Counselling

How are Solution Focused Therapy (STF) and Person-Centred approaches to counselling similar? How are they able to aid medical professionals in disciplinary proceedings? Abstract Counselling theories are varied and are often theoretically different at their origin. In the 1950s Humanistic psychology spawned person-centred therapy (Rogers, 1951) where the key concept is the intrinsic human ability to “self-actualize”. The Solution Focused Therapy approach (de Shazar et al, 1988; 1994) which was formulated much later, believes that problems are not the issues to be dealt with, but the solutions and coping mechanisms of the client are. Although different, the two approaches share a number of values and beliefs which is promising for the unification of counselling theories into an individual scientific paradigm. In relation to counselling medical professionals in disciplinary proceedings, both approaches provide a very client orientated view which would be ideal in promoting self esteem and coping strategies in such a stressful process. Key Words: Counselling; Person-Centred; Solution focused therapy; Disciplinary; Medical; Ethical principles. Introduction When someone has a dilemma or difficulty in their life, what is the difference between seeing a qualified counsellor and a long chat with a well experienced individual (say, a parent)? The fundamental thing to realise is that each professional counsellor will take their own approach yet this will be underpinned by their theoretical perspective. Furthermore, theories in counselling are based on psychological understanding and research. Each is developed from a particular understanding of the way people function. One of the oldest and one of the newest of the counselling theories are the person-centred and solution focused approaches respectively. Although the theoretical basis for these two theories is different, are they comparable? What are the issues surrounding their use in counselling? In recent years, an increasing number of professional organisations have offered counselling for issues that their members might encounter. Counsellors acting in such a service may have to aid employees facing disciplinary procedures (for a number of reasons), a large number of which are often in the medical profession due to the nature of the work, but how can they help? These theories and issues are discussed here. Counselling is a young technique that has only really found its niche in the last 50 years. Therefore, the definition of what counselling entails is often a blurry one. The British Association of Counselling defines it as “work with individuals and with relationships which many be developmental, crisis support, psychotherapeutic, guiding or problem solving” (BAC, 1984). Others have stressed the importance of the professional relationship and reaching ‘self determined goals’ (Burks and Stefflre, 1979). The cultural evolution that has been so key for the practice has left definitions unclear and the range of different ideas that have been involved through the years have made the move towards a unifying scientific paradigm very difficult (Ellingham, 1997). Traditionally, counselling takes one of three core approaches; psychodynamic, cognitivebehavioural or humanistic, which all represent different ways of representing human emotional and behavioural problems (Mahrer, 1989). There are often multiple aims to counselling although one approach very rarely aims to achieve all of them. However, psychodynamic counsellors focus primarily on gaining insight, the acquisition of an understanding of the origins and development of emotional difficulties; humanistic counsellors promote self acceptance and personal freedom and the development of a positive attitude towards self; cognitive-behavioural therapists are mostly concerned with the management and control of behaviour (McLeod, 1993).

Humanistic Psychology Humanistic psychology spawned the “person-centred” approach to counselling in the 1950s. Carl Rogers was the main writer in this approach, and along with the other humanistic psychologists of the time (e.g. Maslow and Buhler), he shared a vision that psychology would have a place for the human capacity for creativity, growth and choice (McLeod, 1993). The idea of counselling from a humanistic direction initially took the form of a “non-directive” approach where the ethos was that clients found their own solutions to their problems (Rogers, 1942). To many this seemed much like a contradictory idea as a client-therapist relationship would automatically infer an influence by both parties. Studies indicated that counsellors using the “non-directive” technique actually subtly reinforced particular statements made by clients but did not offer interest, encouragement or approval for other types (Truax, 1966). Therefore, there were inherent difficulties with the idea of “non-directive” counselling. However, much of the early research noted that the approach was able to initiate changes in the client. It was eventually more aptly renamed “person-centred” (Rogers and Dymond, 1954). Following this, the theory underwent an evolution, consolidating the earlier ideas. The resultant model of the therapeutic relationship included what Rogers (1957) called the “necessary and sufficient” conditions of empathy, congruence and acceptance. The condition of empathy required the therapist to experience an understanding of a clients “inner world” as if it were their own and communicate this to the client. The condition of congruence required that the therapist be is genuine and transparent with the client. Acceptance, otherwise known as unconditional positive regard for the client meant that the therapist should always accept or value the client as a person, despite any behaviour that they might display. Rogers’ Person-Centred Approach Rogers’ formulation of the person centred approach was very much based on trust in the client’s humanity, and like most humanistic psychologist, the belief the humans are selfactualizing1. Indeed, it is supposedly this actualisation that is the motivation for change in the client (Van Belle, 1990). As Rogers himself put it (1986b, page 198), person-centred counselling “depends on the actualizing tendency present in every living organism’s tendency to grow, to develop, to realize its full potential. This way of being trusts the constructive directional flow of the human being toward a more complex and complete development.” The theory identifies that it is the directional flow towards actualization that is to be release by the therapist. The basic person-centred value is that the authority of the person rests in the person rather than in an outside expert (Bozarth, 1990a). This gives emphasis to the internal (i.e., the client’s) rather than the external (i.e., the therapist’s) view. Clients are allowed to go at their own pace and to pursue their growth in their unique ways. The external view is meaningless in the therapy process since the only function of the therapist is to facilitate the client’s actualizing process. Rogers thought the client should be approached naively without preconceptions as a unique individual and be allowed to develop his/her own therapy process. The assumption was that a client's innate actualizing tendency could be fostered most effectively by the creation of a distinctive interpersonal environment fundamentally based on the trust and respect. The therapist's basic task is to listen with respect and understanding and help the client to clarify his/her feelings and thoughts as they are expressed to the therapist. All counsellors agree that a good client relationship is necessary of effective treatment. However, most modern counsellors feel that more than just a relationship with the client is needed for constructive change and therefore they often require a set of interventions in addition. These helping strategies are chosen specifically by the counsellor for each patient, 1

