The Client

Just like any other medical procedure, knowing the client is the first step in the counselling session (Jones, 2010). Knowing the client provides essential information about the difficulties the patient is facing and is the initial opening for a counsellor to form a rapport with the patient.

The patient, Valerie, is a linguist and teaches three languages and economics, is an examiner for the international baccalaureate and is currently doing her Master’s degree. Valerie has a family and during the session she mentioned her husband and daughter. She loves to read and cook and is the author of a cook book which she did in collaboration with her students. She is currently in Hong Kong and our conversation was done virtually using the zoom interface.

The main presenting issues was the amount of stress she is under especially during school days when she has to juggle teaching multiple classes and still tend to her family especially a younger daughter who still needs help getting ready for school. Weekends and holidays are relaxed for her. Our first session was on a Sunday and she admitted that it had been a good day seeing as it was in the summer holiday. The stress comes from non-stop working and the need to do the best at all time and especially in her career.  She admitted that she tries to limit the stressful conditions by being organized and very disciplined with her activities. In her words, her organization is like a military operation. She will plan her classes for the whole academic year and break down that plan into school terms, then half terms, and finally into weeks. She cannot plan for more than three lessons in a week as it is impossible to predict how her students will understand the different concepts they are taught.

She rates her stress levels at a 1 during the weekends and holidays, a 5-6 during school days and a 7 during exam periods. This is because the exam period demands a certain amount of time to grade papers which is out of her control. She realizes that when she is stressed she can be snappy and has tried to make amends by apologizing to people when she deals with them in the stressful state.

Another problem she wanted help with was to find a balance between work and life. She claimed that though she has made peace with her organization routine, she does feel trapped in it and lacks the freedom to live life. She feels guilty during the school term to sometimes focus on her career at the expense of her family. She also does not have time for herself owing to the demands of her career.

Valerie reported problems with sleeping and ever since moving to Hong Kong, she has been falling ill often. She counts about ten days within a month when she has not slept because she was working. She generally wakes up at 6am and gets prepared for work. She does not exercise and in her words, she has never liked to exercise as she does not find it rewarding. She would rather read than exercise. She has exercised once in the last year. She has had a surgery on her leg which limits the type of exercise she can do to prevent further injury.

The patient appeared calm and confident during the whole session. She maintained eye contact and her tone remained calm. She only appeared slightly agitated when talking about the ills of the world such as racism, and misogyny brought by lack of proper education. She would smile when talking about reading or baking which is evidence of how much she enjoys those activities.

Valerie’s expectation of the session is that I would help her with creating time for herself. She felt that by having time to herself would help her be more relaxed from the stress. It would also give her the sense of freedom that she seeks and the guilt she feels from neglecting her family for her job. Though she does not like to exercise, she acknowledges the its importance in life and is willing to discuss exercise only in a way that gives a sense of reward. The underlying theme of the session was how to handle stress and other negative consequences of stress and how to make time to relax from the pressure of intense careers.

The Therapeutic Alliance

Therapeutic Alliance refers to the relationship between the counsellor and the patient that enables the two to engage with each other to effect beneficial change for the client. The aim of the therapeutic alliance is to provide patient centred care with the therapist assuming the role of a facilitator in the achievement of set goals (Lambert, 2015). Setting a good therapeutic alliance encourages the patient to participate in the conversation and the therapist is able to assess issues like psychosocial pain which would be overlooked in the traditional unidirectional therapy interactions. I achieved a strong therapeutic alliance in three ways.

The first was agreement on suggested interventions. One of the interventions we arrived at was the need to introduce some form of activity for Valerie to help her get some downtime away from her work and family. This intervention was set through a shared decision making process. The collaborative effort is necessary to make sure the client owns the process and the interventions so as to make it easy to implement. Valerie agreed that activities away from work and family would help her get some time to relax and be less stressed. She was also looking forward to such activities leading to better sleep outcomes.

The second component of therapeutic alliance that I used with the patient was collaborative goal setting.  The idea is to help the patient make specific, measurable, attainable, relevant and time limited (SMART) goals. Collaborative setting of goals helps the patient adhere those goals which increases the chances of improved outcomes. The immediate goal we set was for Valerie to start exercising by walking two times a week for twenty minutes. We settled on the walking days being Wednesday and Saturday. Wednesday because it is in the middle of the week and this would help maintain the stress levels between the week and Saturday because she is free on the weekends which would make it easy to remember to exercise.

