Identification of Common Mental Disorders and Counseling Skills
Item
- Title
-
Identification
of
Common Mental Disorders
and
Counseling Skills - extracted text
-
Identification
of
Common Mental Disorders
and
Counseling Skills
A Trainer's Manual for Community Based Organizations
I
j(<lA
Department of Health and Family Welfare, Government of Gujarat, India
2004
II
This manual is the outcome of the training programs carried out under the project titled "Capacity Development
for Community Based Mental Health Interventions in Gujarat", commissioned by the Government of Gujarat,
implemented by Ahmedabad Management Association in July 2003. The information given in the manual
does not necessarily reflect the views of the Government of Gujarat.
Government of Gujarat does not guarantee the accuracy of the information included in this manual.
The production of this manual was supported by the Royal Netherlands Embassy, Development Cooperation
Division, New Delhi.
Identification of Common Mental Disorders and Counseling Skills: A Trainer's Manual (2004)
First Published 2004
Copyright © I
vernment of Gujarat.
d without prior written permission from the
All rights resa
publisher.
Cover and la)
Printed by Sh
Published by
Community Health Library and
Information Centre (CLIC),
SOCHARA
359, 1st Main, 1st Block, Koramangala,
BENGALURU - 560 034.
ernment of Gujarat, Gandhinagar
Phone: 080 2553 1518
email: clic@sochara.org
website: www.sochara.org
'■ Wt' Tlf
Ill
Foreword
It gives me great pleasure to write a foreword for this manual. During my clinical experience of
more than 40 years, to my mind, the most important lacunae in mental health delivery services in
our country, has been the absence or inadequacy of counseling services. With the advent of great
advances in Biological Psychiatry, it is possible to affect improvement in most of the psychiatric
disorders to a significant level. However, I have always felt that this can never replace counseling
to deal with psychosocial factors that not only contribute to mental disorders but are also important
in relapse of disorders. Further, in the field of Preventive Psychiatry, counseling has more important
a role to play. It is, therefore, evident that we need a network of counselor services to provide
effective mental health services.
In India there is a shortage of mental health professionals and it may not be possible to meet the
ideal requirement of patient-doctor ratio in the years to come. It, therefore, becomes necessary to
train lay counselors working with NGOs and medical doctors to provide primary care. At the
same time it is necessary that training should be standardized so that the basic minimum standard
of care can be maintained. This manual has been prepared keeping these training needs in mind.
The manual covers both theoretical and practical aspects of mental health interventions, such as
identification of common mental disorders, interview and counseling skills, techniques of
counseling, counseling process and ethics of counseling. The appendices will be of great practical
use for identification of signs and symptoms of CMD.
It is therefore highly commendable that Dr. Snigdha Nautiyal and Ms. Shveta Kumaria have
prepared this manual. I have no hesitation in recommending this manual as an important guideline
for training counselors. I also wish to congratulate the authors for doing such an excellent job.
Dr. Anil. V. Shah
Consulting Psychiatrist
Former Head of the Department of Psychiatry
B. J. Medical College and Civil Hospital
Ahmedabad
V
Preface
The Government of Gujarat has a vision: to provide complete health for the people of Gujarat. But
this cannot be achieved unless the issue of mental health is also addressed. Keeping the paucity of
resources and the social dimension of this issue in mind, the Mental Health Mission Report 2003
recommended the development of cost-effective community based mental health interventions.
The Government of Gujarat, therefore, commissioned the project, "Capacity Development for
Community Based Mental Health Interventions in Gujarat". The project was implemented by
Ahmedabad Management Association, Ahmedabad. The nodal agency for this project was Indian
Institute of Management, Ahmedabad, and it was supported by the Royal Netherlands Embassy,
Development Cooperation Division, New Delhi.
This manual is the culmination of the capacity building training programs in mental health
conducted for various community based organizations in Gujarat during the period of 2003-2004.
This is a trainer's manual and should be used only by mental health professionals or by those
with at least a bachelor's degree in Psychology or by those who have undergone training in capacity
building for mental health interventions. The manual can be used as a reference for developing
training modules in mental health.
This manual has two sections - Identification of Common Mental Disorders and Counseling Skills.
Section I gives an introduction to the area of mental health, outlines the interview skills required
to conduct an identification interview and describes the various Common Mental Disorders. While
reading Chapter 2 (Interview Skills), it would be advisable to refer to Appendix A, a pro forma for
history taking. Chapter 3 gives brief descriptions of the Common Mental Disorders and is supported
by Appendix B, which features the detailed criteria for identifying a disorder. It is best that they
are used together.
Section II is dedicated to counseling skills, which includes information on the qualities and skills
of a counselor, the counselor-client relationship, the various techniques of counseling, the counseling
process and the ethics of counseling.
This manual comes with an audio-visual aid, which can be used as an adjunct to the text during
training sessions. The video has been developed in Gujarati. The English script has been provided
vi
in Microsoft Word Document in the CD. It has five sections, four role-plays and one puppet show.
The first two sections arc devoted to the identification of Common Mental Disorders with the help
of role-plays and support Section I of the text. The third and fourth sections are role-plays on
counseling skills and relate to Section II of the text. The fifth section is a puppet show, which can
be used as part of an Awareness Program on Mental Health conducted either at the organizational
or community level.
Both the text and the audio-visual aid can be used either in parts or as a whole for developing a
training program, depending on the modules covered. This manual is by no means the last word
in mental health interventions. It is meant to be used only for basic training in mental health.
'•'■■-I#'
VII
Acknowledgements
This manual is the result of the training workshops held during the project period, feedback received
from participants of workshops and assessment of NGOs needs for inputs in mental health. The
aim of this manual is to provide a framework of structure and content to trainers who wish to do
capacity building or strengthening in mental health. In the process of giving the manual a final
shape we have received inputs and cooperation from many individuals and organizations.
