational Living Therapy,Schema Focused Therapy and Dialectical Behaviour Therapy.Albert Ellis is considered to be the father of CBT with his brand of therapy which he calledRational Emotive Therapy in the mid-1950s. Ellis believed in the notion ‘Men are disturbednot by things, but by the view which they take of them’ (Epictetus, stoic philosopher). Ellisreacted to the psychoanalytic tradition which he felt was inefficient and non-directive. Theapproach was further developed by Alfred Adler. Although Adler classed himself as a neo-Freudian (out of psychoanalytic tradition) he too stated that, ‘I am convinced that a person’sbehaviour springs from his ideas.’Ellis was also impacted by the behaviourists who were much more directive in theirapproach in therapy. Ellis developed the ABC model of working with people. A stood forActivating event, B for Beliefs and C for Consequential actions. Later Ellis reworked thismodel adding D and E for Disputations to challenge irrational beliefs and Effective newbeliefs to replace the irrational ones. By this Ellis identified that all of us are impacted byevents in life, however the beliefs we have about these events will influence our actions. Toassist clients, therapists need to help them to dispute irrational and unhelpful beliefs and putnew and better beliefs in place. The following illustrates this.Activating events: Marty’s car has finally broken down. He had planned to buy a new carand had imagined himself in this car feeling important and powerful. Hisflatmate has moved out and has left him with some unpaid debts and theother half of the rent to pay.
  26. 26. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 6Beliefs: Marty believes that everything always goes wrong for him and that nomatter how hard he tries bad things will always happen to him. He hasused the events to extend the likelihood in his mind that further and morenegative situations would come and never allow him to live his dreams.Consequential actions:As a result of his thoughts his feelings are impacted and he is feeling angryand aggressive but at the same time powerless. He imagines yelling at hisold flatmate, putting thumb tacks under the wheels of his flatmate’s cartyres and feeling frustrated and glum. He decides not to go out withfriends on the weekend and stays at home and drinks himself into astupor.Disputations to challenge irrational beliefs:Marty’s counsellor identifies with Marty where the idea that nothing willever work out for him has come from. Marty has had a number of negativeearly life events that have contributed to this ‘mind set’. Marty’s counselloralso identifies with Marty other times in his life where things have goneextremely well and other situations in his life that are currently fine.Marty’s counsellor talks him through the effects of his thoughts and offersmore helpful thoughts.Effective new beliefs:The counsellor helps Marty to work on new ‘mantras’ that can be usedwhen he feels low and when any negative event occurs including ‘mostnegative events are short lived’ and ‘I am incredibly resourceful’, and onethat Marty liked in particular ‘what doesn’t kill you makes you stronger’.The counsellor helps Marty to commit to different thinking and to practisethis between sessions and coaches him in the benefits to his life of morepositive beliefs.Dr Marsha Linehan, also a CBT proponent and author of Dialectical Behaviour Therapy, hasadded to traditional CBT by an insightful statement: ‘you are loved the way you are,however you must strive to change’. By this she meant that at the heart of therapy theremust be acceptance by the therapist and the client that they are worthy, and from thatposition it is then possible to work on areas of change in life. Linehan has been fundamentalin forging treatments for people with Borderline Personality Disorder who have been mostdifficult to help because they have developed a self-hatred in childhood as a result ofmistreatment or neglect by parents and caregivers. If people have an unrealistic view oftheir need to be positive and perfect then the ‘work’ of change becomes self-defeating. Itmerely proves to the client that they are a mess and any homework and practice reinforcesa self-hatred. Linehan realised that all clients need to come to a peace with the fact thatthey are human and need to accept this as first base.
