1. The Process of
Counseling &
Psychotherapy
Kirti Shivakumar
June 2014

2. •What happens in a counseling and psychotherapy
session?
•It is like a story: it has a beginning, a middle, and an
ending

3. Six Stages
• Stage One: Rapport & Relationship building
• Stage Two: Assessment (and Diagnosis)
• Stage Three: Formulation of counseling goals
• Stage Four: Intervention and problem solving
• Stage Five: Termination and Follow Up
• Stage Six: Research and evaluation

4. THREE PHASES OF COUNSELING
1. Phase of the Heart 2. Phase of the Mind 3. Phase of the Hand
(FACILITATION)
A. Rapport Building
B. Get Facts
C. Get Reactions &
Feelings
(Risk Assessment)
(TRANSITION)
A. Identify Coping
B. Generate Insights/
Sense Making/ Finding
Meaning
(ACTION)
A. Plan for Moving On
B. Ask What Other
Support They Need/
Giving a
Referral List
C. Closing

5. 1. Rapport & Relationship Building
THE INITIAL SESSION.
• It is during this time both the client and the counselor are assessing one another
to see if the relationship will work. It is here the subject of the subsequent
sessions will be discussed and determined.
• Tasks here include…
• 1. Laying foundations for trust
• 2. Establishing the structure and form the relationship will take
• 3. Informed consent process
• 4. Articulating roles of counselor and client – developing a collaborative
working alliance

6. First Sessions or Intake Counseling/
Psychotherapy Assessment
• Establishing a rapport
• Making a clinical diagnosis
• Assessing clients strengths and weaknesses
• Giving Information
• Enabling the client to feel understood
• Arriving at a case formulation or plan
• Giving Hope
• Gathering information about cultural needs and expectations
• Obtaining consent
• Explaining the way therapy works
• Opportunity for client to ask questions and decide whether to enter therapy or
not
• Making practical arrangements like place , time , etc.

7. 1. Rapport & Relationship Building
•Consider how do we develop rapport, create
relationship with our clients?
•What is it that we bring to the relationship that helps
us create a foundation of trust and willingness to work
collaboratively toward goals?

8. Three important factors
• Client characteristics
• Therapist qualities
• Change Process

9. Defining the therapeutic relationship:
Statements from research questionnaires

10. Defining the therapeutic relationship:
Statements from research questionnaires

11. 1. Rapport & Relationship Building
• When working with a client, you want to send a message that you are
listening.
• This can be done by being attentive both verbally (responding to the
client) and nonverbally.
• SOLER is an acronym which serves to remind us how to listen.

12. SOLER
• S: Face the client squarely; that is, adopt a posture that indicates involvement.
• O: Adopt an open posture. Sit with both feet on the ground to begin with and
with your hands folded, one over the other.
• L: As you face your client, lean toward him or her. Be aware of their space needs.
• E: Maintain eye contact. Looking away or down suggests that you are bored or
ashamed of what the client is saying. Looking at the person suggests that you are
interested and concerned.
• R: As you incorporate these skills into your attending listening skills, relax.

13. 2. Assessment (and Diagnosis)
• Gathering information to promote understanding of
client’s situation and perspective…..
• Systematic way to obtain information about the
client’s problems, concerns, strengths, resources, and
needs.
• Foundation for goal-setting and treatment planning

14. Assessment Considerations
• Assessment is always an ongoing process, changing as you learn more
about the client.
• Who is complaining or alarmed? Who thinks there is a problem?
• What is the person complaining about?
• What is the person motivated for? What does he or she want?
• What does the person do well? (Find contexts of competence.)
• Skills, hobbies, sports, activities, avocations, life experiences, etc.
• Exceptions/previous solutions/times when situation was better
• Best coping moments?
• What are the goals? How will we know when we are done?
• Get specific about the problem-free future.

15. Assessment Considerations
• What are the patterns of the problem? How is it performed? Search
for regularities of action and interaction, time, place, body behavior,
etc. Get specific (so could imagine seeing/hearing the problem on a
videotape)
• Scan for potentially harmful actions of clients or others in clients'
lives (e.g., physical violence, drug/alcohol abuse, sexual abuse, self-
mutilation, suicidal intentions/attempts, etc.) that may not be

16. Different types of Assessments
1. Clinical Assessments that involves skills like
observation, inquiry, associating facts, recording
information, forming hypotheses (clinical “hunches”).
2. Intake forms and interviews
3. Psychological tests and assessments

17. Assessment Tool
“Rule of Thumb”
• Never diagnose with a test or screening instrument only.
• Tests are useful in validating information provided by the client in the
subjective interview.
• Testing tools should only be used by those with training in using that
tool.
• All testing tools have limitations.
• Never replace the expertise, training, and experience of the clinician
with a test.