Throughout this challenging and gratifying process their faith and unstinting support made this
manual a reality. We would like to take this opportunity to thank them.
We express our gratitude to the Department of Health and Family Welfare, Government of Gujarat,
for commissioning the project in 2003. In particular we thank the Honorable Minister of Health
and Family Welfare, Mr. I. K. Jadeja, Mr. R. L. Meena, Principal Secretary, Department of Health,
Dr. Amarjeet Singh, Commissioner of Health, Medical Services and Medical Education, and Dr.
Manorama ben Shah, Additional Director, Medical Services, Department of Health and Family
Welfare, Government of Gujarat. We would also like to thank former health secretary, Mr. S. K.
Nanda and former Commissioner of Health, Mr. V. A. Sathe, for their support and encouragement.
We extend our heartfelt gratitude and thanks to Dr. Ravi. H. Bakre, Program Officer, Mental Health
Program, Medical Services and Medical Education, Government of Gujarat. Dr. Bakre provided
us with technical support throughout the manual development and review phase and was generous
and unconditional with all information.
We would like to thank the Royal Netherlands Embassy, Development Cooperation Division,
New Delhi, for supporting this endeavor. In particular we would like to thank Mr. Jaap Jaan
Speelman and Mr. Rush! Bakshi, Senior Program Officer for their support and encouragement.
We thank Dr. Anil. V. Shah, practicing psychiatrist, Ahmedabad, for kindly agreeing to write the
foreword for this manual.
We would like to express our thanks to Indian Institute of Management, Ahmedabad, the nodal
agency for the project. Our deep gratitude and sincere thanks to Professor Ramesh Bhat, Professor
Sunil Maheshwari, IIM, Ahmedabad, whose support, advise and guidance at every stage helped
us overcoming the obstacles in the path. We would also like to thank Prof. Dileep Mavalankar
from IIM, Ahmedabad.
-
viii
We extend our sincere thanks to Dr. Kiran Rao, Additional Professor, Department of Clinical
Psychology, NIMHANS, Bangalore, for guiding us through every step of this manual. Her
unstinting critical review and evaluation, technical support and guidance helped us fine-tune the
manual to its final stage.
1 his manual went through an exhaustive review process and we would like to thank our reviewers
for taking out valuable time to give us their vital feedback. In particular we thank Dr. G.K. Vankar,
Professor and Head, Dr. Minakshi Parikh, Associate Professor, Mr. B.K. Sinha, Associate Professor
(Clinical Psychologist), Department of Psychiatry, B.J. Medical College and Civil Hospital,
Ahmedabad, Dr. Rithambhara Mehta, Associate Professor and Head of the Department of
Psychiatry, Surat Medical College, Surat, Dr. Bharat Panchai, Professor and Head of the Department
of Psychiatry, Sir Takhtasinghji Hospital, Bhavnagar, Dr. Mukesh. J. Samani, Professor and Head
of the Department of Psychiatry, Pandit Din Dayal Upadhayay General Hospital, Rajkot, and Dr.
Jilendra. N. Nanawala, Surat.
•
Our deep appreciation and thanks to all NGOs who participated in the training workshops from
■ the five regions of Ahmedabad, Vadodara, North Gujarat, South Gujarat and Kutch. The
incomparable experience that we had with them in the training programs has enriched our
knowledge in many ways to make this manual practical and useful. In particular, we would like
to thank Ahmedabad Women's Action Group (AWAG), Ahmedabad, Sarjan (ASAG), Ahmedabad,
Saath Suicide Prevention Center, Ahmedabad, Saath Charitable Trust, Ahmedabad, Mahila
Patchwork Cooperative Society, Ahmedabad, Samarthan Trust, Ahmedabad, and SWATI,
Dhrangadhra, forgiving their consent to do the role-plays for the audio-visual part of the manual.
We also owe a special thanks to Mr. Harinesh Pandya and Mr. Imitaz from Janpath, Ahmedabad
who helped us to network with NGO's from South and Kutch regions of Gujarat.
We would like to thank Ahmedabad Management Association for their invaluable service in the
flawless implementation of this project and manual. Many thanks to Mr. K. K. Nair, Executive
Director, AMA, Ahmedabad and his staff for maintaining an efficient system which ensured that
the manual faced no glitches in running smoothly and reaching its final destination.
We would like to thank Ms. Swati Merh for translating the English version to Gujarati. Our grateful
thanks to Ms. Subashree Krishnaswamy for the excellent editorial work she has done for this
manual. We owe many thanks to Mr. Nagji Prajapati and Mr. Anil Gajjar for designing the cover
page and illustrations in the manual. Our appreciation and thanks to Ms. Juhi Dua, who directed
the audio-visual part of the manual and Mr. Vipul Patel and his team who shot the video.
ix
We would like to thank Ms. Sejal Prajapati, Research Associate for the project for efficiency,
commitment and hardwork.
Lastly, we would like to thank Shree Ambica Traders for printing this manual.
Dr. Snigdha Nautiyal
Project Coordinator
Ms. Shveta Kumaria
Technical Associate
xi
List of Contents
Section I
Chapter 1 - Introduction
3
Chapter 2 - Interview Skills
13
Chapter 3 - Identification of Common Mental Disorders
23
Section II
Chapter 4 - Overview of Counseling
41
Chapter 5 - Techniques of Counseling
51
Chapter 6 - Counseling Process
77
Chapter 7 - Ethics in Counseling
85
Appendix A
Appendix B
CHAPTER 1
Introduction
The emotional and psychological well-being of a person is called Mental Health. It is the
balance between the mind, body and the social environment. These three parts are a whole,
interacting and influencing each other. Ill health or distress in one sphere may also reflect
in the other spheres.