Maslow also used “self-actualization” in many of his theories.

sometimes considering a relative probability of success for the client. These Interventions often reflect the theoretical standpoint of the counsellor although some counsellors are more eclectic in their approach and therefore prefer a variety. Solution-Focused Therapy (SFT) One of the more recently developed theories in use in modern counselling is known as Solution-Focused therapy (SFT). SFT is an approach to counselling based upon the building of solutions rather than more specific problem-solving. It delves into current resources and future hopes of the client rather than present problems and past causes. The approach was first developed by de Shazer et al (1986) and it originated from an interest in what were identified as “inconsistencies” in problem behaviour. The group noted that however serious, fixed or chronic the problem there were always exceptions and these exceptions could contain the origins of the client’s own solution. de Shazer (1988, 1994) and Berg (Berg, 1991; Berg & Miller, 1992) also found that the clearer a client was about their goals the more likely it was that they were achieved. Finding ways to elicit and describe future goals has since become intrinsic to SFT. Theoretically, the approach was evolved from problem focused therapy2 but believes that problems are not the issue to be dealt with, the solutions are. A solution focused perspective is essentially interactional. Many typical solution focused questions are phrased in a way designed to elicit information about interactions between key individuals. Thus the solution focused practitioner gains an interactional perspective about clients concerns and wishes put into a context of their relationships with others (Saunders, 1998). As the practice of SFT has developed, the ‘problem’ has come to play a lesser and lesser part in the interviewing process (George et al, 1999), to the extent that it might not even be known by the counsellor. Instead, all attention is given to developing a picture of the ‘solution’ and discovering the client’s strengths and resource to achieve it (Iveson, 2002). Sometimes clients’ lives are so difficult that they cannot imagine things being different and cannot see anything of value in their present circumstances. One way forward is to be curious about how they cope – how they manage to hang on despite adversity (Letham, 2002). For the Solution focused counsellor, problems do not represent an underlying pathology or deficit and sometimes only the smallest of changes is required to set in motion a solution to the problem (George, Iveson and Ratner, 2000). To build a picture of a client’s preferred future the counsellor needs to get a picture of where the client wants to get to, without the problem that has led them to counselling. The miracle question was devised with this in mind: ‘Suppose that tonight, while you are sleeping, a miracle happens and the problem that has been troubling you sorts itself out overnight… what would you see the next morning that would let you know the miracle had happened? What would you find yourself doing the day after the miracle, what would others notice you doing?’ (Lethem, 2002; Iveson, 2002). The counsellor then looks for exceptions to the problem in the client’s life and highlights any success and resources they might have. The idea is to empower the client in taking control over their own change and affirming the client as an expert (Greenberg & Ganshorn, 2001; Saunders, 1996). A counsellor may also use “Scales” where 10 equals the achievement of all goals and zero is the worst possible scenario. The client is asked to identify his or her current position and the point of sufficient satisfaction. Within this framework it is possible to define objectives, what the client is already doing to achieve them and what the next step might be (Greenberg & Ganshorn, 2001). How are Person-centres approaches and SFT similar? Although the approaches of person-centred therapy and solution-focused therapy have taken a very different theoretical evolution, they seem to have a number of features that take the same view (Hales, 1999). Primarily, both approaches highlight the strengths and resources of 2

