CFN9885 - The Fundamentals of Counseling and Treatment: Lessons for Beginning and Experienced Mental Health Clinicians
THE FUNDAMENTALS OF COUNSELING AND TREATMENT: LESSONS FOR BEGINNING AND EXPERIENCED MENTAL HEALTH CLINICIANS
by Ron Fagan, M.A., Ph.D.
Ron Fagan, M.A., Ph.D. is formerly a Professor of Sociology at Pepperdine University in Malibu, California. Dr. Fagan currently works as a licensed Marriage and Family Therapist in private practice and as a Clinical Care Manager, Employer Solutions, Magellan Health Services.
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This course is designed to provide the mental health clinician with a comprehensive overview of the most essential components of providing counseling. Upon completing this course, the trainee will understand the following:
- Counseling and therapy trends in the United States
- The major counseling approaches and common factors in the counseling approaches
- The components of effective counseling and the stages of counseling
- The fundamentals of the client/counselor relationship
- Fundamental counseling skills and techniques
- The human relations counseling model
- Common problems for beginning counselors
- The fundamentals of ethical counseling
- Fundamental assessment and goal setting skills
- Client motivation, the five-stage model for change, & motivational interviewing principles and techniques
- Ways to effectively terminate counseling
6 contact hours: core clinical
This beginning level course is primarily designed for clinicians in the very earliest stages of their clinical career. For more advanced clinicians, this course is a useful review of the most important concepts in providing successful counseling services.
Section I: Introduction
Section II: Components of Effective Counseling
Section III: Questions Clinicians Should Ask Themselves
Section IV: The Human Relations Counseling Model
Section V: Common Problems for Beginning Clinicians
Section VI: Being an Ethical Clinician
Section VII: Overview of Clinical Assessment
Section VIII: Counseling and Treatment Goals
Section IX: Client Motivation
Section X: Five-Stage Model for Change
Section XI: Motivational Interviewing
Section XII: Interventions
Section XIII: Termination
Section XIV: Conclusion
References and Test
Section I: Introduction
Counseling and Treatment in the United States
Throughout the history of counseling and mental health services, there have been three central roles undertaken by the practitioner: the remedial, the preventive, and the educative-developmental (Gelso & Fretz, 2001). The remedial role involves working with individuals and groups to assist them in addressing or solving problems. The preventive role involves helping people to make changes in their personal and interpersonal lives to minimize or eliminate the occurrence of problems in the future. The educative-developmental role involves working with individuals and groups to enhance or improve their lives.
Traditionally, most counseling has involved the remedial role, but the other roles are equally important, especially counseling that is done in educational, work place, hospital, correctional, and community settings.
Counseling and therapy models in the United States have generally evolved over the years from:
1) The traditional psychodynamic approaches, which assumed an intra-psychic, individual perspective, to
2) Integrated cognitive/behavioral approaches developed in the 1970s and 1980s, which took an individual problem-solving perspective, to
3) Systemic/ecological approaches which focus on the individual as embedded in the context of his/her primary family, which is embedded in the contexts of larger interpersonal, institutional, economic, legal, social, and cultural systems, and, most recently, to
4) Outcome-oriented brief approaches which focus on addressing client problems in a time limited format (Okun, 2002).
Today, it is common for clinicians to be eclectic in their counseling in that they may use a variety of therapeutic orientations and techniques depending upon the clinician, client, and the requirements of the counseling or treatment setting.
The current emphasis on short-term, outcome-oriented brief therapies has come about primarily because we are currently in an era of cost-contained managed health care. Increasingly, in order to receive counseling or treatment clinicians must be able to show there is a “medical necessity” that meets criteria established by the managed care companies for treatment reimbursement.
What this has come to mean is that there is an emphasis on direct, action-oriented treatment of clients’ presenting problems (often with the use of medication) usually within six to eight sessions. Additional treatment and sessions may be granted, but only if they meet guidelines specified by the managed care companies.
This means that managed care companies are making the primary decisions on what types of conditions will warrant treatment reimbursement, who will be seen in treatment, who will be doing the treatment, the type of treatment, the number of sessions, and what constitutes treatment success. This has resulted in less attention being paid to education and prevention, early intervention, long-term treatment when necessary, and tailoring the treatment to fits the needs of individual clients.
In order to work within the managed care guidelines clinicians need the skills to be able to build rapport quickly with their clients, do a quick and accurate assessment that meets the provider’s guidelines, and develop and implement effective counseling and treatment interventions that have measurable outcomes to address clients’ needs in a limited treatment package. This has also meant that there is increased competition for limited resources among the various helping professions.
While the availability of some counseling and treatment services has been changed by the policies of managed care companies and the changes in funding by city, county, state and federal agencies, there seems to be significantly greater public awareness and acceptance of the need for counseling and treatment services. The stigma that was once associated with receiving counseling has been reduced. Counseling services are now being offered in a wide variety of settings, by both professional and lay people, using many different approaches.
While there are some disadvantages of outcome-oriented brief interventions, there are also some benefits. The primary benefits are:
1) Fewer people are involved in long-term, open-ended inpatient and outpatient counseling without measured goals;
2) There is increased use of an interdisciplinary team approach to meet the multidimensional needs of clients and an emphasis on the involvement of other individuals, groups, and organizations in addressing the client’s overall needs; and
3) There is more emphasis on what types of counseling or treatment work best with what types of client problems.