Mental health is defined as the successful
performance of mental functions, in terms of a stable
mood and behavior that results in productive
activities, fulfilling relationships and the ability to
adapt, change and effectively cope with adversity
(Sadock & Sadock, 2003).
The area of mental health is best understood in terms of a bio-psycho-social model. This
model adopts an integrated approach to understanding human behavior. The biological
system refers to the anatomical, structural and cellular substrates of an individual's
physiology. The psychological system refers to the motivation and the personality make
up of an individual. The social system includes the familial, environmental and cultural
factors in which the individual lives. These three systems interact to influence an
individual's behavior.
Biological
Social
Psychological
4
Identification of Common Mental Disorders and Counseling Skills
Life Cycle Theory
The life cycle theory helps us to understand human behavior and the stages through which
all individuals pass - from birth to death. This theory states that development occurs in
successive, clearly defined stages and in a particular order in every person's life. Each
stage in life is characterized by events or crises (difficulties, problems or conflicts) that
must be resolved satisfactorily if development is to proceed smoothly. If resolutions to
these problems are not achieved within the given life stage, all the subsequent stages may
reflect difficulties in the form of physical, cognitive, social or emotional mal-adjustments.
At every stage of the life cycle individuals are expected to play different roles. As children
they are expected to study and do well in school. Passing exams successfully to go to
higher classes is one of the difficulties that every child faces. Failure or not doing well in
an exam leads to frustration, humiliation and a sense of defeat in the child, which may
cause emotional problems. As children grow older, new demands are placed on them.
They are expected to become economically independent, marry, have children and take
on more responsibilities. Each stage, therefore, comes with different sets of demands and
successful resolution of difficulties at every stage is important for the growth of an
individual into a mature adult. If individuals are not biologically, psychologically and
socially ready to take on the expectations and demands of that stage, then they may face
crises or conflicts. This in turn may cause mental tension and stress. For example, an 18
years old girl is biologically ready for marriage, and socially it may be the accepted norm.
However, if the girl does not feel ready psychologically to marry and take on the role, she
will face a crisis in her life. She may find it difficult to adjust to a married life and cope
with the role demands placed on her.
The life cycle theory helps us understand the development of individuals in society, the
role expectations that are placed on them, the way they learn to adapt and cope with
different kinds of crises in their lives, and, finally the social context in which they grow. It
helps us to understand the development of an individual's behavior in terms of biological
maturity, psychological capacity, adaptive behavior, role demands, social behavior and
interpersonal relationships. In that sense it takes a bio-psycho-social perspective. In addition
to going through the successive stages of life, it takes into consideration the fact that each
individual has to be prepared to take on the role demands of that stage. All these
components arc necessary in order to understand both the concept of mental health and
the kinds of mental disorders people are likely to develop in their lifetime.
--
Introduction
5
What is Mental Disorder?
People sometimes show changes in the usual way of thinking, the way they express their
emotions and the way they perceive the world and the people around. This results in poor
judgment and socially inappropriate behavior - the person is then said to be mentally ill.
Sometimes stressful events or problems may result in a person feeling sad, depressed or
anxious. He/she may find it difficult to concentrate on work, enjoy pleasurable activities
or feel tired and dull for most part of the day. These changes can cause distress to the
individual and to the people around him/her, like family, friends or colleagues. These
changes also disturb the day-to-day functioning of the individual.
Let us take a moment here and differentiate mental disorder from psychological distress.
Often we come across individuals who may be experiencing tension and stress due to life
problems. Stress and tension can arise from certain issues in the environment of the
individual - financial problems, domestic violence, broken marriage, long-term illness,
discrimination, poor living conditions, poverty, etc. Problems can also arise because of
the way individuals think or perceive the world around them. For example, a person
might think, "Whatever I do I will fail", "How can I do this thing when I don't have any
education or talent". Such a person is likely to feel sad and not attempt to do that job at all.
The problem then is related to the way the person thinks rather than the difficulties found
in the environment. Any stress or tension, whether arising from difficulties in the person's
social context or environment or the way he/she thinks and perceives the world, causes
distress (stress that makes us unhappy, uncomfortable or sad). This is known as
psychological distress and it may arise due to life situations, which cause stress, tension,
worry or sadness. But, it does not necessarily mean that the person will develop a mental
disorder, which may require medication. The levels of distress may vary with time, the
6.^
age of the person and the socio cultural factors. Mental disorder, on the other hand, is
identified when a certain number of signs and symptoms are present together for a certain
period of time (discussed in the next segment).
NGOs are more likely to come across individuals with psychological distress in their
fieldwork. If distress in this target group is identified in the early stages itself, it can be
easily handled through psychosocial methods of counseling.
1
6
Identification of Common Mental Disorders and Counseling Skills
Classification of Mental Disorders
Let us begin with defining some of the concepts that will be used frequently in the text.
□ Symptoms are the complaints that a person comes with
to the doctor. For example, a person may come to a
doctor with a complaint of feeling tired through the
day or difficulty in sleeping. Symptoms are complaints
reported by the person.
□ Signs are those observations and objective findings that
Oi
0:
j
? the doctor picks up on examination. For example, if an
individual complains of tiredness through the day, the
doctor may also note that the person is looking tense,
worried and has lost a significant amount of weight.
Signs are drawn out through specific questioning.
□ A mental disorder is identified when a certain number
of signs and symptoms are present together for a certain
period of time.
