The Therapeutic Consultation
Therapists are as unique as their clients and their methods of conducting the consultation will reflect their uniqueness. It is, therefore, not possible, or even desirable, to suggest a blueprint which all should follow. However, there are certain issues that need to be recognised and addressed so that an informed choice of procedure can be made.
Objectives of Consultation
The length of the consultation will depend on the objectives of the therapist. The consultation could be as long as one and a half to two hours or as brief as half an hour.
Some therapists will leave the detailed case study until the second interview (the first treatment session), while others will obtain a full case history at the initial interview. The former might argue that in the first session they are only meeting a potential client and, therefore, a detailed enquiry is inappropriate: whereas the latter might respond with the argument that in order to assess the true nature of the problem and their competency to deal with it, a very thorough interview is necessary at the outset.
There will be still others who adopt a very unstructured approach and consider the consultation a superfluous and ineffectual activity.’ While the National College recognises and respects a wide range of philosophical approaches, it draws the line at any suggestion that the consultation and case study may be omitted from the practice of its graduates.
The consultation is the time and place to establish the all important rapport.’ The establishment of rapport is amongst the most important objectives of the consultation and many believe that the success of the therapy depends upon it.’ Rogers placed great emphasis on the relationship between client and therapist and the student is referred to his writings on this subject.’ In order to build the all important relationship, the client needs to feel respected, heard, understood and liked by the therapist.
Another objective of the initial interview is to discover the client’s ‘working model’, ‘working image’, or ‘characteristic patterns of living’ (Nelson-Jones 1982). These provide the therapist with a set of hypotheses, not necessarily shared with the client, concerning his/her strengths, weaknesses, etc., around which the therapist is able to make decisions about treatment.
The initial interview is a conversation between two or more people conducted in order to accomplish previously defined goals.’ A mistake that inexperienced interviewers often make is one in which they fail to clarify these goals.
Goals are based on the information elicited from the client during the compilation of the working model.’ They are not final but temporary and flexible, always amenable to modification.’ They are always specific to the client.’ They are goals that are attainable, realistic, and appropriate to the client’s emotional state.’ It is important not to expect too much of the client too soon.’ Goals that are too ambitious or introduced prematurely can increase anxiety and threaten the client.
The consultation is the time to explain to the client working methods and techniques.’ It is the time to dispel misunderstandings about therapy in general and hypnotherapy in particular. It is an opportunity for the client to ask questions about the therapy and the therapist.
In his book ‘Client-Centred Therapy’ Rogers made an important plea: if counsellors were to be effective and skilled in their work it was imperative that they knew where they stood in relation to the people they were seeking to help and that they communicated this to their clients.’ ’ The point he stressed as being the crucial one was the attitude of the therapist towards the worth and significance of the individual.
Where is John Smith?
Therapists should have addressed a fundamental question before they invite a client into their consulting rooms/offices: how do I regard the person I am hoping to communicate with and help?’ The answer they give to this question will determine how the therapeutic encounter will be conducted in the subsequent weeks, months of therapy.’ The following anecdote will make the point clear.
A learned professor was showing a group of students around his science laboratory.’ Ranged along the shelves that covered the walls, were neatly labelled jars containing substances that in total amounted to the composition of the human body.’ The complete substance, he informed them, of a man named John Smith.’ The students took notes as he listed the contents of each individual jar or bottle: Water to fill a 10 gallon barrel.’ Fat for 7 bars of soap. Carbon for 9000 lead pencils. Phosphorus for 2200 matches.’ Iron for 2 nails.’ Enough lime to whitewash a chicken coop.’ Sprinklings of magnesium and sulphur.’ After writing up his notes, one student addressed the professor: “Very fascinating stuff, sir.’ But where is John Smith?” The professor replied: “The answer to that young man belongs to the philosophers.”
As psychotherapists confronted with the real John Smith that the student was enquiring about, we need to consider how we see him.’ Do we see him as another human being or as an object, as a tripartite system of id, ego, superego, as an organism, etc?’ ’ We need to weigh this question carefully because what we do, what we ask, what we conclude, how we behave, will be heavily influenced by our answer.
THE INTERVIEW IN FIVE STAGES
(These notes do not claim to include all areas of enquiry or list every way of sensitively dealing with the therapeutic encounter but seek to point in certain directions and open up topics for further discussion.)
The following is one of many possible approaches to the initial interview.
