Counseling Techniques in Diagnostic Interviewing - Term Paper Example

__________________________________ Number:______________ Question You are a counsellor, and seeing a client for the first time. By the end of your 90-minute interview, you will be required to make a provisional diagnosis. Carefully describe the approaches you will use in the interview and justify each. Support your answer by reference to authorities in the field of diagnostic interviewing. As an aspiring counsellor with goals of helping people in trying to lighten, if not eradicate their psychological burdens, I need to learn the essential skills in conducting interview sessions, especially in diagnosing the problem of my future clients. From my research, I have found that expert counsellors/ therapists in the field have shared their counselling approaches and tips that I can learn much from. I shall present the things I have learned which I will consider incorporating in my future practice. Being aware that the first counselling session is crucial in establishing the quality of the following sessions, I, as the counsellor should ensure that my clients are appropriately oriented on our professional relationship and how I can help in resolving issues brought forth in the diagnostic interview. It is but common for two strangers meeting for the first time to gauge each other and adjust one’s demeanour in accordance to how one judges the other. As a professional, I should be able to establish rapport well to make clients feel at ease so they can lower their defences and begin honestly sharing with me the real reasons why they considered counselling. Frances (2013) asserts that the first interview is challenging and risky because if the counsellor and client succeed in engaging in a harmonious relationship, the client is encouraged to commit to attending the next sessions. However, if at first, trust and collaboration are not achieved, the client may decide not to come back for a second session. Counsellors must remember that “People often wait until their suffering is so desperate that it finally outweighs the fear, mistrust or embarrassment that previously prevented them from seeking help” (Frances, 2013, para. 1). Hence, counsellors should be sensitive enough in dealing with them. Building rapport entails good listening skills as well as empathy. Davidson and Lax (1992) recommend that although conversations may seem light and friendly, the counsellor or therapist should be keen in observing clients’ non-verbal communication and be able to read between the lines. This means that the counsellor should be able to give emphasis on the meanings that the clients ascribe to their world. Clients may formally express their issues in their narratives by providing a description of the problem. They may present it in the context of another person and such context picked up by the counsellor is the one developed in the context of clinical interpretation (Davidson and Lax, 1992). In the diagnostic interview, the counsellor objectively listens to the client, withholding any judgment or evaluation until all the pieces come together to form the puzzle. An understanding is formed through the embedded meanings throughout the conversation which both counsellor and client agree to. Empathy is essential in coaxing the client to reveal more information about the problem and for assurance that many other people go through the same situations and overcome them. Seeking diagnosis should be a joint project collaborated by both the counsellor and the client. Information and education is provided so that the client leaves the session feeling both understood and enlightened (Frances, 2013). Key Counselling Skills Rapport-building is a skill that must be manifested by the counsellor and this includes showing interest in the client and the issues and concerns that brought about his or her coming to a counselling session (Corey, 2012). Being attentive to the client may be exhibited by the counsellor’s maintenance of good and sincere eye contact, nodding and sprinkling the conversation with “uh huh” or “I see” or “go on..” in acknowledging the client’s ideas and opinions. It encourages the client to keep talking, assured that someone is intently listening. The counsellor should also use non-verbal communication well to convey openness by smiling, leaning forward and other body language that is perceived as warm and non-judgmental. These would send positive signals to the client that the counsellor is approachable and easy to trust (Schultz & Schultz, 2005). Aside from asking open-ended questions and expressing empathy, using reflexive responses is also a key counselling skill. Here, the counsellor encapsulates what the client just expressed, reflecting back what was said to clarify the points made (Cowan, 2012). Leading the client deeper into the issues and probing with the right questions is a sensitive skill that the counsellor needs to learn. Still another is smooth transitioning from one topic to the next in order to see the whole picture. This needs good timing and consideration. It is usual for an interview to begin with a discussion of the reasons why clients have decided to come to therapy. This allows both parties to engage in neutral conversation while allowing the counsellor to more fully understand the clients’ idea of therapy and the magnitude of how they see their problem. The counsellor should adjust to the pace of the client in order for them to remain connected. The conversation should continue in a manner that is very similar to the client’s style, pace and willingness to proceed, if not, then the client might be intimidated and become unyielding to open up (Davidson & Lax, 1992). The counsellor needs to summarize the client’s expression of thoughts and feelings every so often just so the session is kept organized and the client is kept abreast of the progress of the discussions. It is also a way to verify if what was heard from the client was accurate (Pervin, Cervone & John, 2005). Diagnosis Counsellors and therapists diagnosing clients’ problems should use both open-ended and close-ended questions. Based on DSM criteria, symptoms of suspected disorders should be asked of the clients, and to supplement these, clients should be free to share further information about symptoms they report to have manifested within themselves. Frances (2013) suggests the use of screening questions to hone in on the diagnosis. After listening to the client’s presenting problems, the counsellor or therapist should select the closest category of disorders in which the symptoms belong to, and then