The Counseling Process

The Counseling Process

John R. Stafford

Brandman University

Abstract

The counseling process is an in-depth exploration of a client, and a problem or a combination of the issues presented. Through thorough assessment, proper diagnosis, effective treatment plans, and decent connection with the client, the therapist compels the client to explore, understand, and ultimately acquire the appropriate skills to address the reasons he or she sought therapy. Severe situations like traumatic exposure create extreme stressors on the individual’s consciousness, interactions with others, and ability to function in normal daily routines. We will explore how such an event does this and the process of helping the client process the meaning of associated emotions, feelings, and responses to control the impact the initial event maintains over daily functionality.

Keywords:  Clinical Counseling, Counseling Processes, Clinical Assessment, Clinical Diagnosis, Clinical Treatment Plans, Trauma Exposure

The Counseling Process

Individuals and families enter counseling for a variety of issues that somehow impact their ability to function in certain aspects of daily life. For this reason, the therapeutic process and the therapist must maintain a level of fluidity while keeping a clinical perspective. Although this process may appear an easy task, or even as simple as conversational interaction, we quickly learn that not to be a correct assumption. Therapy requires an in-depth understanding of the client, the presenting problem[s], and other factors that produce a direct and indirect influence on the therapist’s ability to effectively work with the client.

The clinical process requires an in-depth exploration of the client’s fears, emotions, feelings, and reactions to significant events like a loss, stressful interactions, traumatic experiences, and illness. Other relevant information like employment, spiritual beliefs, sexual orientation, relationship status, and family history are gathered during the initial assessment to be incorporated into the case conceptualization because this information is paramount to understanding the invccdivual[s] in treatment (Bucci, French, & Berry, 2016). Additionally, the therapist uses the evaluation to determine the client’s stability, if he or she is of harm to self or others, support mechanisms, and to develop an initial concept of how to proceed in therapy. By definition, case conceptualization is an alternative explorative process to medically derived approaches that use a person-specific and flexible method to assess mental health concerns (Bucci, French, & Berry, 2016).

The process of exploration aids the client in ways of discussing and ultimately making sense of the problems to develop robust methods of managing those issues effectively. Although the reasons a person enters therapy and the theoretical processes used to work with the patient varies, the core foundations of the clinical process remain constant. Productive and responsible therapists begin the process by performing an initial assessment, which provides an overview of the client’s daily life, general capabilities, and presenting problems (Ridley, & Jeffrey, 2017).

Upon completion of this initial assessment, the therapist is better informed about several aspects of the client as a whole person and can develop an initial hypothesis about the presenting problem that he or she will use in helping the client address and work through the issues presented in the initial session (Zubernis, Snyder, & Neale-McFall, 2017). It is also time for the initial hypothesis to be confirmed or modified based on follow-up exploration with the client. Using a concept map to help form a case conceptualization is one method used to provide the client with a visual aspect of how the information gathers comes together in a relational manner (Liese, & Esterline, 2015). In some cases, the therapist might discover that the presenting problems are minor and the client needs a compassionate sounding-board. However, other clients may present with issues of more severe nature that require a tremendous amount of exploration to overcome (Zubernis, Snyder, & Neale-McFall, 2017).

No matter the reason an individual seeks counseling, he or she is seeking help from a trusted professional. The onus falls to the therapist to develop a productive alliance with the client through thoughtful, professional and empathetic collaboration, development of proper diagnosis and treatment plans that align with the client’s presenting problems and personal values and moral structure (Zubernis, Snyder, & Neale-McFall, 2017). A critical variable in the process is the theoretical orientation the clinician uses to work with the client. Clinicians are inclined to gravitate to a specific theoretical perspective, and some practices may provide enhanced results for particular issues. No single view is a one-stop solution because each client and every presenting problem is unique as it relates to the client seeking treatment (Zubernis, Snyder, & Neale-McFall, 2017).

Assessment

The assessment process is a crucial component of any therapeutic process. It is the cornerstone of providing proper treatment to the client (Liese, & Esterline, 2015). Although the assessment process is designed to gather as much valuable information regarding the client and the presenting problem[s], it also provides the opportunity to address areas like informed consent, so the client is aware of the benefits and limitations to the therapeutic process. Many of the questions in the initial assessment are a constant fact-finding process used to gather general information about the client’s life. However, as the client and therapist explore the presenting problem[s], the therapist will undoubtedly formulate additional questions to help broaden his or her understanding of all facets involved.

Important Questions

In the case of Catherine, there is additional information needed to compile a useful hypothesis of the presenting problem and underlying factors.

Ideations of self-harm or of being harmful to others

An important aspect is her current or past ideations of self-harm or causing harm to others. This information is critical because of the nature of her presenting problem relates to a violent and traumatic attack, and helps the therapist identify any immediate concerns for the client’s well-being.

Intimate relationships within the immediate family

This information will deliver an idea of how close relationships with immediate family members has been affected by the attack and what her emotional state is when she is in personal environments. Many victims experience mild to severe inability to relate with family members as they did before the incident. These complications could arise from the individual not being able to share his or her experience[s] with those closest to them, or the traumatic experience has rendered them unable to provide an emotional connection to those they share daily life.