The key word here is warmth.’ It is most important that the person seeking help is, on arrival, immediately the focus of attention.’ All other concerns of the therapist and his/her staff are secondary to this.
The client (this term is used for want of a better one) is bringing an urgent story, problem, and is likely to be self-absorbed.’ If he/she is required to wait for attention, through poor organisation or plain insensitivity, the therapist has made an unfortunate start. Sensitive and efficient service is what is required from the outset.’ A smile, a pleasant word and clear directions should lead the client into the consulting room with the minimum of fuss where he/she is already beginning to feel more comfortable.’ In other words, the therapist is immediately responding to the client’s needs, apprehensions, etc.’ After inviting the client to sit down, a cup of tea or coffee is offered and soon arrives.
At this stage the therapist may decide to make reference to the client’s journey, mention a previous telephone call or prior correspondence and establish how the client wishes to be addressed i.e., first names, etc.’ Some comment should also be made about the safety of the environment such as, “We’ll be able to talk freely here without interference or interruption”. This should not only be said but be apparent and felt by the client.’ The word confidentiality should crop up in the early exchanges and be explained to the client.’ Remember, perhaps, that therapists have social responsibilities, as well as responsibilities in respect of an individual client. We may treat as confidential a client’s infidelity to his/her partner; but the client should not expect a similar response if, say, he/she intended to murder that partner.’ All of which is intended to make the person feel safe and accepted.’ It is also very important though, unaccountably frequently forgotten, to actually ask the client how he/she is feeling.
Some therapists may at this stage choose to ask the client to fill in basic forms which seek information such as name, age, marital status, telephone number, name of doctor, etc.’ There is no reason why this shouldn’t be included at this stage but the therapist must be flexible and if it is clear that a client is distressed and wants to get straight to the heart of the matter, being presented with forms to read and sign may well be felt to be inappropriate and intrusive – a set-back in the therapist’s desire to show empathy.
The client has come to tell the therapist something. That something may well have been waiting a long time to be released. In certain cases it may be as ripe as a boil ready to burst.’ It is important that the therapist at this stage of the interview allows the person seeking help to tell his/her story.’ Intervention at this point is almost certain to be intrusive and counter-productive. The therapist should listen to the story and only occasionally interrupt, and where he/she decides to do so, solely for the purpose of clarification or amplification of parts of the client’s story.
The therapist may introduce this stage of the interview with words such as:
“Now, tell me your story in your own way and in your own time.’ I shall only interrupt you occasionally and when I do so it will be in order to understand your story more clearly. You see I wish to understand, as accurately as possible, what has been happening to you and how you have been feeling.”
While the story is being told, the therapist is being shown by the client’s body language a parallel story, equally relevant.’ Sometimes this parallel story will reinforce the words and confirm them while at other times it may appear to contradict them.’ So the therapist is required to listen and observe intently in order to follow the client’s story. The therapist has already invited the client to tell the story ‘in his/her own time’. It is important that this is remembered. There must be no barging into silences, silences in which the client is clarifying his/her own feelings, making sense of the story being related.
It was mentioned previously that the therapist affects, and is affected by, the interaction with the client throughout the course of the interview (in his/her capacity as participant observer). Thus the listening and observing carried out by the therapist will have been directed internally as well as externally. He/she will have been monitoring personal feelings and reactions to ensure they were not in any way contaminating the client’s message, distorting the story.
When the client has finished, the therapist will briefly paraphrase the story and seek the client’s approval that the essential points are accurate. Where this is not strictly the case, the therapist will invite the client to correct inaccuracies.
This stage of the interview will be brought to a conclusion by a suitable empathic comment from the therapist such as: “I think you managed that very well, don’t you?’ Now, how do you feel?”.
Having heard the story and checked on its accuracy, both therapist and client are ready for the next stage.’ It should be remembered, however, that this story is almost certain to be altered,’ modified, enlarged upon during the course of therapy.’ ’ But, for the moment, it is the agreed story.
During the spotlighting stage, the client is invited to select the parts of the story that seem to be most significant, most worthy of attention.’ He/she has already told the story but now is the time to concentrate on aspects of that story that seem to carry the most emotional weight.’ The client is controlling the spotlight and the therapist is waiting to see what is revealed. The therapist may well have his/her own agenda but it must wait. Wherever the client goes, the therapist follows.