This is another counselling theory that was developed just before SFT. The main writers were: Weakland et al., 1974; Watzlawick, Weakland, & Fisch, 1974; Fisch, Weakland, & Segal, 1982.

the client during the process. The belief by person-centred counsellors, that clients are “selfactualizing” (Rogers, 1961) is played upon explicitly by STF in identifying strengths and resources to a client (Saunders 1998). From a person centred approach, the emphasis placed on these factors by SFT is directly facilitating the self- actualization of the client. In addition, both approaches look at the “whole picture” of the client’s situation. The importance of the whole person in person-centred counselling equates to interest in the whole context of a person’s life in STF (Iveson, 2002). SFT acts on what the exceptions to the problem there are in other areas. It is seen as useful to point out the wider context of a clients difficulties without belittling them (Lethem, 1994), and this equates very much to the personcentred approach’s gestalt view of looking at the whole and not just individual parts of a person (Rogers, 1980). It is clear that person-centred therapists like to believe that the client is “in-charge” of the counselling process and that it is the client that makes all the judgements about experiences and decisions. Again, it seems that SFT uses this idea much more explicitly and clients are often asked directly what they want out of counselling, how they want to change and how they would know when the counselling has done its job. Both approaches seem to share an emphasis on the client making the decisions during the process even though in SFT, the therapist may seem to be much more active (Hales, 1999). The implicit understanding of “self-actualization” by person-centred therapist is made explicit by STF where clients are often asked questions related to what they think life will be like when they have overcome their problems and difficulties. Indeed, person centred theorist may suggest the SFT is highlighting the intrinsic nature of a person to self-actualize via methods such as the “miracle question”. Following on from this, both STF and person centred approaches value the concrete and specific details of actual experience rather than abstract labels or explanations. The counsellor encourages the client to translate abstract ideas into specific details. For example, what exactly is “better”? What would be different if things were better? The specifics of lived experience are detailed in inner thoughts and feelings and are often played out in actions. SFT is more explicit than person centred therapy in linking inner processes and actions. SFT makes explicit what the exactly a person wants to achieve in their life, so an inner thought or feeling is appeased, while the person-centred approach assumes that this is intrinsic to the client (Hales, 1989). It is clear and obvious from the evaluation of the two approaches that they share many of the same beliefs and values, yet STF makes them much more explicit to all parties involved. Some have posited that there is a lack of empathy in SFT (Hales, 1999) but as Letham (1994) points out “acknowledgement is the hidden ingredient of solution focused therapy”, and is often used to find a starting point for solution strategies. Ethical Considerations McLeod (1993) notes that many, if not most people who seek counselling are dealing with a moral dilemma of sorts. In person-centred counselling and STF, many of the decisions that will be made throughout the process will have some moral and ethical components. Although in these approaches the focus is on the client to make the decisions, the counsellor must subtly influence the ones that will most help the client. The level of disclosure and the relationships that are formed between clients and counsellors often means that information discussed is of a very detailed and personal nature to the client, and may involve several other parties. Determining the appropriate course to take when faced with a difficult ethical dilemma can be a challenge, especially as the need for trust in the client-counsellor relationship is so vital for success. Indeed, such is the prevalence of ethical

dilemmas in the field of counselling the ACA has even developed an “Ethical Decision Making Model” using work combined from several authors3. Much of counselling literature related to ethical consideration refers to Kitchener’s (1984) work. He noted that there are four main areas that a counsellor can draw upon when tackling a moral and ethical dilemma. These are personal intuition, ethical guidelines of professional organizations (such as the ones published by the BAC or ACA), ethical/moral principles and general theories of moral action (which includes more general moral theories such as Utilitarian or Kantian ethics). Kitchener’s (1984) five moral principles often appear as the cornerstone of many professional counselling association’s ethical guidelines: 1. Autonomy is the principle that addresses the concept of independence and allowing an individual a freedom of choice and action. In doing this, it must be remembered that the client should be helped to understand how their decisions and their values may or may not be received within the context of the society in which they live, and how they may impinge on the rights of others. Also, a consideration of the client's ability to make sound and rational decisions is necessary and clients not capable of making competent choices should not be allowed to act on decisions that could harm themselves or others. 2. Non-maleficence is the principle of not causing harm to others and reflects both the idea of not inflicting intentional harm, and not engaging in actions that risk harming others (Forester-Miller & Rubenstein, 1992). 3. Beneficence is the counsellor's responsibility to contribute to the welfare of the client by being proactive but also preventing harm when possible (Forester-Miller & Rubenstein, 1992). 4. The principle of Justice does not mean treating all individuals the same. Kitchener (1984) points out that the formal meaning of justice is "treating equals equally and unequals unequally but in proportion to their relevant differences" (page 49). 5. Fidelity involves the notions of loyalty, faithfulness, and honouring commitments. Clients must be able to trust the counsellor and have faith in the therapeutic relationship if growth is to occur. When exploring an ethical dilemma, examining the situation and seeing how each of the five principles may relate to that particular case can help clarify the issues enough that the means for resolving the dilemma become obvious and an ethical decision to be made. How can counselling help those undergoing disciplinary action? Counselling is now a wide spread phenomena, and more often than not, you will be able to find a counsellor for any type of problem. In a career related context, counsellors have been used in areas such as career development and by organisations in the form of EAPs. There is no doubt that these sorts of schemes are successful. Borrill et al (1988) evaluated two NHS trust staff counselling services, finding a reduction in the proportion of clients with significant levels of psychological disturbance from 87 per cent at intake to 27 per cent after an average of five sessions. In a study into counselling provision in the Post Office, Cooper & Sadri (1991) found marked reductions in symptoms of depression and anxiety, as well as significant organisational benefits. Yet, one of the most stressful times for an employee is when they are parting with their employer on bad terms. Employees undergoing disciplinary action will be not only 3