  27. 27. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 7Three examples of CBT that are particularly useful are: Mind Mapping or Life Maps Behavioural Experiments Thought StoppingLife MapsLife Maps involve mapping the various areas of a person’s life visually and identifying thedomains where there may be problems occurring for a person. By mapping all domains youare also able to predict what might become a problem. It also assists the counsellor and theclient to begin to set small goals to solve or reduce the problems that might be facing aclient. We covered Life Maps in Module 3.Once the domains are listed you can begin to ask questions about each area of the person’slife and ask how the person would rate each of these. You can then find out which onemight be worked on first and together with the client create goals for growth and success ineach of these domains. While this method doesn’t specifically target thought change withthe client, it does present a new way of thinking about issues for the client simply throughpresenting an overview. It is therefore a great way of working with very distressed clients asit is behaviour focused and doesn’t require any mental gymnastics. The life map below is anexample of how this works.FinancesExercise &foodFriendshipsRelationshipwith familyRelationshipwith partnerGrowtheducationWorkRecreationJay isdepressed,not sleeping,not coping
  28. 28. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 8Life Maps for kidsAnother way of working with Life Maps is to draw a stick person to represent the client anddraw a line representing water across the middle of the person representing the waterlinethat they don’t want to sink beneath. Attached to the hands of the person are balloonswhich are keeping them afloat — representing good things in their life — and attached tothe legs are weights which are weighing them down. The client identifies the strengths theyhave in the balloons, both personal strengths and other things going well, and also theissues that are pulling them below the water level. The counsellor then works with the clientto come up with strategies to cut off the weights and to provide goals and strategies tomeet those goals.Again while this technique doesn’t specifically target thoughts, it does so generally through avisual arrangement of the way someone sees their life and provides mastery through a stepby step strategy to make things better. This technique may be used for someone who isquite low emotionally as it visually presents their resiliencies and also the issues that arecurrently weighing them down with the focus on the strategies to reduce these.Behavioural experimentsIn Cognitive Behavioural Therapy behavioural experiments are designed to test the validityof thoughts. For example for a client who wants to lose weight and is experiencingdepression you may set up an experiment with them to test the power of self-criticism orself-kindness in reducing over eating. You may set homework for a period of time to allowthem to think critically about themselves and their weight and overeating and see whatimpact this has on their overeating. It would be important to record this daily. In anotherperiod you might look at more helpful thoughts that they could use for themselves and seehow that impacts overeating.Individuals may believe by criticism of a partner or child they will be able to influence themto do better in a particular area. Behavioural experiments test the validity of these kinds ofthoughts.Thought stoppingThought stopping is nearly impossible. If a client has a nasty or negative thought the simplecommand to stop it will not happen. It is like saying to someone don’t think about the purplerabbit. Once it is identified it actually becomes MORE of a focus.Thought stopping therefore needs some strategy. One such strategy is outlined below.Recognise – the negative or nasty thoughtFor example thinking ‘I am stupid’ causes me emotional pain and its probably not a goodthought to have.Refuse – to tolerate this kind of thoughtIt’s time to change this thought for good.
  29. 29. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 2 9Relax – don’t tense when you recognise the thought in its various forms – after all it’s beenthere for a while, it might take some time to see it leave.Reframe – make the thought situational and non-permanent.For example ‘any one of us can feel stupid in a particular situation’ ‘I’m a motor mechanic. IfI compare my knowledge of computers to an IT consultant I will feel stupid, but perhaps theIT consultant will feel stupid if he compares his knowledge of car engines to me’.Resume – note the things you don’t feel stupid about.2. Person-centred therapyTherapy Orientation Movement Responsibility DurationPCT Present Reflective/acceptingAffective/CognitiveShared howeverthe client takesthe leadMediumterm‘It is that the individual has within himself or herself vast resources for self-understanding,for altering his or her self-concept, attitudes and self-directed behaviour - and that theseresources can be tapped if only a definable climate of facilitative psychological attitudes canbe provided.’ Source: Carl Rogers, The Foundations of the Person-Centred Approach 1979.PCT is a form of talk-psychotherapy that was developed by psychologist Carl Rogers in the1940s and 1950s. The goal of this therapy is to provide clients with an opportunity todevelop a sense of self, to help them realise how their attitudes, feelings and behaviour arebeing negatively affected, and make an effort to find their true positive potential.Counsellors adopt this technique to create a comfortable, non-judgmental environment bydemonstrating congruence (genuineness), empathy, and unconditional positive regardtoward their clients while using a non-directive approach. This aids clients in finding theirown solutions to their problems.The primary objective of PCT is therefore to resolve the incongruence of clients and helpthem be able to accept and be themselves.Unlike many other therapies, PCT maintains that the client, not the counsellor, is responsiblefor improving his or her life. This is a shift away from psychoanalysis and behaviouraltherapies where the patient is diagnosed and treated by a ‘doctor’. Instead, the counsellorguides clients to consciously and rationally decide for themselves what is wrong and whatshould be done about it. The counsellor takes on the role of a friend who listens andencourages on an equal level.PCT requires the counsellor to Listen, Accept, Understand and Share. However owing to theunique nature of each counselling relationship, PCT does not propose a pre-defined or pre-set methodology that can be applied to a range of cases. Of utmost importance is thequality of the relationship between the client and counsellor.
