COUNSELLING

APPROACHES

Liya Jemal
 Key Points:

• What is counselling?

• Goals of counselling?

• The PROCESS of counselling - the counselling

clinical cycle.

• Counselling Strategies.

• Ending counselling.
 What is counselling?
• A confidential conversation between a trained counsellor & client.

• Counsellor identifies & clarifies problems and helps client find ways to
improve situation; solutions & coping.

• Helping client explore problems, emotions (feelings), & thinking

(cognition) through sensitive questioning.

• Use basic communication skills (verbal & non-verbal communication,

listening, paraphrasing, questioning).

• Counsellors use a framework (system) to categorize & understand

client problems.
What Counselling IS NOT
• About uncovering past traumas (unless client wants to speak
about this!).

• About making decisions for, or advising, the client.

• A lengthy treatment (i.e. over 6 or 7 sessions).

• It is NOT psychotherapy (Longer term, in depth therapy).

• About the client becoming dependent on the counsellor.

• A psychiatric intervention (this requires prescription of medication

by an MD / CO)…though counsellors may work collaboratively
with these staff with some of the same clients.
 Counselling Objectives
• Identify problems and improve coping to reduce symptoms.

• To help client understand situation & be able to handle it using own resources.

• Allow expression of emotions in a safe environment (e.g. coca-cola metaphor).

• Reinforce or introduce new coping behaviors or strategies.

• Via questioning & discussion, counsellor helps client to come to own decision.

• Recognize & normalize psychological reactions (the situation is ABNORMAL

but reaction to it is NORMAL; many people going through similar situations
would feel same way).
 Process/steps of counselling?
• Assessment (listening skills/exploration. Build rapport. Explain
confidentiality. Be curious, ask sensitive questions. Personal
details. Problem identification. Coping identification).

• Formulation - 5 types of problem.

• Objective (Goals) – SMART GOALS!!!

• Intervention - Treatment Plan & use of strategies.

• Evaluation – is intervention working?

The Counselling Clinical cycle
Assessment
follow assessment format –
confidentiality, personal details,
problem identification and coping
strategies

Evaluation Formulation / Hypothesis

is your intervention helping the
client? Ask the client and if
necessary re-assess problems
and return around cycle.
Summary & ideas about client difficulties
and coping & how to intervene based on
assessment information. Setting SMART
goals for sessions. Can be based on “5
types of problem”.

Intervention
What strategies will you use
to address problem and
enhance coping
ASSESSMENT FORMAT
1. Warm introductions & explain role, nature of service.
2. Establish Trust (explain confidentiality).
3. Explain counselling process (assessment, formulation,
intervention, evaluation).
4. Collect information about personal details.
5. Explore why the patient has come to see you – exploration of
problems (including history of problems, severity etc.).
6. Explore coping – strengths & abilities of patient, particularly in
relation to their community & family.
7. Explore MH history, substance misuse, risk of harm to self/others.
8. Develop preliminary FORMULATION (hypotheses / summary) and
plan goals together with client for next session.
9. Arrange follow-up appointment.
 ASSESSMENT SKILLS
1. LISTENING
• Give attention, listen, paraphrase and summarise.
• Help a client explore psychosocial aspects of self & situation, provide different
perspective.
• Help a client move towards “action”.

2. QUESTIONING
• Define problem and goals.
• Have a “solution focus” rather than a “problem focus”.

3. EXPLORATION
• Define the problem and the history of the problem.
• Which things are still going well.
• What resources are available.
 Pitfalls for counsellors early in the
session…
• Quick advice

• Lack of understanding of the client’s feelings

• Judgmental attitude
 ASSESSMENT →
FORMULATION
By end of session 1, counsellor:

• Has developed a FORMULATION – summary of client problems & coping (e.g. 5-

types of problem).

• A FORMULATION is NOT a diagnosis (i.e. one-word summary), but more

detailed picture to explain client’s situation.

• Together with client develop goals about primary problem (client needs to be
supported to make OWN decisions).

• GOALS need to be SMART:

SPECIFIC
MEASURABLE
ACHIEVABLE
RELEVANT
TIME-SPECIFIC
5 Types of Problem
• One way of developing a formulation
Problem Example of situation
1. Inner Inner conflicts where person is
Problems torn with a decision
2. Practical Lack of basic needs (food,
Problems water, shelter), arguments with
families
3. Lack of Children with developmental
Skills delays, persons with
confidence problems, social
skills difficulties.
4. Symptoms Where a patient is
of Stress & / experiencing symptoms
or Trauma indicating stress or trauma (e.g.
sleep problems etc.)
5. When a person experiences
Overwhelming intense feelings of anger,
feelings sadness, shame etc. as a
(emotions) consequence of their
experiences.
Intervention strategies – EXAMPLES!!
1.Speak to supervisor about these problems / challenges
2.Discuss without showing that you prefer one option over
another – e.g. use pro’s and con’s lists.
1. Helping define the problem
2. PFA – e.g. helping refer the patient to other services that
can support.
3. Pro’s and con’s lists around decision-making
1. Role Play
2. Attachment & Child Development strategies (e.g. play)
3. Talking about strengths and abilities
4. Giving appropriate praise
1. Psychoeducation around thoughts, feelings, behaviours.
2. Helping client to come to own decisions about treatment
3. Grounding techniques
1. Psychoeducation around feelings
2. Relaxation exercises
3. Breathing exercises
4. Doing an activity to stimulate a “positive” emotion.
A formulation example…
(This could be explained to the client using psychoeducation)

THOUGHTS
These are statements in one’s head E.g. “I’m worthless”, “I can’t cope”,
“Nobody loves me”.