For the ease of understanding, mental disorders are divided into four categories -Severe
Mental Disorders (SMD), Substance Abuse (SA), Childhood Disorders and Common
Mental Disorders (CMD). The focus of this manual is largely on CMD. We have tried to
give some basic information on SMD, Substance Abuse and Childhood Disorders as well.
Our reason for focusing on CMD is that this is the group of disorders commonly found in
the community that often go unreported. These disorders are often associated with social
and economic stressors. If identified early, they respond well to both medical and
psychosocial treatment methods. These are the type of disorders NGOs are likely to find
in the community. Therefore, our effort is towards providing information on CMD, so
that NGOs can do early identifiqation/psychosocial counseling with clients and refer them
to the mental health professionals when needed. The descriptions of CMDs are based on
the International Classification of Diseases (ICD-10), published by the WHO and is widely
accepted by mental health professionals in India for diagnosis of mental disorders.
Introduction
7
A preliminary data on the prevalence of mental disorders in Gujarat is given in the following
table.
Range of Prevalence
High Risk population
Community
PHC/CHC
CMD
3.23%- 13.9%
11%-46.5%
Substance Abuse
17.3%-38.6%
Men, older or retired men,
unemployed, low SE status,
youth labor.________________
SMD
1.61%- 14.2%?
Migration, social isolation,
i 11 iteracy and low SE'statuTh — —
Overall psychiatric morbidity
4.8%-26.9%
18.4%-53.7%
Women, illiterate, low socioeconomic(SE) status, disaster
affected, violence affected.
Low SE status
Source: The Mission Report 2003: Priorities for mental health sector development in Gujarat. Department of
Health and Family Welfare, Government of Gujarat, India.
The overall psychiatric morbidity (i.e., the number of people suffering from mental
disorders) in the community in Gujarat is 10 percent, which means 2.8 million adults at
any given time are likely to be suffering from mental disorders.
Severe Mental Disorders
SMDs are less common and these are the ones usually recognized in the community as
'mental illnesses'. They are often associated with neuro-developmental, genetic or neuro
chemical factors in the brain. These disorders are easily identifiable because the signs are
very obvious to other people. The changes may occur in the form of withdrawn behavior,
reduced activity, talking to oneself, making bizarre gestures, talking and laughing loudly
without relevance to the context, being abusive to others, tearing off one's clothes, behaving
inappropriately in a social situation, etc. SMD affects role functioning - for example, the
individual may stop going to work or attending to household activities and may not attend
to personal hygiene. These disorders impose a heavy burden on families who are the
primary caregivers. Examples of SMD: Schizophrenia, Bipolar Affective Disorders (BEAD).
Substance Abuse
Substance Abuse refers to the category of disorders where an individual develops
dependence on a particular substance like alcohol or drugs (ganja, hashish, cocaine, heroin,
etc.). Dependence on a substance is defined in two ways - behavioral and physical.
?
8
Identification of Common Mental Disorders and Counseling Skills
Behavioral dependence develops when an individual actively seeks ways of finding a
substance, whereas physical dependence refers to the physical effects of the use of a
substance. These substances affect the mood state (feeling elated, happy, sad, irritable)
and behavior of a person. Those with substance abuse have often been found to have
other mental disorders like Depression, etc.
Childhood Disorders
Childhood Disorders refers to that category of mental disorders found among children
and adolescents. Individuals below the age of 18 years come under this category. Some of
the more commonly found disorders among children are Attention Deficit Hyperactivity
Disorder, Conduct Disorder, Childhood Depression and Substance Abuse. Sometimes
severe mental disorder like Schizophrenia is also seen in children. Counseling children
also includes counseling parents or caregivers and sometimes school teachers. Apart from
the conventional methods of counseling, play and art therapy have been found to be very
effective with children.
Common Mental disorders
CMDs are typically those disorders, which are commonly found in the community. They
do not cause major disruptions in day-to-day functioning. These disorders often go
unreported because the signs are not very apparent. Persons suffering from CMD may
neglect or ignore the symptoms because the functional level is not disrupted and they are
able to carry on daily activities, although, with greater difficulty, effort and less interest.
As a result, family members also do not pay attention to these problems. If at all treatment
is sought, it is usually for the physical symptoms that cause distress. For example, people
may go to a general physician because of complaints of bodily aches and pains, loss of
appetite, poor sleep, low energy levels, but not because they feel irritable, tensed, cry
often, etc. It is in the course of examination that the physician may recognize that the
person shows signs and symptoms of a common mental disorder. Examples of CMD are
Depression, Anxiety, Phobia, etc.
A Common Mental Disorder can be present at a clinical or sub-clinical level. A disorder is
described as being at a clinical level when it fulfills the criteria as per the classificatory
system (in our case the ICD-10) of the number of signs and symptoms and the time duration
for which they should be present. For example, in order to be identified as Depression, at
WJiLJUk.
Introduction
9
least 4 symptoms must be present for a period of 2 weeks continuously - only then it can
be called Depression. In case of Anxiety Disorder, for example, at least 4 symptoms must
be present for a period of 6 months continuously. If the signs and symptoms meet the
criteria, it is then called a clinical disorder.
However, sometimes the signs and symptoms of a particular disorder may be present, but
may not fulfill the criteria according to the classification of disorders. In which case, the
disorder is said to be at a sub-clinical level. For example, a person may be feeling sad and
dull, is not able to concentrate on work and is not sleeping very well. These are signs of
Depression. However, if these symptoms have been present for less than a period of 2
weeks continuously then the Depression would be at a sub-clinical level. Alternatively,
the person may have just 2 symptoms of Depression for a period of 3 months - it will still
be called sub-clinical Depression.