  30. 30. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 0Carl Rogers identified six key factors that stimulate growth within an individual. Hesuggested that when these conditions are met, the person will gravitate toward aconstructive fulfilment of potential. These six factors are:1. Counsellor-Client Psychological Contact: there must be a distinct andrecognizable relationship between the therapist and the client and it must bevalidated by both parties.2. Client Incongruence, or Vulnerability: a client is vulnerable to fears and anxietiesthat keep them from leaving a relationship or situation and that there is clearevidence of incongruence between what a client is aware of and the actualexperience.3. Counsellor Congruence, or Genuineness: it is evident that the counsellor isinvolved in the relationship with the client for the purpose of healing. Counsellorsshould be genuinely interested in their clients’ recovery and can access their ownexperiences as an aid in the recovery process.4. Counsellor Unconditional Positive Regard (UPR): there is an element thatsupersedes all others, and that is the element of unconditional acceptance. Byproviding a platform of openness and acceptance, the client can begin to dispeltheir skewed perceptions of themselves that they have gathered from others.5. Counsellor Empathic understanding: a client feels genuine empathy from thecounsellor with regard to their internal construct and perception. This feeling ofempathy helps reinforce a sense of trust, understanding and unconditional love.6. Client Perception: the perception of unconditional positive regard and completeempathic acceptance and understanding is perceived by the client, if even onlyminimally.3. Behaviour therapyTherapy Orientation Movement Responsibility DurationBehaviourTherapyPresent DynamicBehaviourCounsellor Short toMediumTermThe key assumption behind all forms of behaviour therapy is that behaviour is learned fromthe environment, and symptoms are acquired through classical conditioning and operantconditioning.As we saw in Module 4, the occurrence of a stimulus unconditionally, naturally, andautomatically triggers a response. For example, when you smell one of your favourite foods,you may immediately feel hungry. In this example, the smell of the food is theunconditioned stimulus.