Valerie would walk while reading on her kindle. She does not like to exercise and for it to work, the exercise must be combined with something she likes to do so that it has the rewarding feeling that she lacks in most exercise regimens. Aggressive exercising would not be possible due to her injured knee.  She likes to walk and is more likely to keep up with the exercise. She also mentioned that the circuit she would use to walk is the school track field where she is not likely to bump into cars of people making it safe for her to walk while reading. Valerie said that her husband is willing to go with her on the walks as a way to provide motivation and this will help to make this goal attainable.

Lastly I made sure that there was an effective bond between the patient and me. This is achieved by being keen on that they were saying and paraphrasing it back to them to ensure I did not miss any detail. I also refrained from being judgmental of anything the patient said to avoid discouraging her from being open and honest during the conversation.

The effect of the therapeutic alliance is that it enabled Valerie feel free to talk about her work and family and due to the rapport formed, it was easy to identify when she was talking about something she like and what she didn’t like. I remember complementing her disciplined planning nature and the zeal she puts in her work and she smiled an indication that she appreciated my words and that her work was something she was proud of.

Counselling Skills

There are certain skills that every counsellor should have for a successful session with the patient. There are some skills I used to help Valerie give her story and also reach collaborative agreements by the end of the session.

I was keen to exercise listening skills during the conversation with Valerie. Listening is not only be being silent to hear what a person says but also being attentive to their nonverbal sues. Counselling session require the counsellor to give their undivided attention to the patient. This includes making eye contact, encouraging verbalizations, leaning forward and mirroring body postures and language (Drab, 2015). For the nonverbal cues, which account for almost 80% of the communication, I was on the look out to understand their facial expression, the themes of the content being expresses and interactions like smiling or frowning. With Valerie, what worked was maintaining eye contact, and encouraging verbalization especially where I wanted more details on her daily schedule and how she prepares for work to avoid stress. It was also an important tool when we were discussing the goals and interventions. Her facials expressions were helped me understand things she liked and didn’t like. An example was with her dislike for exercise. As much as she tried to make it sound like something she mildly resisted, the family expression showed much more dislike for the activity and it became evident later during the conversation. Having this conversation virtually as opposed to being in the same room created some difficulties in assessing all nonverbal cues like the posture which also speak towards certain attitudes of a person. Using zoom limited the listening skills to just the words and the facial expression.

I also used empathy skills in my conversations with the patient. Empathy allows a counsellor to perceive the experience of the patient and communicate it back for the patient to either clarify or amply the same with their understanding. Empathy is not identifying with the patient or sharing similar experiences (Drab, 2015). Throughout the session, I paraphrased the content of the patient’s communication especially where I needed clarification. An example is when she was explaining why she cannot plan for more than three lessons in a week. I did not fully understand the rationale of the three lessons but upon paraphrasing the same to her, she clarified that this was because she could not pre-determine the level of understanding her students would have to the lessons. She needed a week to gauge the understanding of the students and make new plans for the weeks ahead. Recalling bits and pieces of information she gave throughout the session and repeating it to her was part of exercising the empathy skill. Whenever I needed to talk about her family I referenced her daughter and husband who she had mentioned at certain points of the conversation.  Perception checks are also great ways to show empathy to the patient. Normally they take the form of brief questions to which the patient will agree or disagree with the paraphrasing of the counsellor (Drab, 2015). I used the perception check when asking about her husband involvement in the goals we had set. I said, “Let me see if I get this, you said your husband was willing to go with you on the walks as you exercise”, to which she affirmed that her husband is supportive and would be willing to go on walks with her.

The third skill I employed being genuine with Valerie. Being genuine requires that there is congruence between what a counsellor says and their actions shown in the way they approach certain topics(Drab, 2015). I did not show any discomfort at anything she said even when she gave her pinion about wondering why people would elect a person like Donald Trump as President yet he shows signs of racism, misogyny and rudeness.