A point to remember: in order for a disorder to be identified as clinical it must fulfill the
criteria of both the number of signs and symptoms and time duration. This distinction
between the clinical and the sub-clinical is important because in the community NGOs
may often come across individuals who show sub-clinical symptoms of a disorder. Another
factor to be kept in mind is that when an individual with a clinical disorder is identified, it
is important that she/he must be immediately referred to a mental health professional.
Factors Related to Mental Disorders
There are several factors that contribute to the development of mental illness. For ease of
understanding we have divided these into three main areas - biological, familial, and
social.
Biological-factors - Certain types of changes in the brain can lead to severe types of mental
illnesses like Schizophrenia, Mania, etc (described in chapter 3). These changes can arise
because of increase or decrease of certain chemical substances in the brain. A family history
of mental disorder is also seen as a risk factor for developing mental disorder.
Family and childhood factors - A number of commonly found mental disorders seem to
be related to childhood and familial factors. A child's first experience of the world is at
home. While growing up children need love, support, guidance, emotional understanding
and discipline. A lack or excess of any of these can lead to problems in their healthy
development. Such children, when they grow up and are exposed to difficulties in life,
10
Identification of Common Mental Disorders and Counseling Skills
may develop emotional or behavioral problems. Another related factor is the temperament
of the child. All children are born with a temperament. Some children are easy going,
whereas others are difficult to handle. Some children get along easily with others, whereas
others are shy and withdrawn. When temperament and environment interact, they together
influence an individual's personality.
A happy and healthy family environment also influences the development of the
personality of an individual. Poor communication between parents and children, marital
discord among parents, frequent and violent fights, broken families, etc., can cause mental
problems in an individual. When resources are limited and have to be shared, there is a
lack of understanding and interpersonal relationships get strained. Thus people living in
such families find it stressful to interact with others. Poor interpersonal relationships
within the family may affect interpersonal functioning in the social world, thereby leading
to psychological distress.
Social factors - Every individual is a part of the society he/she lives in. Chronic stressful
situations and events, such as financial difficulty, poverty, domestic violence, divorce,
problems in the occupational area, sexual difficulties, failures, frustrations, etc., can cause
distress in an individual. Discrimination on the basis of caste, religion, community, injustice,
exploitation, crimes, violence, etc., can also lead to a high level of psychological distress or
a mental disorder. Poor living conditions, a disorganized way of life, inconsistent and
confusing value systems add to the stress in an individual's life. If these stressors are
severe and/or continue over a period of time then the individual is at a risk of developing
a mental disorder.
A point to be noted: mental disorders do not arise out of a single factor. Often a mental
disorder or psychological distress is related to a combination of physical, social, cultural
and familial factors. These factors interact and influence each other, thereby leading to
psychological distress. That is why mental health is best understood in the context of a
bio-psycho-social model.
Introduction
11
Why should We Pay Attention to the Area of Mental Health?
The Mental Health Mission Report prepared by the Government of Gujarat (2003) states
that there are 2.8 million adults with common and severe mental disorders at any point in
time in the state of Gujarat. This increases the burden of disease on the health system,
society and the family of the ill person. At this point in time, mental health services (public
and private) are more focused towards the treatment and care of the severely mentally ill
individuals who usually need hospital based care. The need of the hour, however, is to
develop a system where treatment and care can focus on common mental disorders as
well - Depression, Anxiety, etc. These commonly found disorders do not usually require
hospitalization and can be treated with medicines and counseling.
NGOs have played an important role in the health sector. Given the history and strength
of NGOs in community-based approaches, their involvement in the mental health sector
is crucial and significant. The major strength of NGOs is their ability to develop an effective
and sustainable relationship with the community at large. They can thus play an important
part in the integration of mental health into their area of service delivery and become a
bridge between mental health care personnel and the communities.
However, there is relatively little knowledge and skills available to the personnel working
in NGOs. This affects their ability to develop and implement good intervention programs
in the area of mental health. Though NGOs are not trained or skilled in the area of mental
health, it is by no means a new concept for them. In their existing service delivery, they
often come across people in whom they are able to recognize emotional or behavioral
problems. Not being able to adequately handle these problems often frustrates them and
makes them feel helpless.
Therefore, if people working in NGOs are trained adequately to identify individuals with
CMD, they will be able to help people with psychological distress. They can refer people,
when needed, to mental health professionals. Community care and early identification of
Common Mental Disorders leads to cost-effective methods of treatment in the community
and reduces the disability and distress.
12
Identification of Common Mental Disorders and Counseling Skills
At the end of this chapter you should have learnt:
1. The definition of mental health.
2. How mental health is understood in terms of a bio-psycho
social model and the life cycle theory.
3. The classification of mental disorders.
4. The factors related to mental illness.
5. Why mental health is an important area.
6. The role NGOs can play in developing the mental health
sector.
CHAPTER 2
Interview Skills
An interview is a conversation with a specific purpose. It involves two people, an
interviewer (the person who will ask questions to get information) and an interviewee
(the person who will give information). We will refer to the interviewer as the counselor
and the interviewee as the client. In the kind of interview that you will be conducting as a
counselor with clients, your aim is:
1. To help clients explore in detail the distress they are experiencing. Here the counselor
tries to obtain information on the signs and symptoms that clients have.
2. To understand the nature of the problem and the circumstances associated with or
related to the distress that clients experience - family situation, marital history (if
married), chronic stressors, socio-cultural factors, etc.
3. To identify whether the symptoms are at a sub-clinical or a clinical level.
4. If the symptoms are at a clinical level - convince clients to seek help from a mental
health professional.
5. If the symptoms are at a sub-clinical level - inform clients how you and your
organization can help them with their problems and the distress they are experiencing.