  31. 31. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 1The response occurs naturally as a reaction to the unconditioned stimulus. In our example,the feeling of hunger in response to the smell of food is the unconditioned response.A second layer is added to this initial concept with the conditioned stimulus and conditionedresponse.The conditioned stimulus is previously neutral stimulus that, after becoming associated withthe unconditioned stimulus, eventually comes to trigger a conditioned response. In ourearlier example, suppose that when you smelled your favourite food, you also heard thesound of a whistle. While the whistle is unrelated to the smell of the food, if the sound ofthe whistle was paired multiple times with the smell, the sound would eventually trigger theconditioned response. In this case, the sound of the whistle is the conditioned stimulus.The conditioned response is the learned response to the previously neutral stimulus. In ourexample, the conditioned response would be feeling hungry when you heard the sound ofthe whistle.Behaviour therapy is driven by this entire concept of Classical conditioning. It involveslearning of a particular behaviour by way of association and is typically the cause of phobiasin human beings.This also implies that if behaviour can be learned, it can also be ‘un-learned’. The aim ofbehaviour therapy is to help clients understand how changing their behaviour can lead togood changes about how they are feeling. Behaviour therapy is usually based on increasingclient engagement in positive or socially reinforcing activities.This kind of therapy is a methodical approach that identifies what the client is currentlydoing, and then seeks to increase the chances for a positive experience by helping tochange behaviours.Typical tools for behaviour therapy are diaries where clients are encouraged to mapdifferences in behaviours and the results. Therapists look to build in rewards to reinforcecertain desired behaviours and to extinguish undesirable behaviours through variousconsequences.4. Expressive therapiesTherapy Orientation Movement Responsibility DurationExpressiveTherapyPresent ReflectiveAffectiveShared Short termExpressive therapies make use of the creative arts as a therapeutic process. They employ arange of self-discovery processes to bypass the logical mind and tap into that world weknow exists but cannot seem to comprehend consciously. This experiential and holistic wayof working involves more than ‘just talking about the problem’ and provides the opportunity
  32. 32. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 2for real and lasting change. It is based on the belief that each person has their own innerwisdom and that the expert on who we are and what we need is actually inside us.Expressive therapies allow a client to not just express in words a particular issue, but to alsofeel the energy of their inner experience. When we connect with and really feel this energywe become open to new ways of understanding the problem. This method allows a feelingof release, insight, increased energy and a sense of well-being and resolution.Expressive therapies include, but are not limited to: Art therapy Dance therapy Drama therapy Music therapy Poetry therapyAny form of creative expression can be used as an expressive therapy. The important aspectis allowing what’s happening inside the client to come out, not whether or not one producesa ‘good’ drawing. It’s about self-discovery through the expressive process, not the endresult.Just as other therapies listed use gateways for change so do expressive therapies. Thesetherapies use the ‘emotion’ or affective gate to foster change for a client.5. Family therapyTherapy Orientation Movement Responsibility DurationFamily Therapy Present Goal OrientedCognitiveBehaviouralCounsellor ShortFamily therapy is a branch of psychotherapy that works with families and couples in intimaterelationships to nurture change and development. It tends to view change in terms of thesystems of interaction between family members. It emphasises the role of family andrelationships as an important factor in psychological health.Family therapy maintains that, regardless of the origin of the problem, and regardless ofwhether the clients consider it an ‘individual’ or ‘family’ issue, involving families in solutionsoften benefits clients. Families are therefore asked to directly participate in the counsellingsession.An important concept in family therapy relates to the illness of family members. Particularlyan issue of one family member may be a symptom of a larger family problem. To treat onlythe member who is identified as ill is like treating the symptom of a disease but not thedisease itself. It is possible that if the person with the illness is treated but the family is not,
  33. 33. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 3another member of the family will become ill. This cycle will tend to continue until theproblems are examined and treated.A family therapist: Teaches family members about how families function in general and, inparticular, how their own functions. Helps the family focus less on the member who has been identified as ill andfocus more on the family as a whole. Assists in identifying conflicts and anxieties and helps the family developstrategies to resolve them. Strengthens all family members so they can work on their problems together. Teaches ways to handle conflicts and changes within the family differently.Sometimes the way family members handle problems makes them more likely todevelop symptoms.During counselling sessions, all participating members of the family take responsibility forthe family’s issues. The family’s strengths are used to help them handle these issues andproblems. It might be discovered in these sessions that some family members may need tochange their behaviour more than others.Typical family therapy sessions are quite active in that family members are often givenmeaningful assignments. For example, parents may be asked to delegate moreresponsibilities to their children.The number of sessions required may vary, depending on the severity of the problems andthe willingness of the members to participate in therapy. The family and the counsellor setmutual goals and discuss the length of time expected to achieve the goals.6. Gestalt therapyTherapy Orientation Movement Responsibility DurationGestalt Therapy Present Existential/ExperientialAffective/BehaviouralClient Short tolong termGestalt therapy focuses heavily on increasing one’s self-awareness. Fritz Perls, the founderof Gestalt therapy, famously said: ‘Lose your mind and come into your senses’.This is a type of therapy used to deepen our awareness about ourselves and our feelings ina less intellectual manner than the more traditional forms of therapy. ‘Gestalt’ means thewhole; it implies wholeness.
