Core Counselling Skills

If non-directive counselling is simply the mindful practice of basic counselling skills (Kessler 1997; 2001) then it is important to briefly review some of the core counselling skills required. In addition, you are directed to Table 1 and Table 2, which highlight some of the therapeutic and non-therapeutic communication techniques useful for all counsellor-client interactions.

 

Building Rapport

Building rapport with people who come for counselling can be a challenging task for a health professional – this is particularly the case where sessions are limited and the issue is very complex. Regardless of whether or not you have an established relationship with a client, it will be important to build rapport specifically around the pregnancy-related issues needing to be discussed. Keep in mind that the pregnancy will probably have affected all areas of the person’s life and that the client may not have sought counselling for the ‘problem’ they are experiencing – this may be a particular issue where the woman has been referred by a GP without any real understanding of the purpose of the referral.

 

If the client appears somewhat defensive, deceitful, evasive, resistant or hostile, it will be important to reflect on your own attitude or response to determine whether or not the woman feels that she is at risk of being judged (there will be more about self-reflection in Module 3). Being able to understand and validate the client’s position will be pivotal in the establishment of rapport and the ongoing task of building a relationship, albeit a brief one, that will be therapeutic. Many studies have shown that it is the therapeutic relationship itself, over and above sophisticated psychological strategies, which is the most active ingredient in a therapeutic relationship. While it is important to validate the clients position, it is often the job of the health professional to hold hope for the client, even when they have lost hope for themselves, and while respecting their wishes and acknowledging their level of motivation, letting them know that you are ready to engage a collaborative therapeutic relationship.

 

Alternatively, the client may be experiencing a degree of shame about disclosing aspects of their behaviour, or fear how they will be judged. The shame they are experiencing may be as a result of their sexual behaviour leading to the pregnancy, the misuse or lack of use of contraceptives, or it may be in relation to the way the woman is thinking about the pregnancy, particularly where she is contemplating a termination of pregnancy for genetic reasons (Mouniq & Moron 1982). The shame may also be culture-bound. In some cultures the shame of abortion is only outweighed by the shame of a severely mistimed entry into motherhood (Johnson-Hanks 2002). Shame is very silencing; if a person has been shamed they are less likely to talk. A strategy to address feelings of shame might be to get the client to feedback their understanding of what has been said, this provides the counsellor with the opportunity to observe how the client is interpreting the information and whether any misinterpretations have been made. It is also possible that a woman has simply had many ‘bad’ experiences of counselling previously and find it hard to trust professionals. Acknowledging the distressing physical, emotional and psychological discomforts if their situation will assist the health professional to be aligned with the client.

 

Click here for several strategies one can use to build rapport

 

Non-directive Counselling: What it is not
Non-directiveness is not simply the absence of directiveness. It may be helpful to look briefly to directive counselling and how it is described in the literature, in order to more fully understand what non-directive counselling is not.

There are different types of Directive counselling commonly used in psychological therapies – e.g. Cognitive Behaviour Therapy (CBT), Motivational Interviewing (MI), Interpersonal Therapy (IPT). Each of these therapies is focused on change. CBT looks at identifying maladaptive cognitions and changing behaviours. MI is designed to promote client motivation and reduce motivational conflicts and barriers to change (Wagner & McMahon 2004). IPT is a behavioural therapy based on exploring issues in relationships with others. The therapist’s goal is to help identify and modify interpersonal problems, to understand and to manage relationship problems (McCauley 2006).

Each of these directive therapies is based on an evidence-based framework using specific tools (questions, attitudes and approaches).

However, there are other ways that therapy can become directive. In genetic counselling for example, a ‘directive’ style of counselling attempts to influence the client’s behaviour (or the outcome) in a specific way, whereas non-directive counselling is the attempt to influence they way the person thinks about the issue at hand and the process by which they make some form of decision. In this setting (i.e. not in the evidence based directive therapies outlined above), directive counselling can be described as the use of deception, threat and/or coercion and can include:

  • limiting access to information (or withholding information about a salient option)
  • engaging in persuasive communication (which suppresses choice and individual autonomy)
  • having a hidden agenda
  • attempting to secretly gain control over the client’s attitudes or behaviour
  • creating a sense of powerlessness and fear within the counselling setting and
  • deliberately emphasising one point of an argument over another. (Kessler 1997)

Non-Directive Counselling

In the 60s, non-directiveness was introduced into the field of genetics counselling (GC) and by the mid 80s was widely endorsed as an appropriate industry model, this in response to a shift in thinking in line with the growth of the consumerism movement (Kessler 1997). In 1991 its ethos was incorporated into the GC Code of Ethics.

 

It is relevant to this training program to investigate non-directiveness as it has evolved in the genetic counselling literature/setting, as it is this form of counselling which most closely resembles the type of counselling required for pregnancy-related concerns. Genetic counselling, while being non-directive, is neither Rogerian nor client-centred as such, primarily because in a genetic counselling session the client is never fully in control of the agenda, pace or direction of the session (Kessler 1997) because it has a completely different purpose and clinical basis.

 

Pregnancy-related counselling and genetic counselling have a number of facets in common: both are brief interventions up to several sessions (in contrast with psychotherapy which is long-term); both require that counsellors respect the profoundly personal nature of reproductive decision making (Biesecker 1998 pp148-149); both are areas which are value laden, but which require counsellor value neutrality in certain aspects of the process (particularly, in regard to the client’s decision (Biesecker 1998)); and both involve women, and sometimes men, who are having to address intense physiological as well as psychological and emotional situations.