18. 2. Assessment: Gathering Information
• Types of Questions:
• Open—allows the client to answer the question in a free-flowing or
narrative style. Used when you want more detailed and elaborate
answers.
• • Tell me how this is working for you?
• Closed—this type of question requires only a one or two word
response. Usually…Yes or No.
• • Do you enjoy that type of work?

19. 2. Assessment: Gathering Information
• Types of Questions:
• Probes—a questions which begins with a who, what, where, how, or
when.
• What do you plan to do to complete your project?
• Requests for Clarification—Asking the client for more information.
• Help me understand what this relationship is for?

20. 2. Assessment: Gathering Information
• When you can take the time to build the relationship with the client &
gather information, there are other skills which you must possess and
develop.
• In efforts to build the relationship, you should concentrate more on
the client’s attitudes and emotions.

21. 2. Assessment: Gathering Information
• Restatement/Content Paraphrasing.
• A re-statement of what you heard the client say in slightly different
words.
• Reflection of Feeling.
• Similar to a re-statement, but you are concentrating more on the
emotional aspect & the non-verbal communication.

22. 2. Assessment: Gathering Information
• Summary of Feelings.
• A simple summary paraphrase of several feelings which have been
verbalized (nonverbal and verbal).
• • Acknowledgement of Non-verbal Behavior.
• You are noting to the client what you are seeing. You are not
interpreting the nonverbal content.

23. Focus :Presenting problem and context
Basic Questions
• What concerns brought you
here?
• Why now?
• Has this happened before?
• How is it impacting your
daily life?
Detailed Inquiry
• Clarify stressors
• Elicit
- coping skills,
- social support,
- and resources
• Clarify life function
- work
- family
- health

24. Focus
- Mental status
Basic Questions
• How do you feel now?
• How is your mood affected?
• Had any unusual
experiences?
• How is your memory?
• Do you think that life isn’t
worth living?
Detailed Inquiry
• Note
- age & mannerisms
- dress & grooming
- orientation . . . .
• Probe
- anxiety symptoms
- form, content,
thought.
- suicidal ideation

25. Focus
Developmental history and dynamics
Basic Questions
• How would you describe
yourself as a person?
• Shift to the past, how
were things when you
were growing up?
Detailed Inquiry
• Clarify
- current self-view
- level of self-esteem
- personality style
• Note
- Developmental
milestones
- experience in school

26. Focus
Social history and cultural dynamics
Basic Questions
• How would you describe
yourself as a person?
• Shift to the past, how
were things when you
were growing up?
Detailed Inquiry
• Clarify
- current self-view
- level of self-esteem
- personality style
• Note
- Developmental
milestones
- experience in school

27. Focus
Health history and behaviors
Basic Questions
• Tell me about your
health?
• Health habits?
Detailed Inquiry
• Identify
- prescriptions
- substance usage
- health status
- health habits

28. Focus
Client resources
Basic Questions
• How have you tried to make
things better?
Results?
• How do you explain you’re
symptoms?
• What is your / my role in
your treatment?
• When will things change /
get better?
Detailed Inquiry
• Probe
- Efforts to change
- Efforts vs. successes
• Clarify client explanatory
model
• Identify treatment
expectations
• Specify readiness for change
Sperry, Carlson,

29. Focus
Wind down and close
Basic Questions
• What else would be
important for me to know?
• Do you have any
questions for me?
Detailed Inquiry
• Use an open-ended query
- Allows the client to add
information.
- Creates sense of reciprocal
and collaborative
relationship.

30. Assess Client’s stage of change
(Meeting the client where they are)
1. Precontemplation - "I really don't want to change. “
2. Contemplation -“I'll consider it.“
3. Preparation - "I'm making a plan for it.“
4. Action - "I'm doing it, but not regularly.“
5. Maintenance - "I'm doing it.“
6. Termination - "I have no desire to go back to my own ways."

31. 3. Formulating Client’s Goals
• The client articulates where they want their counseling journey to take
them
* Client role as one of driving the bus
* Enhances sense of ownership and motivation –factors
important in the change process
• Well identified goals help create a roadmap and means to evaluate
• Goals may change, evolve as therapy progresses

32. Goal Functions
• Define desired outcomes
• Give direction to the counseling process
• Specify what can and cannot be accomplished in counseling
• Evaluate effectiveness of counseling and when counseling should be
stopped
• Determine the client’s intervention
• Measure client progress

33. 3. Formulating Client’s Goal
Mutually defined by the client and counselor.
Counselor Client
Greater objectivity
• Training in
– Normal and
– Abnormal behavior
• Process experience
Experience with the
problem
• History of the problem
• Potential insights
• Awareness of personal
investment in change

34. Goal Guidelines
• Goals are mutually agreed on by the client and counselor.
• Goals are specific.
• Goals are relevant to behavior.
• Goals are achievement & success oriented.
• Goals are quantifiable & measurable.
• Goals are behavioral & observable.
• Goals are understandable & can be restated clearly.