Unconditional positive regard is a necessary skill for all counsellors. This involves conveying acceptance of the patient’s message without judgment or being critical of their verbal and non-verbal cues. The positive regard is a tool that can be used to communicate the belief that every person has the strength and capacity to choose their path and make their decisions independently(Drab, 2015). Communicating such a belief will give the patient the will to implement any goals and interventions suggestions. I was careful not to be judgmental of Valerie. While current exercise routine is of concern for her health, I tried to encourage her to pick up the habit without critiquing her current lifestyle. When encouraging her to take up walking, I was careful to instil the belief that this was something she could do as part of her weekly routine.

I felt that I exercised patience skills during the counselling sessions. Sometimes patient s may not be fully aware of what is the exact problem they want to deal with and will give too much information in a manner that is not coherent. A counsellor needs patients to listen to all the pieces of information and to lead the patient to a coherent flow of information (Drab, 2015). Patience is also required to help the patient narrow down to more details in their story to try and work out interventions. From the beginning of the conversation, Valerie seemed overwhelmed by the amount of work she does daily and especially when schools are open. I helped her narrow done to explain the stress levels brought by each activity she does from teaching, marking exams and parenting.

There are some skills I felt I need to develop for future sessions with Valerie and other patients. The use of open questions during the conversation is something I should develop for future sessions. Open questions assist the patients to explore different emotions. Using open questions requires the counsellor to be careful not to ask too many questions or create an interrogatory feeling to the session (Drab, 2015). Using open questions will require that I follow up the question with a reflection to encourage the client to say more about the issues they are facing.  One of the reasons I did not use this skill is because Valerie was good at expressing her situation and I felt there was no need to keep interrupting with open questions. Additionally, using open questions is usually reserved for emergency questioning assessment and the case with Valerie does not qualify as an emergency.

I also felt I need to develop counsellor self-disclosure skills so as to share my personal experiences with the patient in a way that is relevant to the situation and encourages them to continue sharing their story with me. Thought the general rule is that counsellor should not use this skill unless there is a pressing need, it is sometimes necessary to connect with the patient using personal experience (Drab, 2015). The issue of stress is not too personal and is common with many people and sharing my experiences with her may have made her more comfortable to delve deeper into the root causes of her stress.

Feedback from the Client

At the end of the session, I asked Valerie for feedback on what she thought of the first session. Feedback from the client helps to gauge if she felt she was receiving any help from me and also for me to learn where to improve on in the next session.

The first thing she pointed out was that she appreciated how I actively listened when she spoke. She stated that by sending back paraphrased information to her for clarification was an indication that I was listening and that it encouraged her to keep going. The suggestions I put across during the conversation were helpful in continuing the conversation without sounding repetitive.

She also commented that is showed great empathy by putting myself in her shoes t try and understand her situation, She remembered when I commented by saying, “it must be hard” in reference to all the activities she juggles and that made her feel like I understood her situation. She also did not feel any judgment from me during the session which made her comfortable in sharing her story with me.

Valerie pointed out in her feedback that I helped her prioritize the issues she was facing starting for the biggest to the smallest issue. She stated that the prioritizing helped to create a clear picture of what needs to be done and lead to creating practical suggestions that would be easy to implement before the next session. The fact that I created a follow-up for the next session was an advantage for her as we did not waste time in creating interventions. She stated that getting the interventions right away would create something to analyze in the next session.

Lastly, Valerie appreciated that I facilitated a conversation in which a solution was found and not giving my own ideas as the solution. She appreciated that even though I did give insights and ideas for some interventions, the final solution came from her. She thought the session was productive and is looking forward to more sessions.

She however pointed out that I could improve on the use of open questions in the conversation.

Getting feedback from Valerie was easy as we had already established a rapport from the beginning of the conversation. I had already created an environment of trust and openness with the patient so giving feedback was not difficult for her. By applying listening and empathy skills, I created an avenue of openness that the patient could rely on when giving her feedback.

The patient’s feedback about the session was similar to the one I made about my skills during the session. This validates the fact that I carried out an honest assessment on myself and that the patient and I were in agreement about the rapport created for the session. It was also a reflection that there was honesty between us during the session and I hope that this reflects in the patient’s willingness to put effort into the goals that were set during the session.