  34. 34. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 4The idea in Gestalt therapy is that at some point in time all of us have had to repress orsupress aspects about ourselves because they were not accepted or supported by thosearound us, especially those who matter. It is these aspects of one’s self or our feelings thatend up in the background and can become unfinished business.Gestalt therapy can help shed light on such unfinished business by helping us to focus ourawareness on our feelings (or lack of feelings) moment to moment. Once we recognise ourunfinished business (i.e. uncomfortable feelings, stuck patterns of behaviour, or ways inwhich we perceive ourselves and others that are based on our experiences as opposed toreality), we become better equipped to understand ourselves and to choose whether wewant to make changes or not. This awareness includes insight, self-acceptance, knowledgeof one’s environment, a responsibility for choices and an understanding of the concept ofchange.For the client — they will experience a discovery — they will realise new things aboutthemselves, see old situations in a new light and look differently at significant others. Theywill additionally recognise that they have a choice in their lives and that they may behavedifferently, influence their own environment, deal with daily surprises and have theconfidence to improve and improvise.The signature technique of Gestalt therapy is the ‘empty chair’ exercise. It is a method offacilitating the role-taking dialogue between the client and others; or dialogue betweendifferent parts of the client’s personality. Two chairs are placed facing each other: onerepresents the client or one aspect of the client’s personality, and the other representsanother person or the opposing part of the client’s personality. As the client alternates therole, he or she sits in one or the other chair.The counsellor may simply observe as the dialogue progresses or they may instruct theclient when to change chairs, suggest sentences to say, call the client’s attention to whathas been said, or ask the client to repeat or exaggerate words or actions.7. Narrative therapiesTherapy Orientation Movement Responsibility DurationNarrativeTherapyPresent, Past,FutureReflectiveCognitiveShared MediumNarrative therapy was developed by Michael White and David Epston. It is a respectful andcollaborative approach to counselling and community work. It focuses on the stories ofpeople’s lives and is based on the idea that problems are manufactured in social, culturaland political contexts. Each person produces the meaning of their life from the stories thatare available in these contexts.A wider meaning of narrative therapy relates significantly to a relatively recent way ofthinking about the nature of human life and knowledge which has come to be known as
  35. 35. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 5‘postmodernism’ which maintains there is no one objective ‘truth’ and that there are manymultiple possible interpretations of any event. Thus within a narrative approach, our livesare seen as multi-storied vs. single-storied. These stories both describe and shape people’sperspectives on their lives, histories and futures. They may be inspiring or oppressive.Often by the time a person has come to therapy the stories they have for themselves andtheir lives become completely dominated by problems that work to oppress them. These aresometimes called ‘problem-saturated’ stories. Problem-saturated stories can also becomeidentities (e.g. ‘I’ve always been a depressed person’, or seeing an adolescent as a youngoffender vs. a young person who has been in trouble with the law). These kinds of storiescan invite a powerful negative influence in the way people see their lives and capabilities(e.g. ‘I’m hopeless’). Counsellors and therapists interested in narrative ideas and practicescollaborate with people in stepping away from problem saturated and oppressive stories todiscovering the ‘untold’ story which includes the preferred accounts of people’s lives (theirintentions, hopes, commitments, values, desires and dreams). Counsellors are listening tostories of people’s lives, cultures and religions and looking for clues of knowledge and skillswhich might assist people to live in accordance with their preferred way of being.In essence, within a narrative therapy approach, the focus is not on ‘experts’ solvingproblems, but on people discovering through conversations, the hopeful, preferred, andpreviously unrecognised and hidden possibilities contained within themselves and unseenstory-lines. This is what Michael White would refer to as the ‘re-authoring’ of people’s storiesand lives.An example of narrative therapy would be when a counsellor allows a client to verbalisetheir problems and then re-phrases the narrative in a disconnected way. For instance, if aclient believes he/she suffers with depression and feels like a failure, a narrative therapistmay offer the suggestion that rather than being a failure, the client had succeeded in livingwith depression. Narrative therapists give credibility to emotions by naming them, but at thesame time place them in the desired place on their client’s landscape. When a client feelslike a failure, the therapist may acknowledge that the job they were employed at ended andit caused a sense of failure, thus removing the feeling of failure from the client andexternalising it.8. Solution focused therapySolution focused brief therapy (SFBT) can be termed solution focused or brief therapyinterchangeably.A solution focused strength based approach is compatible with Marsha Linehan’s notion ofbuilding self-love as part of a program of change. The key proponents of SFBT has beenSteve de Shazer and his wife Insoo Kim Berg who created the term in the 1980s. Howeverthey built on the work of Milton Erickson and others who termed ‘Brief therapy’ in the 1950s.Richard Bandler, John Grinder and Stephen R Lankton have also been credited with theinspiration and popularisation of Brief Therapy.