6. To give information, advice, guidance and suggestions - explain the nature of the
problem, talk about available methods of treatment. If clients agree to counseling, they
have to be given information about counseling: how it will be done, what clients are
expected to do during the process of counseling and what benefits (both short-term
and long-term) they are likely to get from it.
The interview is an opportunity for the counselor to begin the process of establishing a
relationship with the client. Such a relationship is called a working relationship. A good
working relationship with the client is essential to build trust. Unless clients trust the
counselor, they will not be comfortable with sharing information about themselves. They
have to be convinced that the counselor will work in their best interests and keep the
information confidential. Therefore use the first interview with clients as an opportunity to
establish a good working relationship with them.
14
Identification of Common Mental Disorders and Counseling Skills
The first interview with the client can be divided into three phases. While describing the
phases, we will also pay special attention to the skills the counselor needs to conduct an
effective and fruitful interview. Although certain skills have been outlined in each phase,
please remember that these are skills that are used throughout the interview and are not
specific to any one phase. For example, good listening skills, patience and alertness are
required throughout the interview. However, special skills such as assuring confidentiality
will have to be used by the counselor in the first phase of the interview and, if need be,
repeated at the end of the interview.
PHASE - I
This is the introductory phase of the interview. You meet the client and introduce yourself
and once both of you are seated comfortably the interview begins. One of the first things
that the counselor does in an interview is to establish a rapport with clients. What exactly
is rapport? The counselor makes an attempt to put clients at ease, provides a secure and
supportive environment and encourages them to talk about their problems freely. This
establishes a working relationship with clients. Establishing rapport is necessary because
often when clients come for help, they are anxious or frightened. They don't know how
the counselor can help them. They are already distressed by the problem they are having.
Therefore time is taken initially to make clients comfortable, so that they can talk without
hesitation, fear, shame or guilt. Establishing rapport is a way of gaining the trust of clients.
It is on the basis of this that clients decide whether or not to come for counseling.
A good way to establish rapport with clients is to give some information about yourself
(the counselor) - your name, where you work, the name of your organization and what it
does.
Once you have introduced yourself to clients, ask them to introduce themselves in return.
Allow clients to talk for the first 10-15 minutes. Focus on general topics: for example, the
background of clients, what they do, where they come from, whether married or not (refer
to Appendix A). These neutral questions help clients to feel comfortable. Sometimes, clients
are anxious, frightened or fearful. Take time to make them comfortable. Reassure them
that it is perfectly all right to feel a bit hesitant since this is a new situation for them.
Reassure them about the confidentiality of information and always tell them that they can
start talking about their problems only when they feel really comfortable.
•
■
■
VO,:.-.
•
Interview Skills
15
Counselor's Skills
□ Greeting - Greet clients with a warm and friendly smile.
□ Appear confident - A counselor's sense of self-confidence will reassure clients that
they have come to the right place and are in competent hands.
□ Maintain eye-to-eye contact - Look at clients so that they get the impression that you
are interested in what they are saying.
□ Listen attentively - Listen carefully to what clients are saying and avoid interrupting
when they are talking. Pick up cues from their talk and decide on the questions you
should ask in the subsequent phase of the interview.
□ Be alert and observant - Notice whether clients feel comfortable or not, whether they
appear anxious, distressed, upset or tense, whether they are interested in talking to
you or not. Information given by clients verbally is important, but equally important is
the non-verbal language. How clients sit, the tone of voice, whether they maintain eyeto-eye contact with you, whether what they are saying agrees with their emotional
expression, etc., are all important.
□ Ask both open-ended and close-ended questions - Closed-ended questions can be
asked to find out the background information of clients ("How old are you?", "Are
you married?", 'What do you do?" etc.). Open-ended questions are asked to encourage
clients to talk about the problems they are facing - "Can you tell a little about the kind
of problems you are facing?", "What brings you here"? "Tell me, what can I do for
you?" etc.
□ Be patient - Sometimes clients may hesitate to give information, because they are
embarrassed or ashamed. Sometimes they may get angry with the counselor if they
don't get what they expected out of the interview. At such times, it becomes important
for the counselor to be patient and explain clearly the interview situation to clients.
□ Assure confidentiality - Confidentiality means that the counselor will not reveal any
of the information given by clients to anyone, without the consent of the clients. At
this phase assure clients that all their disclosures will be kept strictly confidential.
16
Identification of Common Mental Disorders and Counseling Skills
PHASE - II
This is the main phase of the interview. This phase onwards, the focus of the interview is
on elicitation of the signs and symptoms and getting information about the nature of the
distress. Given below is a format that helps in drawing out systematically the problems
and situations in a step-by-step manner. Please refer to Appendix A.
1. Chief complaints - These are the problems that clients speak about spontaneously.
When you ask open-ended questions like "Tel 1 me what brings you here?", "Can you
describe what problems you are having?", "What can I do for you?", clients will start
talking about the problems they are having. Note them down carefully. The answers
of clients will give you the direction for further questioning and clarification.
2. Duration - How long have the signs/symptoms been going on, in terms of days,
months, weeks or years? Sometimes clients are not able to give exact details of the
number of years or months. A good policy is to ask when it all first started or when
they first noticed a change.
3. Onset and course - How did the symptoms start? Did they start slowly and become
worse with time or did it all start suddenly? Have the symptoms worsened over time,
or have they remained the same as in the beginning?
4. Precipitating factors - Was there a stressful event (financial loss, death, natural disaster,
divorce, fight, physical illness, etc.) that might have upset the clients before these
symptoms started? It is important to ascertain whether the symptoms are related to a
specific event or general circumstances in life.