FEELINGS
BODY SENSATIONS
These are EMOTIONAL FEELINGS that you have, e.g. Sad,
These are physical changes in the body, e.g. sweating,
anger, happy, guilty, worthless, nervous, worried,
heart palpitations, headaches, shaking etc.
anxious, ashamed / shame, frustration, confusion.

BEHAVIOUR
This is WHAT A PERSON DOES and unlike thoughts and feelings can be SEEN
BY OTHER PEOPLE. E.g. aggression, hostility, isolation, running etc.
And what can be done about it…
(This could be explained to the client using psychoeducation)
-Confidence-boost through
discussion.
-Discussing difficult thoughts
-Distraction through enjoyable THOUGHTS
activities
-Educate about feelings (e.g.
-Psychoeducation about
what is a feeling? What is
thoughts, feelings, behaviours
anger, sadness etc.?)
-Do something that will make
you feel better in short-term
(e.g. enjoyable activity).

BODY
FEELINGS
SENSATIONS

-Psychoeducation
-Relaxation
-Breathing exercises
-Gentle exercise,
walking etc. -Attempt different behaviours
-Reward for behaviours that are
wanted
BEHAVIOUR -Challenge avoidance behaviour
 Treatment Plan
The client is expert of own life and counsellor is
expert of therapeutic process. The 2 experts build
together the therapeutic process & plan. The
treatment plan will be different for each client
knowing that are differences in life history and also
in resources available.

i.e. It HAS TO BE BASED ON YOUR FORMULATION

OF CLIENT STRENGTHS AND COPING ABILITIES.
 INTERVENTIONS – depending on
formulation
• Sharing clear formulation (counsellor hypotheses about client).
• Psychoeducation (information; e.g. diagnosis, emotions, thoughts, etc.)
• Active listening –to provide a different perspective on the issue.
• Help client to explore thoughts, feelings and emotions around an issue.
• “Working through” of emotions (e.g. coca-cola) in controlled way.
• Relaxation Techniques
• Clarifying problems and problem-solving (e.g. pro’s and con’s lists)
• For children & families – attachment, child-development interventions
• Supporting client to make own decision – enhance self-control.
• Confidence building – asking client to talk about strengths.
• Supporting client to engage in social activities they enjoy
• Role plays to practice challenging situations.
• Grounding techniques for handling flashbacks.
• Restoring daily activities / structure / routine.
• Behavioural experiments (what will happen if you did X differently).
 Follow Up & Closure
• Ensure when possible a follow up session.

• Use initial session to assess, formulate and plan, and follow-up sessions to
attempt strategy development for client.

• Evaluate together with the client the goal set up in the beginning of the
counseling process. Use SMART goals.

• Patients should use the service in a short-term way – remember it is not detailed
psychotherapy.

• Some patients will drop out – think about necessity to follow-up

• Endings are important – have a good ending, thank the patient for coming and
sharing detailed information about their lives. Make sure the patient is
welcomed to come back if they need to.
Supervision (individual and group)
This is essential to good counselling practice – why???
1. It ensures that counsellors are adhering to good practice
2. It provides a different perspective about a case
3. It can generate new ideas about how to move forward with cases
4. It can provide an opportunity for counsellor to speak about how
they are feeling about a patient in a safe space
5. It can help follow-up on safety concerns (e.g. suicidality, aggression)

How to do it…
6. Should be weekly, for at least 1 hour
7. Someone should present a case in detail (around 10-15 minutes),
and others should comment on the case and add ideas
8. This should be done in a safe and non-judgemental way, so the
counsellor feels SUPPORTED not CRITICISED.
Single session counselling
• Not recommended in most cases, other than for PFA - WHY?

• However, necessary to be prepared for the fact that it may not be possible
to see the patient again in the immediate term.

• Read the single-session counselling guidelines provided.

• There is a specific form for this.

• You need to move more quickly with these assessments, because it is

ESSENTIAL that the patient leaves with;
a) A feeling of having been heard
b) A discussion about the most prominent problem for the individual
c) A chance to reflect on their coping strategies (how could you cope? What have
you done to cope with similar situations before?)
d) Leaving with 1 or 2 additional strategies to help manage (e.g. relaxation
exercises)
CASE STUDIES
What would you do if you met the following
clients in your sessions?

Try as role-plays – one client, one counsellor,

one observer.
 Case 1
Aster, 30 years old, from Eritrea. She is a mother of 5 children.
During a bomb attack on her village her house was destroyed and
her 2 youngest children (one of which was her only son) and her
husband were killed. She survived as did her 3 oldest children who
were at school during the attack.
This happened six months ago. Now Aster is living with her family in
law and is grieving the loss of her family. She was brought to the
Counseling center in Hitsats by her mother in law because she has
lost interest in her surviving children and does not care for them.
She does not do her household chores. Moreover, She is very sad.
When she is reminded of her husband or dead children she starts
to cry.
 Case 2
18 year old male, Ibrahim from Eritrea, currently living in a
Hitsats camp comes to the counseling to see the medical
doctor asking for medication to help him sleep (sleeping
pills). He has severe insomnia the past 3 weeks.
This problem started when he was told by one of the
community mental health worker. The psychiatric doctor
refers the patient to the MH program without prescribing
any medication.
 Case 3
16 years old woman, Meron is brought to the emergency room in
Hitsats MSF IPD by her father after a suicide attempt in which she
ingested rat poison. After the patient regained consciousness she
refused to talk to the male doctor. The female counselor was
therefore called urgently to the IPD to evaluate the patient. Once
alone in a private room, the patients discloses that she wanted to
kill herself because she was informed by her father that she is
being forced to marry a friend or her fathers who is 45 and who
lives in Shire.
Meron is very upset because she does not want to leave her family ,
especially her mother, and marry this man.
THANK YOU