  36. 36. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 6SFBT has been used in addictions counselling very successfully and also in the field ofChristian pastoral counselling as well.It is particularly useful for clients who have a very low self-esteem and are normally not ableto build successes in their life although it makes sense for all clients and is a popular therapyas it provides ways to build confidence.Therapy Orientation Movement Responsibility DurationSFBT Present andfutureGoal actionorientatedCognitiveBehaviouralShared Short termSFBT has many techniques, many of which take the form of questions. The client is asked toexplore an aspect of themselves, or their life or goals. There are no right or wrong answersto these questions, rather the client is encouraged to put as great and vivid detail aspossible into their responses. Two examples of solution focused strategies to use with clientsare The Five Column Approach and the Miracle Question.The Five Column ApproachThe Five Column Approach requires you as the counsellor to discuss with your client theareas that are causing them distress or concern ‘The Problem’, you then move to discusswhat they would imagine would be the ‘Ideal Picture’ or how they would prefer their life tolook. Then you would discuss with the client their strengths in great detail and draw theseout. You would then ask your client whether they have exhausted all their strengths inaddressing their problem.In approaching the problem from the base of talents, gifts, skills or attributes particularlythat haven’t been utilised to date the client begins to see that they have more resourcesthan they first thought. Once ideas are generated you can talk about what else is needed toassist the client and then you can assist the client to put in a plan of action. The strategy isvisual, goal orientated (fixing the now for the future) and requires implementation ofstrategies or homework. The strategy is Cognitive Behavioural as the client is changing theirthinking particularly on the basis of reviewing their assets and strengths in meeting achallenge. It is also asking them to put in a plan and an action towards change.The Issue/Story Strengths/ResourcesWhat is stillneededFirst stepstowards thegoalIdeal PictureDo this first Do this third Do this fourth Do this last Do this secondThe Five Column Approach is very helpful for couples in conflict or family therapy as well.