Now the co-operative venture takes off.’ The therapist is not unlike a sensitive director watching and listening to an actor, respecting his/her contribution but stimulating, through thoughtful, empathic prompting, deeper exploration of the part. The therapist will seek clarification and amplification of feelings, thoughts and experiences.’ Both present and past concerns will be scrutinised.
When the client has finished then the therapist puts under the spotlight areas of the client’s experience that he/she feels may have been overlooked intentionally or unintentionally. These are areas, in the therapist’s judgement, that may reveal important information.
At the end of the spotlighting stage, the therapist and client will have, by their mutual exploration, considerably deepened the content of the original story and by so doing entered into a trusting relationship.
The detailed content of the enquiry that has just taken place will be the subject of discussion throughout training as will the manner in which such information about person and symptoms is obtained.’ It is in the spotlighting stage of the model here presented that the case history is built up or, to be more accurate, the beginning of the case history is compiled – it is an ongoing process.
It is at this stage that some therapists may wish to make notes and/or introduce questionnaires. Again, how this is done and whether this is the place to do it is a matter for discussion.’ Is the introduction of the questionnaire an aid to therapist and client or an intrusion?’ Whatever methods are used for gathering information in order to understand and empathise with the client and his/her problems, they must be employed sensitively.’ In this respect the therapist should consider carefully what questions need to be asked and how they should be formulated for maximum effectiveness.
The way in which the therapist chooses to respond to the client’s emotional communication will have a consequence.’ Rogers identified five different categories of response (Engler 1979).’ These were the probing response, the evaluative response, the interpretative response, the reassuring response and the reflective response.’ Whichever of these responses the therapist chooses to adopt, he/she should be aware of the consequences of the chosen approach.
Rogers chose the reflective response which puts its emphasis on capturing the underlying feelings.’ Therapists whose sympathies lie with other approaches may well choose responses suitable for their chosen orientation or indeed choose a mixture of responses.
At the end of the spotlighting stage the therapist will have had an opportunity to amplify and clarify aspects of the client’s original story, look at areas of the client’s experience that seem to him/her to be particularly significant, approach areas untouched by the client, if only tentatively, in case they have a relevance but are being defended.
It is likely that, by the end of this stage of the interview, the therapist will know the reasons for the request for therapy, will have assessed the client’s coping strategies, will have a knowledge of the availability of environmental support or its lack, will have gathered full and specific details of the presented symptoms and the client’s attitude towards them.’ Furthermore, it is likely that he/she will have had a strong indication of the client’s self-esteem and motivation for change.
The therapist will probably have learned about the family background and the emotional experience of the client within that background, e.g: Was there a healthy respect for the development of independence? Was there destructive rivalry?’ Was there fear?’ Was there non-possessive love?
Almost certainly, relationships will have been discussed and problem areas explored, such as the handling of friendships and intimacy, the need for space and distance, loneliness and isolation.
So, too, will the world of work have been under the spotlight.’ Does it afford satisfaction? Is it stressful?’ Does it occupy a disproportionate amount of the client’s life?’ How does he/she establish balance?’ What recreational activities are followed and enjoyed?
The therapist will have enquired into the medical history of the client and obtained a physiological as well as a psychological picture.’ During this enquiry, permission may have been sought to involve the client’s GP or other medical advisor where this is deemed to be necessary.
The therapist brings the spotlighting phase of the interview to a conclusion by asking the client how he/she is feeling.
The client will almost certainly have experienced some discomfort as a result of journeying through the territory of the past as well as some relief.’ The enquiry into both present and past concerns can be an exhausting experience and should be recognised as such.’ The therapist, sensitive to this, shows empathy and allows the client ‘breathing space’.’ A few words of encouragement will not go amiss:
“Parts of our discussion must have been quite difficult for you.’ I think you handled it very well.’ How are you feeling?”
At the conclusion of this part of the interview, the therapist will have collected valuable information about his/her client.’ Important though this information might be, if it hasn’t been gathered with the interests of the client placed firmly as the major concern a situation such as the following might result:
“….These investigations seemed to me like a bill of complaints, quite as though in looking for the cause of feelings, they became more at fault and more real….’ I went home more unhappy, more blameworthy, more isolated than ever, without any contact, alone in my unreal world.”‘ (Sechehaye, 1951).
Students may wish to consider whether this stage of the interview is the most appropriate time for recording essential details about the client.’ Following the ‘breathing space’, details of personal and medical history, etc., can be written down and the client asked to sign to confirm their accuracy.