 

This module will provide participants with:

 

* A brief overview of the discussion in the literature about what non-directive counselling is and what it is not

* Review of basic communication/counselling strategies which should be used in a non-directive framework

* An opportunity to test your understanding of the principles of non-directive counselling.

 

 

Copyright 2006. 81010 Non-Directive Pregnancy Counselling Training Program for Mental Health Nurses.

Produced by the ACMHN with a grant from the Commonwealth Department of Health and Ageing.

 

 

Non-directive Counselling: What it is

Non-directive counselling has been referred to in the literature as ‘supportive listening’ or ‘listening-visits’ (Gamble et al 2002) and is associated with the descriptors ‘client-centred’, ‘empathic’, ‘non-judgmental’ (Bartels et al 1997), ‘unstructured’ and ‘participant-led’ (Gamble et al 2002).

In psychotherapy and other forms of counselling, non-directiveness implies that the therapist practices ‘neutrality’, that is, the maintenance of curiosity, acceptance, interest and respect for the person’s point of view, and the avoidance of taking a position for, or against a particular outcome or behaviour change (Mackinnon & James 1987). Bailey (1973 in Cain 1999) also suggests that neutrality is maintained, in its weakest sense, if the counsellor (or in his example, teacher) ‘refrains from offering his own substantive beliefs…as though incontrovertibly true, or as shared by all or most sensible and intelligent people’. Or, in its strongest sense, neutrality would imply that the counsellor 'refrains from giving his own substantive belief at all on an issue under discussion’ (Bailey 1973, p36 in Cain, 1999). Van Zuuren (1997) notes that in Western society there is an absence of ‘general and absolute moral directives’ (p70) and that as such, neutrality should guarantee that clients have the right to make their decisions freely based on their own values and moral judgements.

While there seems to be general consensus that non-directive counselling is the promotion of autonomous decision making by clients (Bartels et al 1997), there is lack of consistency in its definition and operationalization (D’Rozario & Romano 2000) and this lack of definitional consensus is reflected in the genetic counselling literature (Goh 1992 in D’Rozario & Romano 2000). Kessler (1997) attempts to rectify this problem by defining non-directive counselling broadly, as procedures aimed at promoting the autonomy and self-directedness of the client (p166). Shiloh comments that “helping clients reach a decision wisely rather than reach a wise decision” (in Elwyn 2000) is the purpose, helping clients to work to their strengths and accomplishments, to assist them to feel confident in their capacity as a decision maker.

Some question whether non-directiveness is ever truly achievable – particularly because, information giving is always tailored to the individual’s specific set of circumstances and as such, will always influence their decisions (Elwin et al 2000). However Kessler (1997; 2001) states that at its essence, non-directiveness is simply core counselling skills used in a mindful manner.

Be aware that this discussion is primarily around taking a non-directive tone in your counselling sessions, with the aim of assisting women with pregnancy-related problems to reflect on all aspects of their current situation. There are a number of non-directive therapies which you may be interested in accessing further information and training about – e.g. Narrative therapy and Solutions Focused Therapy (both of which will be touched on briefly later this module), Gestalt Therapy and Psychodynamic Psychotherapy.

More Information Online

8100 Non-Directive Pregnancy Counselling Training for Mental Health Nurses

Introduction
Non-directive counselling has its origins in psychotherapy, particularly in the theory of Carl Rogers, where it was used to foster free associations in long-term therapy (Kessler 2001). Roger’s theory, based within a humanistic (‘self’) framework, was initially known as non-directive therapy, and later, ‘client-centred’ therapy, because the client was seen as the director of the process of therapy – setting agenda, pace and direction (Kessler 1997). The primary tool of Rogers’ ‘client-centred’ therapist is the process of ‘reflection’ – of mirroring the client’s emotional communication, in an effort to communicate to the client that what they have said has been heard and to engender a feeling of acceptance.

Ref: Dr C.G. Boeree Psychology Department Shippensburg University

Rogers identified three ‘necessary and sufficient’ qualities required of a non-directive, or client-centred therapist (without which, no form of therapy would be successful):

1. Congruence
Congruence is about being in the same ‘place’ as your client and using individualised communication rather than ‘professional-speak’ or jargon. Jargon can alienate the client giving the impression that you respond to everyone in the same way. Being genuine and honest will assist you to be congruent.

2. Empathy
Expressing empathy can be defined as ‘the process wherein an individual is able to see beyond outward behaviour and sense accurately another’s inner experience’ (Townsend 1993 p59). Empathy is not to be confused with sympathy, where ‘the nurse actually feels what the (woman) is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on assisting the (woman) to resolve the problem at hand’ (Townsend 1993 p59).

3. Respect
Respect is showing acceptance and unconditional positive regard for the client –  respecting the person as a worthwhile human being. Using the person’s name, letting them do the talking and being open and respectful in interactions are key characteristics. Establishing a basis for trust –  a foundation for the development of the relationship beyond the superficial, is also important. This can be achieved very simply by doing concrete things to demonstrate caring and a willingness to help e.g. offering a cushion to sit on to increase the client's comfort, keeping a box of tissues handy in preparation for the situation where the client becomes tearful.

Click here for more information about the theory upon which Carl Rogers based his idea about client-centred therapy.