Well over 400 theoretical counseling approaches have been identified. However, most of the approaches are influenced by five major theories: psychodynamic, cognitive/behavioral, humanistic, transpersonal, and systemic. (Corsini & Wedding, 2000, Hackney & Cormier, 2005)
1) Psychodynamic perspectives focus on unconscious factors that motivate behavior with attention given to the events of the early years of life as determinants of later personality development.
2) Cognitive/behavioral perspectives focus on the role of thinking and belief systems as the root of personal problems, applying learning and reinforcement principles to address problems.
3) Humanistic perspectives focus creating one’s own destiny by taking personal responsibility for one’s life and finding meaningful life goals.
4) Transpersonal perspectives focus on the quality of the person-to-person therapeutic relationship believing clients have the capacity for self-direction without active clinician intervention or direction.
5) Systems perspectives stress the importance of understanding individuals in the context of their surroundings including gender-role socialization, race and culture, family, and other systems.
If you examine the significant theories and perspectives, it becomes apparent that most of them evolved as a result of an interaction between clinicians who had a style of doing therapy which matched their personality, life experiences, and training and client populations with specific characteristics and needs. All of the therapeutic approaches have the common goals of helping people to think, feel, and behave in desired ways, however the approaches differ in how best to accomplish these goals.
Clinicians’ theoretical orientation will influence how they work with clients, that is, what they look for, what they see, and how they interpret what they see. Clinicians’ theoretical perspectives influence how they assess clients, the goals they feel are important in counseling, the strategies and techniques that are employed, and the function and role of the client/clinician relationship.
Developing a counseling perspective is more involved than merely accepting the principles of a particular theory or combination of theories. Clinicians’ theoretical approaches are not only a reflection of their training and clinical experience, they are also a reflection of how the clinicians see themselves and the world. However, a counseling theory is not a rigid structure that every clinician uses the same way with every client. Instead, a theoretical orientation is a set of general guidelines that influence clinicians in their work with their clients. (Corey, 2001c)
Common Factors in Counseling Approaches
Although there are a large number of counseling approaches, each with their own orientation and techniques, most of the current research shows that no one theory, school, or technique is necessarily superior to another. In fact, factors common across treatments account for a substantial amount of the improvement found with people who receive counseling or treatment. A review of the counseling theories found the following common factors (with the three most frequently noted examples of the factors included):
- Client Characteristics: positive expectation/hope or faith, client distressed or incongruent, client actively seeks help
- Therapist qualities: general positive descriptors, cultivates hope/enhances expectations, warmth/positive regard
- Change processes: opportunity for catharsis/ventilation, acquisition and practice of new behaviors, provision of rationale
- Treatment structures: use of techniques/rituals, focus on “inner world” exploration of emotional issues, adherence to theory
- Relationship elements: development of alliance/relationship (general), engagement, transference
One way to conceptualize these common factors is to divide them into three categories: support factors, learning factors, and action factors.
- Support Factors: catharsis; identification with therapist; mitigation of isolation; positive relationship; reassurance; structure; therapeutic alliance; therapist/client active participation; therapist expertness; therapist warmth, respect, empathy, acceptance, genuineness; and trust.
- Learning Factors: advice; affective experiencing; assimilation of problematic experiences; changing expectations for personal effectiveness; cognitive learning; corrective emotional experience; exploration of internal frame of reference; feedback, insight, and rationale.
- Action Factors: behavioral regulation; cognitive mastery; encouragement of facing fears; taking risks; mastery of efforts; modeling; practice; reality testing; success experience; and working through.
The developmental nature of this sequence presumes that the supportive functions precede changes in beliefs and attitudes, which precede attempts by the clinician to encourage patient action. (Lambert & Bergin, 1994)
The Art and Science of Counseling
Attempting to practice counseling without at least a general theoretical perspective is somewhat like trying to drive somewhere without a map, or not knowing how to get where you want to go. While clinicians need a theoretical approach that guides them in doing counseling, they also need an approach that works with their strengths and fits the client’s characteristics and needs.
Counseling is essentially both a science and an art. The science of counseling is the research and writing that has been done about the counseling process. The art of counseling is the creative application of this knowledge as clinicians adapt their approaches to the unique and emerging needs of their clients.
Successful clinicians need to understand and learn both the science and art of counseling. To learn the science of counseling, clinicians need to be trained and knowledgeable in the theories, orientations, and techniques that underlie their counseling practice - including keeping up to date on the latest developments. The art of counseling is learned through practical experience and feedback from other trained professionals. The science of counseling will be ineffective without the art of counseling and, equally so, the art of counseling with be ineffective without the science of counseling.
What this means in practice is that clinicians need competencies in a number of different approaches and need to be able to do an accurate assessment and develop a treatment plan based upon a diagnosis for each client. Clinicians may use a number of approaches and techniques in working with a client depending upon what areas are being addressed and where they are in the therapeutic process.
Clinicians should be constantly asking: What treatment, by whom, is the most effective for this individual with this specific problem, and under what set of circumstances. No matter what perspective or model clinicians use, they must decide who should do the counseling or treatment, what techniques, procedures, or intervention methods should be utilized, how to use them, when to use them, and with which clients. (Paul, 1967) Some people call this the who-how-whom factor, that is, what counts in counseling is who does it and how and to whom it is done. (Corsini & Wedding, 2000)