  37. 37. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 7The Miracle QuestionLike the Five Column Approach this technique focuses on what clients want to achieve in theend rather than on the problem or problems for any length of time. It focuses on thepresent and the future. The counsellor uses ‘respectful curiosity’ to question the client abouta possible preferred future. Discussion follows about strategies large and small in terms ofgetting to this future. The counsellor in a similar way talks about the client’s strengths andresources and about when the problem isn’t showing up. The counsellor gets the client tonotice what is happening when the problem is not a problem.The counsellor also helps the client to notice small successes. SFBT counsellors will oftenuse ‘scaling questions’ to help clients to notice those changes and to bring encouragement.For example: ‘When we first got together Ben, out of 10 how close to the goal do youfeel you were? What about now: how much further do you feel you havecome towards getting to that goal?’The Miracle Question technique can help the client to envision a future where the problem isno longer present. A typical version of the miracle question would be:‘I want you to imagine something a bit strange if you wouldn’t mind.Imagine after leaving here you go home and nothing much has changed atall and you feel a bit daunted by the problems that you are living with. Butimagine that something weird happened, a miracle if you like, and whenyou woke up the problem was gone. It no longer existed. I want you todescribe to me when you fully realised that a miracle had happened whatyour day was like and what you might do differently.’If, for example, the client’s issue is anger management, they might say that they no longerlose their temper. The counsellor would then probe the client with questions about whatdifference that would make and how they would feel. The counsellor wants the client todevelop positive concrete goals and things that they would do differently, rather than focuson the bad feelings and limitations. They might also add, ‘What would you be doing insteadof being angry when someone called you names, for example?’.Part of the SFBT strategy is to help the client to notice the exceptions that they can buildon. In the example above the counsellor may ask the client about times when they don’t getangry and what is happening in these situations that is different. These are called ‘ExceptionSeeking Questions’. Another form of this is to find out times when the person is coping well.When the counsellor uses curiosity and admiration about the client’s successes andstrengths in a particular situation this provides encouragement. People have greater capacityto change when they feel they are on a roll rather than a complete mess.To a Solution Focused Brief Therapist it is important to have quite a lot of problem free talkwhere conversation might focus on leisure activities and what might look like irrelevantconversation. However when clients are focusing on what is going well and noticing their
  38. 38. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 8‘normality’ they have greater inner strength to manage the changes that are needed toreally move their life in a positive direction.In Module 11 we will talk more about ‘body state’. When we feel good we can tackle theworld. When we feel bad we want to retreat. Our body state and the feelings thatcounsellors facilitate within a session are extremely important. In counselling we often haveonly ‘one bite of the cherry’ in other words if a client doesn’t experience encouragementwith us in the first session and hope for the future they may not return again for a secondsession. For this reason a strengths-based approach using Solution Focused BriefIntervention is a good way to begin a counselling intervention.9. Transactional analysisTherapy Orientation Movement Responsibility DurationTransactionalAnalysisPast, present andfutureGoal actionorientatedCognitiveBehaviouralShared Short term –medium andlong termTransactional Analysis (or TA as it is often called) is a model of people and relationships thatwas developed during the 1960s by Dr. Eric Berne. It is based on two notions, first that wehave three parts or ego-states to our personality, and secondly that these converse withone another in transactions (hence the name). TA is a very common model used in therapyand a variety of information about it is available.Parent, Adult and ChildWe all have ‘internal models’ of parents, children and also adults, and we play these roleswith one another in our relationships. We even do it with ourselves, in our internalconversations.
  39. 39. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 3 9ParentThere are two forms of Parent we can play.The Nurturing Parent is caring and concerned and often may appear as a mother-figure(though men can play it too). They seek to keep the Child contented, offering a safe havenand unconditional love to calm the Childs troubles.The Controlling (or Critical) Parent, on the other hand, tries to make the Child do as theparent wants them to do, perhaps transferring values or beliefs or helping the Child tounderstand and live in society. They may also have negative intent, using the Child as awhipping-boy or worse.AdultThe Adult in us is the grown up rational person who talks reasonably and assertively,neither trying to control nor reacting aggressively towards others. The Adult is comfortablewith themself and is, for many of us, our ideal self.ChildThere are three types of Child roles we can adopt.The Natural Child is largely un-self-aware and is characterized by the non-speech noisesthey make (yahoo, whee, etc.). They like playing and are open and vulnerable.The cutely-named Little Professor is the curious and exploring Child who is always trying outnew stuff (often much to their Controlling Parents annoyance). Together with the NaturalChild they make up the Free Child.The Adaptive Child reacts to the world around them, either changing themselves to fit in orrebelling against the forces they feel.Communications (transactions)