This can be followed by inviting the client to close his/her eyes for a few moments’ relaxation.’ The therapist by this stage will be in full possession of any contraindications, etc.’ There is no mention of hypnotherapy at this stage.’ The client is merely being invited to close his/her eyes and quietly remove any tension that remains as a result of the interview.’ The therapist has a good opportunity here to observe any difficulties experienced by the client.
The client is then invited to open his/her eyes and the therapist asks: “How does that feel?”
The client should be encouraged to ask questions and if the therapist feels important questions have not been asked, he/she should raise the points.’ Such questions may include explanations of the nature of hypnotherapy, its suitability for the client.’ The financial commitment the client will need to enter into, the frequency of treatment.’ The question of ‘cure’ may well need to be addressed.’ The therapist will certainly have to ensure that the client understands that the therapeutic process is a two way one and both parties will be working together to achieve common goals.
The therapist may well be asked at this stage whether he/she can ‘solve the problem’.’ It should be made clear to the client that in some circumstances ‘help and alleviate’ is a more likely outcome and any result will depend on mutual effort and motivation.
Some clients expect an immediate diagnosis of their problem(s).’ The therapist should be wary of being drawn into this trap.’ Even with all the information so far gathered, his/her picture of the client and the presented problems is fragile and fragmentary.’ Any firm assessment is likely to be premature and inaccurate.
The client, however, is entitled to some identification of the areas of concern and an indication of how some of these areas might be further explored should therapist and client agree to work together.’ The length of such therapy is at best tricky to estimate but where possible some guidance should be attempted in this respect.
The therapist brings the session to a close.’ He/she is always the time keeper and prepares the client for its closure. The client is given a last chance to bring up any pressing concerns and final adjustments are made to administrative matters.
It is at this stage that the therapist suggests to the client that a 48 hour period should elapse before any final commitment to therapy is made.’ Both therapist and client have a period in which to consider whether or not a working alliance is possible or desirable.’ If it is decided to go ahead with therapy, after due consideration by both therapist and client, then it is explained that a consent form will need to be signed at the next meeting.’ A few friendly and polite words end the interview.
THE 48 HOUR PERIOD
During the 48 hour period, the therapist has time to reflect on whether or not he/she can be of help to the ‘potential’ client. The information gathered at the initial interview will be carefully scrutinised before coming to a decision. Curiosity about the presented problem(s) is not a good enough reason for accepting the client.’ The therapist must feel that he/she possesses the necessary expertise. Should there be any doubt about this, the decision must be to refer the client to the correct area of competence.
It is during this period of reflection, that the therapist will benefit from having taken a thorough case history and listened carefully to the client’s story.’ The therapist should be alert to the possibility of serious psychiatric disturbance, even in its early stages.’ Any suspicion of manic-depressive illness, schizophrenia, paranoia should have been spotted in a detailed interview and referred to the appropriate places for psychiatric assistance.
In addition, if the therapist feels that he/she cannot empathise with the potential client or has an aversion to the problem(s) presented, then again referral would be the sensible and ethical course of action. Act with sensitivity.
(“I have a colleague who takes a particular interest in this problem”‘ is to be preferred to: “I find your sexual activities with molluscs abhorrent”.)
The client, as a result of the interview, will have a greater understanding of the psychotherapeutic process, the nature of the commitment and a feeling about the therapist as a working partner.’ Armed with such information, he/she is now in a position to make an informed decision about entering therapy.’ The 48 hour period for reflection means that the decision can be made without pressure.
IS THERE AN IDEAL THERAPEUTIC RELATIONSHIP?
An influential study (Fiedler, 1950) came up with the following findings which he claimed transcended the various schools of counselling and psychotherapy.’ Therapists of different orientations described the relationship which they considered ideal. The statements most characteristic of an ideal therapeutic relationship included:
An empathic relationship
Therapist and client relate well
Therapist sticks closely to the client’s problems
The client feels free to say what he likes
An atmosphere of mutual trust and confidence exists
Rapport is excellent
On the other hand, statements that were considered to be least helpful and characteristic of an ideal therapeutic relationship included:
A punitive therapist
Therapist makes the client feel neglected
The therapist seems to have no respect for the client
An impersonal, cold relationship
The therapist often puts the client ‘in his place’
The therapist curries favour with the client
These distinctions may seem self-evident.’ However, it might be worth referring to them regularly to make sure that we continue to fulfil the more desirable criteria.’ (Better still, involve your clients in the assessment?)