5. History of the present illness - What are the signs and symptoms that clients have?
What is the nature and description of the symptoms? How can they be described? The
counselor should question all the relevant signs and symptoms (refer to Appendix B)
of the disorder that they have. Counselors usually get an idea of the disorder in the
initial questioning. However, it is important to rule out general signs and symptoms of
other disorders as well. For example, in the course of interview, the counselor may
come to know that the client is suffering from Depression. But. in order to establish
without doubt that it is Depression alone, the counselor should ask questions about
Anxiety, Phobia, etc. (described in Chapter 3). Sometimes clients may show signs and
symptoms of two disorders. Alternatively, it may be possible that clients have signs
and symptoms ('if one disorder and some sub-clinical features of another disorder. For
example, the client may be suffering from Anxiety, but may also have Panic Attacks,
Interview Skills
17
or a client may be having Depression but may show some features of Anxiety as well.
Therefore it becomes important to check all the signs and symptoms.
6. Biological, social and occupational functioning - Explore the sleep patterns, appetite
and the physical condition of the client. If clients are female, take the menstrual history
- when did the menses start, how long is the cycle, what sort of difficulties do they
have during the cycle, the flow. Find out whether clients meet people, enjoy social
activities, look forward to them or not to ascertain social functioning. Finally, find out
if clients have been able to do their routine work (in a job if employed or housework).
If yes, then how well, and if not, then what are the difficulties they face? Has there
been a drop in the level of functioning? Has anyone complained about their work?
7. Family functioning - Use the genogram (see Appendix A) to get the family structure
details (how many people live in the family, who all, how many children, whether
there has been a divorce, remarriage or death in the family, physical or mental illness
in other family members etc). Additionally, explore the relationships among the family
members - the roles and responsibilities of each individual, marital discord if any in
the family, communication patterns among the family members.
Counselor's Skills
In addition to the skills mentioned for Phase I, these skills are very important for the
second phase of the interview.
□ Be focused and purposeful - The counselor should encourage clients to explain the
details of the problems they are having. If clients start talking about other issues, gently
guide them back to the topic in discussion. 'Purposeful' means that the aim of the
interview - to understand the nature of the problem and identify the mental disorder
- should be fulfilled. At the end of the interview, the counselor should have enough
information to decide whether signs and symptoms of the client are at a sub-clinical or
clinical level.
□ Be flexible - When you interview clients, it may be the first time that they are getting
an opportunity to speak about what they actually feel. Therefore, even though clients
may go off the main discussion, if the information is relevant or related to the problem
they are having, allow clients to speak at length.
□ Be explorative - The counselor should explore all aspects of the signs/symptoms, the
nature of the problem and the cause of the problem. Exploration means that the
counselor should try to understand the how, when, what and where of the problem.
18
Identification of Common Mental Disorders and Counseling Skills
□ Open-and close-ended questions - Ask both types of questions. When you wish to
find out whether a symptom is present or not, ask close-ended questions and when
you want to understand the problem in more detail, ask open-ended questions.
□ Be supportive - Support is provided by giving clients reassurance and acceptance.
The counselor should ensure a safe and secure environment for the client while trying
to understand the problem.
□ Be persistent - Only with persistence can you gain information about the problem the
client is having. Sometimes, clients may give vague information, or only half the
information. At other times, they may refuse to believe that anything can be done to
improve their situation and refuse help flatly. It becomes important to be persistent in
your efforts with clients. It may take more than one session or meeting to convince
clients that they need help. Efforts should not be given up just because clients do not
understand that they require help during the first couple of sessions.
□ Non-judgmental attitude - The counselor must maintain a nori-judgmental attitude,
whether it is regarding the nature of the problems, behavior, patterns of thinking or
feelings of the clients. This means that you do not make a judgment on 'Tight" or
"wrong", "correct" or "incorrect". Being non-judgmental means that the counselor
accepts clients for what they are, is able to look at the problem and related factors
objectively, and does not try to blame clients or anyone involved in the problem
situation. Showing acceptance is a way of gaining the trust of clients. Being nonjudgmental is especially important when clients talk about behaviors or situations that
may be different from the views held by the counselor.
□ Always clarify - Whenever clients give information that is not clearly understood,
always clarify. Repeat the information and ask clients whether it is correct or not.
Clarification is also necessary when the counselor gives information to clients. Always
ask clients to either repeat the information or ask: "Have you understood"? "Is there
anything that you would like me to repeat"?
□ Use facilitating comments - While clients talk about problems the counselor should
always make facilitating comments - "go on", "yes, I understand", "hmmm" etc., which
are some of the commonly used expressions. Facilitation can also be done using non
verbal gestures such as nodding the head, leaning forward towards the client,
maintaining eye-to-eye contact, etc.
□ Summarize - At the end of the interview always take some time to summarize the
information that clients have given. Summarization has two goals - one, as an
Interview Skills
19
interviewer, you are able to clarify any of the points that you might not have understood
properly, and, two, it reassures clients that the interviewer has been listening carefully
to whatever they have been saying in the session. This also builds trust in clients. They
feel that the counselor is concerned about them and would like to help them in the best
manner possible.
PHASE - III
The third and final phase of the interview is called the termination of the interview. The
counselor slowly brings the interview to an end. This phase usually starts with the counselor
summarizing all the information that clients have given. If there are any clarifications to
be made, they are done right away. The counselor uses this phase to achieve the following:
□ Education/Guidance/Advice/Suggestion - Clients are given tentative information on
the nature of the problem and the importance of treatment. They are told about the
various methods of treatment, where they are available, how they can be accessed.
□ Referral - If clients require a referral to the psychiatrist, then suggestions are made
and the reasons for doing so are also explained. Information related to treatments is
given to clients.
□ Counseling - Besides the consultation with the psychiatrist, the counselor should also
give information on what the counselor can do for clients (for example, counseling). If
the counselor feels that the client needs counseling, then the counseling process is
explained.