Impacts on social interactions

In cases of violent assaults, the victim may experience difficulties in normal social interactions. Stressors become exacerbated when the individual is in the same, or similar, environment as where the attack took place because of familiarity of surroundings and the victim's potential to relive the experience. Interactions with friends in social settings and colleagues in work environments are both essential topics for exploration to determine if Catherine has withdrawn from friends and colleagues or have those interactions remained consistent.

What are the client’s Spiritual beliefs

Spirituality is often a significant aspect of recovering from a violent situation. It touches one of the core aspects of the individual’s moral structure and adds a layer to the healing process. Spiritual beliefs and what those beliefs are usually aligned with the person’s cultural history and learned experiences. Typically a person with strong religious practices has access to additional social interactions and other support structures than those who do not engage in spiritual practices.

Her attacker remaining at large

Knowing that her attacker is still at large is bound to affect her daily functioning. The client references how often she thinks about the perpetrator, cries, and fear she has in other situations. However, there is a much stronger undercurrent to this question and how the topic profoundly affects her emotional stability. Exploring this particular issue also permits the therapist to gather more information for the assessment process.

Investment in finding her attacker

The client states that she is determined to locate her attacker. This statement needs additional exploration for several reasons. First, how much time and energy is she investing in finding the individual. It is essential to understand if the client is spending more energy on this process than healing from the assault or is the search helping the process. Other information we want to discover is the potential for the victim to be obsessing over the attacker because finding him is the only way she can feel safe.

Finding her attacker

I believe this is a crucial follow-up question because of potential outcomes that reflect her emotional commitment and assessment of retribution. A concern is how the client would handle coming face-to-face with the assailant on an emotional level, and how the interaction would conclude. There is potential for the victim to commit a harmful or dangerous act, contact authorities, or utterly shut-down in an emotional break.

What it means to be a survivor

Surviving a violent or traumatic situation is more than just being alive. Based on the information already gathered and additional details from further exploration, the state of being a survivor appear associated with the simple fact that she survived the assault with no permanent physical ailments. It is vital to gain her perspective of what being a survivor is and explore how she feels about her mental well-being in the overall picture.

Feelings of hatred toward men

An issue that needs clarification is the expression of disgust towards men. Emotions and feelings become convoluted when a person is a victim of violent crimes. There are many questions as to why the crime happened, what levels of shame and self-blame the victim may experience, and what feelings the victim has toward the perpetrator. Feelings of anger and fear toward the perpetrator might project to individuals that meet a generalized similarity. Recoiling from the touch of a loved one could easily read as a feeling of hatred. This feeling toward men is most likely hurting the client’s relationships both at home and in social settings.

Previous treatments or coping mechanisms

Knowing if the client has undergone any earlier procedures for trauma exposure is very important because it will enhance the historical knowledge of what the client has done to combat the emotions and feelings associated with the experience. It will also tell us whether or not the client has received any prescription treatments along with any counseling she may have had. Additionally, if the client has not received any form of therapy, more questions regarding what she has done to combat the trauma on her own.  

If the client has not received any professional treatment, we would want to explore what she has done in the past to help combat the emotional distress. Knowing this will aid in understanding what things she has done were successful or not. It also opens the door for additional discussion on pinpointing what she is doing or experiencing when or if she does try to mitigate the emotional distress on her own.

Alcohol or substance abuse

This question is crucial to ask the client because alcohol or substance abuse frequently occurs with victims of violent crimes. Those who suffer violent or traumatic experiences that do not seek adequate treatment or even those in treatment are more prone to self-soothing with alcohol or other substances as a coping mechanism to aid in sleep, relieving anxiety, or in an attempt to forget the experience altogether.

Clinical Conceptualization

The client presents with obvious trauma symptoms of anxiety and depression resulting from a violent assault. She appears to have a stable family life, but the anger towards her assailant is most likely interfering with her marital life and interactions with children, as indicated by the short references to both her husband and children. Her experiences probably affect her interactions at work, even though she may appear to be functioning normally. The effects most likely influence her social activities and interactions, possibly causing her to alienate herself from friends and extended family members. She would undoubtedly have daily reminders of the assault because of the location that serves as a constant reminder of the incident, which causes additional stressors on a regular basis. Although the client does not appear to have suicidal ideation, she does emphasize finding her attacker. The concern is that she could be placing too much energy into this particular activity that could lead to an unhealthy obsession. Another matter is her stated hatred toward men. While this feeling is not uncommon for victims of assault, it does raise concerns regarding her interactions with friends, family, colleagues, and typical daily interactions in public spaces.

Furthermore, concerns for this emotional state combined with the search for her assailant could lead to a severe situation should she encounter the individual or even someone who she mistakenly identifies as the individual. The client states that because she is a survivor because she survived the attack. However, just relating to being a survivor does not necessarily mean the individual is healing from time and experience. The assumption is that she realizes that merely surviving a violent assault is only part of becoming a true survivor and that she needs to heal emotionally as well as physically.