As a result of this feedback I will be keen to use more closed questions in the next session. I will try and maintain the same level of keen listening and empathy so that I continue to gain the trust of the patient. From the feedback of the patient, I learnt that with counselling, I just have to let the session be patient-centred. The session is supposed to be an avenue for the patient to express their thoughts and my work is just to facilitate the stimulation of the patient to getting solutions on their own.

The Egan Model

The Egan model is based on Gerard Egan’s work in providing a three stage model to assist counsellors during therapy sessions. The stages consist of skills that the counsellor will use to help the patient get better outcomes. It also helps the therapist to increase their efficiency and consistency in helping their patients (Nelson, 2007). The three stages of the model are the exploration stage where the counsellor seeks to understand what is going on with the patient. The second stage is challenging the patient on what they should do to get the outcomes they desire and the third stage is planning for the required actions for success.

Since this was the first session with Valerie, we did not cover the last stage of creating proper plans for action and this report will not discuss that stage. Our first session was to create a rapport and understand the presenting problems as well as suggest interventions for the next session. Better planning for actions will be carried out in the subsequent sessions.

Exploration Stage

Being the first step, the exploration stage is where the counsellor tries to find out what is going on with the patient. The stage also aims to build a relationship with the patient that allows a safe space for the patient to share their story. This is the stage to create the therapeutic alliance. In this stage the counsellor will question, reflect and summarize what the patient is saying. Consequently, the skills required in this stage are listening skills and empathy. The counsellor in giving attention to the patient is required to give positive reassurances to the patient and avoid coming off as judgmental. It is in this stage that the counsellor helps the patient unearth any blind spots in their story to uncover any hidden feelings (Nelson, 2007).

Questions are very important in this stage and the counsellor will ask the patient what they are feeling and thinking about or their thought son certain aspects discussed in the session. When faced with an agitated or upset patient, the counsellor will use this stage to calm the patient so that they are able to identify any misperceptions and blind spots that may be causing the anger.

This stage with Valerie went smoothly as she was calm and therefore the conversation went smoothly. What started off as a huge problem was broken down into smaller issues by questioning and rephrasing her sentiments. She was able to see the blind spot in her story especially about how lack of creating time for herself was causing her to feel so much pressure from all her activities.

Challenging Stage

Having understood the patient in the first stage, this stage involves challenging the beliefs of the patient. To achieve this, the counsellor encourages the patient to examine if there was any other way they can look at the issue at hand. Basically the counsellor is trying to help the patient look at an issue from another person’s perspective. It is also in this stage that the counsellor will set goals with the patient (Nelson, 2007).

The challenging stage with Valerie was interesting because it forced her to think about exercise as an option to reduce stress which is something she does not like to do. It was interesting to see her consider it from another person’s view and to see how she slowly came to accept that it is something she could try.

Critique of the Egan Model

I feel that the Egan method was a necessary guide in the counselling session with Valerie. It helps the counsellor not to skip any stages that may make the session feel unorganized and distort the patient’s train of thought. The third stage may not be fully covered in the first session because the session is an introduction where both parties are meeting for the first time.  When using the Egan model, it is important that the counsel makes sure it is culturally appropriate to use with the patient. Some patients may not prefer to be slowly inclined into the challenging face especially if they appear agitates and the model may only make them further angry by being forced to take the view of the person who might have angered them.

Conclusion

The counselling session with Valerie was an eye opener to how to carry out the sessions with patient. Thought eh presenting problem was not too difficult, it helped to sharpen the counselling skills that are required for a successful session with a patient. I enjoyed speaking to Valerie and was happy that we collaboratively made interventions and goals that would make her life better. I am looking forward to the next session where we can make detailed action plans.

References

Drab, K. J. (2015). The Top Ten Basic Counseling Skills. 1-3.

Jones, K. D. (2010). The Unstructured Clinical Interview. Journal of Counselling & Development. Vol. 88, 220-226.

Lambert, M. J. (2015). The Therapeutic Alliance: An Evidence-Based Guide to Practice. Psychotherapy Research. 26(2), 1-2.

Nelson, P. J. (2007). An Easy Introduction to Egan’s Skilled Helper Solution Focused Counselling Approach. Retrieved August 28, 2020, from High Gate Counselling: http://highgatecounselling.org.uk/members/certificate/CT1W3%20Paper%202.pdf

Valerie. (2020). Counselling Session One. (Frank, Interviewer)