  40. 40. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 4 0When two people communicate, each exchange is called a ‘transaction’. Many of ourproblems come from transactions that are unsuccessful.Parents naturally speak to Children, as this is their role as a parent. They can talk with otherParents and Adults, although the subject still may be about the children.The Nurturing Parent naturally talks to the Natural Child and the Controlling Parent to theAdaptive Child. In fact these parts of our personality are evoked by the opposite. Forexample, in acting as an Adaptive Child, a person will most likely evoke the ControllingParent in the other person.We also play many games between these positions, and there are rituals from greetings towhole conversations (such as the weather) where we take different positions for differentevents. These are often pre-recorded as scripts we just play out. They give us a sense ofcontrol and identity and reassure us that all is still well in the world. Other games can benegative and destructive and we play them more out of sense of habit and addiction thanconstructive pleasure.ConflictComplementary transactions occur when both people are at the same level (Parent talkingto Parent, etc.). Here, both are often thinking in the same way and communication is easier.Problems usually occur in Crossed transactions, where each is talking to a different level.The parent is either nurturing or controlling, and often speaks to the child, who is eitheradaptive or ‘natural’ in their response. When both people talk as a Parent to the other’sChild their ‘wires get crossed’ and conflict results.The ideal line of communication is the mature and rational Adult—Adult relationship.Roles of counsellor and client in relation to a range of counsellingtherapies and techniquesTherapy requires that counsellor and client adopt roles. These roles are essential to thefunctioning of the therapy and vary between therapies. Failure to maintain the boundariesimposed by these roles can render the therapy ineffective. As we have seen above thevarious ways of working with clients may mean that the client takes a more active role orthe therapist does. Behaviour Therapy may be considered to be a therapy which has a moredominant therapist role whereas with Person Centred Therapy the client takes the moredominant role. Other therapies may be seen as more equal with the therapist and clientworking together equally to move the client forward towards their goals.Indicators of client issues requiring referralTherapeutic counselling can only address so much. Some clients will present you withproblems or behaviours that you might not be able to deal with in your role as counsellorand will require urgent intervention because they may be a danger to themselves or others.
  41. 41. © Copyright CTA CHC51712 MODULE 5 Learning Resource Version Date: 1.05.13 P a g e | 4 1Alternatively, they may be in danger at the hands of others. Sometimes a client will disclosesuch issues to a therapist.While clients might confess to hurting someone or planning to hurt someone or themselves,often they are unwilling or unable to tell a therapist about it. In cases where the client is notforthcoming, some risk factors may be deduced by observing the client. In any case, thereare circumstances that counsellors are unable to deal with on their own and require thenotification of proper authorities.Here are some examples, along with their indicators:Suicidal tendencies A previous suicide attempt, even if it seemed staged or designed to get attention, orboasts of past or secret suicide attempts. Talking about being dead or wishing they were dead, how others would be happier ifhe/she were dead or how much better off others will be when he/she is gone. Repeatedly engaging in very risky or dangerous thrill seeking behavior. ‘Getting the house in order’ – making plans for the care of loved siblings, parents,relatives or pets and giving away cherished belongings to close friends. Extreme mood swings; very depressed episodes followed by happy episodes with noclear reason for the change. Regular expressions of worthlessness, helplessness, sadness and/or loneliness.Drug abuse Sudden change in attitude, work, or behavior – a new, ‘I don’t care’ attitude Sudden deterioration of long friendships, relationships ‘Explosive’ arguments and disagreements over small matters Frequent hangover symptoms Using drug culture jargon Secretive behavior Avoiding ‘straight’ (non drug-users) co-workers or classmates Erratic behaviour, forgetfulness, indecisiveness Deterioration in personal appearance and hygiene Hyper-activity, constant toe or heel-tapping and/or ‘drumming’ of fingers Easy excitability Restlessness, increased physical activity Wearing of long-sleeved garments in very warm weather New financial problems or frequent borrowing of money Small blood spots or bruises on skin Bloodshot or watery eyes Runny or irritated nose, irritating cough, sore throat Speech pattern changes, slurred speech, faster speech, slower speech Tremors or jitters Constant scratching of skin, ‘picking’ at skin and hair on arms, etc.