Diagnosis

Physical healing does not bring closure to a victim of violent assault or other violent crimes. Those who experience severe traumatic experiences are prone to suffer prolonged effects of acute stress disorder [ASD] and posttraumatic stress disorder [PTSD] (Guay, Sader, Boyer, & Marchland, 2018). Depression and anxiety are common feelings for victims of traumatic experiences, but these emotions also become entangled with feelings of anger, self-doubt, self-blame, and in some cases a sense of shame over the initial exposure (Kunst, Winkle, & Bogaerts, 2011).

DSM-V Classification[s]

Posttraumatic Stress Disorder [F43.10]

The client experienced a violent attack that resulted in extreme physical and emotional injury. The following DSM-V criteria are noted. Client experienced a traumatic event [A.1.]. Client experiences recurring distressing memories of the event [B.1.]. Client Experiences prolonged psychological distress and reactions to external cues associated with the event [B.4., B.5.]. Client expresses anger and hatred toward men [C.4]. Experiencing marked alterations in arousal and reactivity [E.1., E.3.]. Clinical symptoms have been experienced for more than one-month [F] and are not attributable to substance abuse [H] (American Psychiatric Association, 2013).

Treatment Plan

A treatment plan for traumatic exposure consists of a variety of processes that aim to help the client understand his or her emotions, feelings, and behaviors associated with the initial event. Treatment usually includes cognitive behavioral therapy techniques like psychoeducation, exposure therapy, relapse prevention and possibly group therapy sessions with other victims of violent crimes to provide additional support structures. Self-reporting assessments also produce insight into the initial status of the client and provide follow-up data the therapist can use to gauge progress.

Self-reporting Assessments

I would recommend the client engages in several self-reporting assessments as the first step of the treatment process. The Beck Depression Inventory-II [BDI-II], The Modified PTSD Symptom Scale – Self Report [MPSS-SR] are helpful to both the client and the therapist as part of the treatment plan because it gives the client a visual representation of her emotions, and provides the therapist with a proper inventory of the client’s status (Guay, Sader, Boyer, & Marchland, 2018).

Cognitive Behavioral Therapy – Individual and with Significant Other

Psychoeducation is very important in aiding the client’s understanding of how emotions, feelings, and behaviors become altered after experiencing a traumatic event. By understanding these interactions, the client is open to working with the therapist to identify and change the maladaptive thoughts and behaviors the client is experiencing. This process includes learning techniques to manage anxiety by performing mindfulness exercises like diaphragmatic breathing (Guay, Sader, Boyer, & Marchland, 2018). Because the client experiences heightened levels of distress when she is around the event location, exposure therapy would be appropriate to aid in overcoming the emotions associated with the parking lot. Sessions with her husband would assist in enhancing communications surrounding the event and the subsequent feelings, thoughts, and behaviors to restore any maladaptive relationship issues.

Group Therapy

Attending group therapy with other survivors of violent crimes is a good step in helping the client associate with other people that have had shared experiences. Group therapy usually adds a layer of support for the victim and aids in alleviating alienating feelings. Exposure to stories of other victims also helps normalize feelings of anger or helplessness and provides the client with various perspectives of violent incidents and how other group members learn to cope with the event[s].

Conclusion

The counseling process is not merely engaging in discussions with a client. It is a complex and detailed process that includes understanding the client’s presenting problems, the underlying issues causing those problems, and building a relationship with the client that establishes a therapeutic direction. Although therapeutic disciplines differ based on the therapist's education, preferred methods, and sometimes the nature of the presenting problem, one constant part of the process is the clinical interview and assessment. In the case of Catherine, the initial information did not yield enough data to produce an accurate assessment. Additional questions need to be formulated to fill in the gaps. The treatment plan needed to be designed to meet the dire needs of the client and facilitate her recovery as efficiently as possible.

References

 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.

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Guay, S., Sader, J., Boyer, R., & Marchand, A. (2018). Treatment of acute stress disorder for victims of violent crime. Journal of Affective Disorders,241, 15-21. doi:10.1016/j.jad.2018.07.048

Kunst, M. J., Winkel, F. W., & Bogaerts, S. (2011). Posttraumatic Anger, Recalled Peritraumatic Emotions, and PTSD in Victims of Violent Crime. Journal of Interpersonal Violence,26(17), 3561-3579. doi:10.1177/0886260511403753

Liese, B. S., & Esterline, K. M. (2015). Concept mapping: A supervision strategy for introducing case conceptualization skills to novice therapists. Psychotherapy,52(2), 190-194. doi:10.1037/a0038618

Ridley, C. R., & Jeffrey, C. E. (2017). Thematic Mapping in Case Conceptualization: An Introduction to the Special Section. Journal of Clinical Psychology,73(4), 353-358. doi:10.1002/jclp.22355

Zubernis, L., Snyder, M., & Neale-Mcfall, C. (2017). Case Conceptualization: Improving Understanding and Treatment with the Temporal/Contextual Model. Journal of Mental Health Counseling,39(3), 181-194. doi:10.17744/mehc.39.3.01

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