proceed to asking screening questions provided for each disorder so that it can be narrowed to the particular diagnostic disorder that best fits the client. In collaboration with the client, the counsellor should explore alternative possibilities while checking if the symptoms may be a result of taking medication or a comorbid illness. The counsellor should not rush the diagnostic process because more details, possibly contradicting the previous symptoms manifested, may still come out that can prove the initial diagnosis wrong. If the client’s symptoms fall under similar categories, the diagnosis maybe termed “unspecified”, meaning the evaluation needs to be extended until a clearer category or condition is confirmed (Frances, 2013). Diagnosing mental disorders entails two conditions for clinical significance. One is that symptoms have to cluster in a characteristic manner so isolated symptoms of known mental dysfunctions such as depression, memory difficulties, attention problems, etc. are not sufficient to justify a diagnosis. The other condition is that symptoms should cause distress or impairment in social or occupational functioning in the client. This implies that identification of symptoms is not enough, but such symptoms should be recognized to cause serious problems for the client that can render them helpless and unable to function normally (Frances, 2013). It is important to document the first counselling session as it is expected that information on the client’s current presentation, personal history, course, family history and previous treatment response are derived (Frances, 2013). Such documentation shall always be referred to during the progress of the client’s case. Counselling Theories Various counselling approaches have been developed by prominent psychologists such as Sigmund Freud for Psychodynamic approach, Carl Rogers for Person-Centered Therapy, Albert Ellis for Rational-Emotive Behaviour Therapy, Aaron Beck for Cognitive Behaviour Therapy, Gerard Egan for the Skilled Helper Approach, Steve de Shazar for Solution-Focused Brief Therapy, among several others. As a counsellor, I should study such approaches and select which one works best for me and my philosophy, personality and values. Each approach has its own strength and it is possible to pick the best qualities from each and integrate into my own counselling sessions. The goals of Psychodynamic therapy are settling unresolved conflicts in a person’s past that deeply affect his current patterns of behavior and personality. It may involve bringing repressed painful memories to resurface to be dealt with consciously through the techniques of free association, dream analysis, hypnosis, transference, and analysis of resistance handled by a skilled psychoanalyst (Corey, 2012). This tedious process intends for the client to reach a level of self-understanding for him to be able to move on with life without heavy emotional baggage. This understanding is necessary for an eventual change in views, personality and character. Applying such approach, I as the counselor/therapist need to be adept and very patient in coaxing the client to unearth repressed thoughts and emotions. The ability to listen and be alert and sensitive to what the client tries to communicate (verbally or non-verbally) is crucial to my valid interpretations and diagnosis about the client. I must also possess maturity and maintain my professional objectivity especially when the client undergoes “transference” of remembered feelings towards a significant person to me. A deep level of trust must be established between me and the client to be able to achieve this feat. The Person-Centered approach shows great respect for the client’s subjective views and potentials for self-actualization. In encourages the client to be congruent, meaning to be real and authentic with no discrepancy between one’s perceptions and one’s being. I, myself need to be congruent before I can decipher incongruence in my clients. My wisdom should enable me to spot clients whose ideal self-concept is far from the truth. For example, they may be mistaken in their perception of their aptitude for a skill, either they believe they are very good at it but they are actually not, or vise versa. My goal as the counselor is to help them become more open to learning the truth, to a wider range of experiences, to develop trust in themselves and an internal source of evaluation and willingness to continue growing (Corey, 2012). This approach values the counselor’s ability to accurately empathize with the clients’ subjective experiences on an interpersonal, cognitive and affective level in fully unlocking their perceptions, feelings and motivations for their behavior (Corey, 2012). I should possess an enormous capacity to understand and accept the client no matter what and convey his or her worthiness as a person. Cognitive Behavior Therapy (CBT) is a psychotherapeutic approach of helping clients understand how their thinking and behaviour affect their emotional state and this in turn affects their feelings and ability to live normal lives (Corey, 2005). Ellis’ Rational Emotive Behavior Therapy (REBT) is considered to be the forerunner of Cognitive Behavior therapies. Its basic hypothesis is that people’s emotions stem mainly from their beliefs, evaluations, interpretations and reactions to life situations. Ellis believes that people have an inborn tendency towards growth and actualization but they often sabotage their movement toward growth due to self-defeating patterns learned. According to Ellis (2005), beliefs include both emotions and behaviors. In turn, emotions are not merely feeling states but also include aspects of cognition and behavior. It follows then that behaviors are not only actions but also include cognitive and emotional factors (Ellis, 1962). Through therapeutic processes, the client learns skills to isolate and dispute their irrational views which were mostly self-constructed and maintained by self-indoctrination. REBT helps clients replace such irrational views with rational and constructive ones, thus resulting in more productive change in behavior and reactions to situations (Corey, 2012). Egan’s Skilled Helper approach in counseling integrates useful practices of several different approaches. Its contribution to the counseling field goes beyond the process of communicating, understanding and counseling in the helper-client relationship and may be applied in a vast continuum depending on the degree of how an individual is in charge of his or her life. At one end of the continuum is the counseling model which