35. Process Goals
• Related to establishing therapeutic
• conditions for client change.
Includes:
– Establishing rapport,
– Providing a non-threatening setting, and
– Possessing and communicating accurate empathy
and unconditional regard.

36. Outcome Goals
•Are different for each client and directly
related to clients’ changes.
•Always subject to modification and
refinement.
•To begin, formulate tentative outcome goals.
•Modify goals as needed to support effective
change.

37. 4. Intervention & Problem Solving
• New perspectives on both the way clients have looked at the problem
and ways they might approach it.
• Categories of Counseling Interventions
1. Affective
2. Cognitive
4. Behavioral
5. Interpersonal/Systemic

38. 4. Intervention & Problem Solving
• Selecting an intervention may become an adaptive process.
• Skills to initiate include
1. Competency with the intervention;
2. Knowledge of appropriate uses;
3. Knowledge of typical client responses;
4. Observation skills to note client responses.

39. Affective Models
• Person-centered therapy
• Gestalt Therapy
• Body awareness therapies
• Psychodynamic therapies
• Experiential therapies

40. Cognitive Models
•Rational-emotive therapy
•Information-giving
•Problem-solving and decision-making
•Transactional Analysis

41. Behavioral Models
•Behavior therapy
•Reality therapy
•Cognitive-behavioral therapy

42. Systemic Models
•Structural therapy
•Strategic therapy
•Intergenerational systems

43. 5. Termination & Follow-up
• No clear cut ending, but no need to
continue beyond usefulness.
• Awareness by the counselor and the client
that the work is accomplished.
• May take the same number of sessions as
rapport building.

44. Termination of a Session
• There is no great secret to ending sessions. There are some
guidelines:
• Start and end on time..
• Leave 10 minutes or so for a summary of the session..
• Introduce the end off the session normally
• (“Our time is coming to a close.”).
• Assign homework..
• Sett up next appointment.

45. Termination of the Relationship
• • Termination is the end of the professional relationship with the
client when the session goals have been met.
• • A formal termination serves three functions:
• o Counselling is finished and it is time for the client to face their life
challenges..
• o Changes which have taken place have generalized into the normal
behavior of the client..
• o The client has matured and thinks and acts more effectively and
independently.

46. Counselor Considerations
• Counselor always mindful of avoiding fostering dependency and is
aware of own needs
• Preparation for termination begins long before
• Open door / plan for possibility of future need
• Termination considered not just at end of successful relationship, but
also is considered when it seems counseling is not being helpful

47. Therapist must carefully consider the most
effective way to terminate each client.
1. How will termination impact the client?
2. What is the client’s history of separation?
• Is the client likely to regress?
3. What is the client’s reaction / opinion about termination? Can he /
she see it as a positive step?

48. Timing of Termination
• There is no one answer when termination is to take place.
• Questions you may wish to ask yourself concerning termination
include:
• Have clients achieved behavioral, cognitive, or affective goals?
• Can clients concretely show where they have made progress in what
they wanted to accomplish?
• Is the counseling relationship helpful?
• Has the context of the initial counseling arrangements changed?

49. Resistance to Termination
• Clients & Counselors may not want counseling to end.
In many cases this may be the result of feelings about
the loss and grief or insecurities of losing the
relationship.
• For clients, this is something to process.
• For counselors, this is an issue for supervision.

50. Types of Termination
• 1. Suggested termination, with client agreement
• 2. Imposed termination
• • Continuing is against client best interest
• • Client is deteriorating, not progressing
• • Incompatibility with the therapist
• • Client using therapy in place of life

51. Types of Termination
• 3. Situational termination
• • Client moves
• • Employment or insurance changes
• 4. Early termination, clients just don’t return.

52. Premature Termination
• Client.
• Many clients may end counseling before all goals are completed. This
can be seen by not making appointments, resisting new
appointments, etc…
• It is a good idea to try and schedule a termination/review session
with the client so closure may take place.
• At this time a referral may be in order.

53. Premature Termination
• Counselors.
• At times, counselors have to end counseling
prematurely.
• Whatever the reason for the termination, a summary
session is in order and referrals are made, if
appropriate, to another counselor.

54. Referrals
• At times, a counselor needs to make a referral. When this is
done, specific issues need to be addressed with the client:
o Reason for the referral.
o Note specific behaviors or actions which brought the need
for a referral.
o Have the names of several other counselors ready for
referral.
o You cannot follow up with the new counselor to see if the
client followed through
• (Confidentiality issue).

55. Follow-Up
• At times, a follow-up may be
scheduled for various reasons including
evaluation, research, or checking-in with
client.
• Follow-ups need to be scheduled so as
to not take the responsibility of change
away from the client.

56. 6. Research / Evaluation
•Generating hypotheses
• Trying other intervention strategies
• Determining if/when goal was met