The model is a combination of work from Van Hoose and Paradise (1979), Kitchener (1984), Stadler, (1986, Haas and Malouf (1989), Forester-Miller and Rubenstein (1992) and Sileo and Kopala, (1993)

experiencing a stressful battle against an organisation that, no doubt, has more money than they do, but also have to deal with unemployment and the emotional consequences of the whole situation. Such individuals can look to their professional body or GP for support and referral to a counsellor (Herrington et al, 2003). Indeed, many employees do not seek the support of a counsellor in such situations, yet it is much more common in the medial profession than most others. The reason for this is largely due to the severity of incident that such a professional will be facing. Medical professionals have patient’s lives in their hands on a daily basis and medical negligence can lead to loss of life or serious damage. The stress of this situation places health care professionals at risk of many mental health problems (Higgs, 1995). It also means that individuals may turn to drugs and alcohol while at work (Gossop et al, 2000), and this can lead to severe consequences. When disasters do occur, there is a long procedure before any disciplinary action is taken. This involves several written reports by all parties involved. If the view is taken that professional misconduct contributed to the occurrence of the disaster then formal disciplinary action will usually be taken to protect the credibility of the hospital and shield it from criticism (Aitkenhead, 1997). There is also the possibility that the medical professional will also undertake criminal investigation and/or civil litigation depending on the circumstances. Indeed the effects of such a process on the medical professional can be harsh. Charles (1987) found that 59% of American physicians in such a situation experienced depression or other psychological symptoms. 57% found that their family life suffered as a consequence and 14% reported a loss of self-confidence. Counselling for professionals in such a situation can be obtained from their professional body or GP referral. Since 1996 the British Medical Association (BMA), has run a confidential counselling service for members and their families. Between 2001 and 2002 the service took over 10,000 calls and received around 150 calls a month. The latest report noted that the service receives more than 10 calls a month related to employment issues. In a similar manner, the Royal College of Nursing (RCN) counselling service also provides free employment law advice to all its members which could be utilized in a circumstance involving disciplinary action. The use of person-centred counselling or SFT in a state of affairs such as this would be useful in raising the self-esteem of the client and helping them cope with the stress of the situation. The idea that clients develop their own solutions and “actualization” may greatly empower someone who is feeling like they are facing a fight against an unstoppable foe (such as a huge medical organisation). It may also aid the strain on the family life of these professionals, who may find counselling as a useful emotional outlet, so as pent up tension is not directed towards their family. The perspective of the person-centred approach and STF is also much more suited to helping in a disciplinary situation than psychodynamic counselling as the problem is certainly not related childhood, but is developed from a real-life concrete experience. Conclusions There have been several calls for modern day counselling to pull together to find a unifying paradigm to enhance the credibility of the practice (Ellingham, 1997). The fact that person centred counselling and STF, originated from different theoretical backgrounds and are now able to demonstrate very simple similarities is promising for this goal. However, maybe one of the strengths of counselling is its ability to offer such a variety of options for a prospective client. In the more specific case of disciplinary action, the focus on “self” by both personcentred and STF approaches makes either approach suitable for counselling such a difficulty. Ideally, the issues to be dealt with are the self-esteem of the client, and their ability to cope with the disciplinary process. Medical professional will often have to deal with more than just disciplinary proceedings and therefore counselling would be need to deal with several issues all resulting from a singular incident. The fact the many professional organisations (such as the BMA and RCN) have counselling services for their members is encouraging for the future of

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