provides guidance in certain problem areas of a person’s life, while on the other end of the continuum is the case-management model for people who are not in charge of their own lives and reasonable dialogue is not possible (e.g. clinical cases like certain psychoses). At this extreme end, issues and methods of intervention are explored to most efficiently and effectively help the client or patient Egan’s Model is a stage-wise counselling model that goes through three stages. Basically, the first stage involves problem definition and insight. Both helper (counsellor) and client build rapport and trust and explore the identified problem. The second stage further investigates the client’s perspectives using insight-focused methodologies to delve deeper into the core of the client with the help of the counsellor’s trained communication skills that unearth deep-seated issues. More involvement on the counsellor is called for as the processes of self-disclosure, immediacy and confrontation take place. This stage clarifies the perspectives of the client and gets him/her ready for the final stage which now focuses on action strategies, planned from a more objective point of view (Egan, 1985). Still another counseling approach is Solution-Focused Brief Therapy, which serves as an alternative to traditional psychotherapies known to last a long time. It is based on the premise that people are most often inherently capable and resourceful in ‘doing more of what works’ and discussing how they cope with challenges and exceptions to the problem help them go on with their daily lives (Freeman, 2007). SFBT’s core principles include “a shift of expertise toward the client (who must be recognised as the expert not only in themselves but also in their resources and ambitions)” and “exploring ways in which the client can do more of what works and stop or reduce doing things which do not.” (Freeman, 2007, p. 32). This humanistic view offers much respect to the clients and empowers them to recognize their capabilities, which they might seem to have forgotten due to their immersion in their negativity. The counselor’s role is to help them find alternative ways that work for them based on their capabilities, resources and ambitions. SFBT may be likened to Cognitive Behavioral therapy in the sense that a client’s thinking and behavior is modified from negative to positive. Goal-setting is essential to the therapeutic process, and clients are assisted by an understanding therapist who keeps them grounded on their own reality. Conclusion Armed with all these knowledge from authorities not only in diagnostic interviewing but in the counseling and psychotherapy field, I have within my reach a myriad of brilliant resources to help me succeed in my counseling practice. It is up to me to apply which ones I believe would work for me on various situations. Meeting a client for the first time for a 90-minute interview, I will begin by initiating interaction to welcome the client to my counseling session and to build rapport. When the client has loosened up, I will bring up the question what brought about the decision to attend counseling. I will assure the client confidentiality and unconditional acceptance without judgment. Based on the information provided to me, I will use reflection, probe deeper into the issues raised and summarize the information to clarify if I understood it correctly. I will make sure I will use all the key counseling skills to gather as much information I can from the client to help me evaluate and diagnose the case well. My keen observation skills shall come into play while the client opens up to me. I would be able to determine if negative thoughts and emotions prevail and take note of the non-verbal communication conveyed by the client. My full attention will be on the client and making conclusions about the presenting case or planning possible interventions can follow after the session. I would not want to miss out on any information that may be shared or observed during the 90-minute initial session. Should the client share some symptoms of a mental disorder, I shall use a checklist based on DSM criteria and if majority of the symptoms fall into a certain mental condition to merit an accurate diagnosis, then I can make a provisional diagnosis. If not, then I need more time in the next sessions to narrow down the symptoms into a more specified category. Once I do, then I can design the appropriate intervention. The initial session wraps up with my sharing of my provisional diagnosis of the client’s problem and the identification of the goals of counseling for both me as the counselor and the client. We should both agree on the rules to be followed in the succeeding sessions such as the schedule of sessions, compliance to interventions, etc. As a counsellor, my hope is to bring light to my clients’ darkened views about their lives. I assume an equal position with them and am not a superior who is expected to provide answers to their problems and tell them what to do. I shall be a collaborator of the clients in seeking possible solutions to problems that burden them. In that case, I help empower them and live their lives with a lighter load and with a more positive outlook and disposition. References Corey, G. (2005) Theory and practice of counseling and psychotherapy (7th ed.). Belmont, CA: Brooks/Cole - Thomson Learning Inc. Corey, G. (2012) Theory and practice of counseling and psychotherapy (9th ed). Belmont, CA: Brooks/Cole, Cengage Learning Cowan, R. (2012) Lasting the course. Therapy Today. 23 (6): 14-18. Davidson, J. & Lax, W.D. (1992) Reflecting conversations in the initial consultation, In S.H., Budman, M.F., Hoyt & S., Friedman (Eds.), The first session in brief therapy, New York, NY: The Guilford Press. Egan, G.(1985) Change agent skills in helping and human service settings. Monterey, CA: Brooks/Cole Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel. Ellis, A. (2005) Can rational-emotive behavior therapy (rebt) and acceptance and Commitment therapy (act) resolve their differences and be integrated?, Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23 (2): 153-168. Freeman, S. (2007) A focused solution to therapy, Primary Heath Care, 17 (7). Frances, A. (2013) 14 tips for the diagnostic interview of mental disorders, Retrieved from http://pro.psychcentral.com/14-tips-for-the-diagnostic-interview-of-mental- disorders/005295.html# Pervin, Cervone & John (2005) Personality: Theory & Research,(9th ed.). Hoboken, NJ: Wiley Schultz, D. & Schultz, S. (2005) Theories of Personality, (8th ed) Belmont, CA:Wadsworth Read More