□ Reassurance and supportive stance - At the end of the session, once again reassure
clients that the counselor (you) is available to discuss any further questions or doubts
that they might have. If clients get upset, start crying, or become angry in the course of
the interview, take time to calm them down before he/she leaves. Clients should usually
walk out of an interview feeling somewhat relieved, reassured and hopeful that their
problems may have a solution and that the future does not appear hopeless and negative.
If clients have agreed to come back for further sessions, fix a time and date for the next
session. Also give information to clients on how they can contact the counseling center or
organization whenever the counselor is not available, This gives clients a sense of continuity
and a reassuring feeling that even though they may not be ready to come back for further
sessions, the possibility of doing so at any time in the future is always open for them.
Identification of Common Mental Disorders and Counseling Skills
20
□ Greeting
□ Appear confident
□ Maintain eye-to-eye contact
□ Listen attentively
□ Be alert and observant
□ Ask both open-ended and
close-ended questions
□ Be patient
□ Assure confidentiality
□ Be focused and purposeful
□ Be flexible
□ Be explorative
□ Be supportive
□ Be persistent
□ Non-judgmental attitude
□ Always clarify
□ Use facilitating comments
□ Summarize
Please Remember!
Here are some important points to keep in mind while doing an interview session:
□ Clients usually talk about their problems without too much difficulty. As long as they
are talking spontaneously, do not interrupt, and encourage them to give details. Some
clients, however, may be too upset to talk about their problems or may have been
forced to go to the counselor by other family members. They may resent the interview
situation as well as the counselor. Some clients may feel helpless or ashamed by the
fact that they have to seek help from an outsider for their personal problems. A few
others may hesitate to talk about their problems because they are not sure about the
counselor and may either remain silent or answer with a short "yes" or "no". In such
cases it becomes important for the counselor to reassure clients and encourage them to
talk. If clients remain silent for a while, do not force them to talk. Once they become
comfortable with the interview situation and the counselor, they will be able to talk
spontaneously.
□ Always remain alert to feelings of clients. Sometimes when they are talking, the
counselor tends to pay more attention to the content of the talk rather than to the feeling
component. Information given by clients verbally is important, but equally important
is the non-verbal language. How clients sit, the tone of voice, whether they maintain
eye-to-eye contact, whether there is agreement between what they say and what you
can see on their face, etc., are all important. Sometimes clients may say, "I am feeling
well", but may look tearful and not look at the counselor at all. The counselor then
Interview Skills
21
should be able to judge the situation that despite what the clients say, they are not
feeling well at all. The counselor should then explore further.
□ It is essential to remain optimistic about the solutions to the problem of the clients. If
clients sense at the time of the interview that the counselor feels that the problem is too
difficult or cannot be handled, then they will also become pessimistic about the outcome
and are unlikely to come back for counseling. But if it is important to be optimistic, it is
equally important to be realistic. Clients should not be given any false hopes. The
situation and what can be done should be realistically explained to clients.
□ Involve the family members in the interview session whenever possible, but always
take the consent of the client. Information from the family members is important: it
gives the counselor an idea of how the family members understand the problem of the
client and to what extent they are willing to help or be involved.
□ Avoid fidgeting or playing with the stationery while conducting interviews. If the
counselor keeps looking here and there, or plays with items on the desk, clierits often
gets the impression that the counselor is not interested in listening to their problems.
□ If clients start crying during a session, do not rush to console them, or try to stop them.
Allow them to have a good cry and then say some reassuring words.
□ If clients become disruptive (turn abusive, start shouting at the counselor, pick up
objects to hit, start tearing at their hair or their clothes, etc.) during the course of the
interview, stop the interview. Tell them to go out of the room or you step out of the
room. Before leaving or asking clients to leave, tell them specifically that unless they
calm down and are willing to discuss their distress or their difficult situation, the
interview will not be held. Also tell them that they can come back to the room or can
ask you to come back to the room (if the counselor has stepped out) once they have
calmed down. Give clients adequate time to calm down. It may sometimes take 10-15
minutes. If despite the time given, clients continue to be disruptive, terminate the
interview and fix a time for another session.
□ Do not feel pressured to give an answer to every question that clients ask. Sometimes,
the counselor may not have the information or may not know the answer. At other
times, clients may pressure the counselor to take up the responsibility of making all
the decisions, or may insist that the counselor give them assurances, which are
unrealistic. The counselor should be firm but gentle and refuse to give in to such
demands. Please remember the counselor is a skilled individual, not a person with
magical powers.
22
Identification of Common Mental Disorders and Counseling Skills
□ The counselor must keep the socio-cultural background of the client in mind while
framing the questions. Language should be kept simple and attempt should be made
to speak to clients in their language. Questions should be framed in such a manner that
clients are not embarrassed or insulted by them.
□ Lastly, if the counselor wishes to document or record information that clients give,
always take consent. Record the sessions only if clients agree to it. Notes should be
taken down during the interview, but if clients are uncomfortable with the idea of the
counselor taking notes, avoid doing so during the session. Write down the notes after
the session is over.
At the end of this chapter you should have learnt:
1. The skills the counselor requires to carry out an initial
interview.
2. How to conduct the first interview, which is mainly used
for identification.
3. How to document information in the three phases of the
interview.
4. The essential points to keep in mind while doing an
interview.
.. —unrii..
CHAPTER 3
Identification of
Mental Disorders
In this chapter we give information on mental disorders. Basic information is provided on
Severe Mental Disorders, but the focus is on Common Mental Disorders. For ease of
understanding, we have given brief descriptions of Common Mental Disorders. The criteria
have been outlined in Appendix B. Please refer to the Appendix while reading this chapter.
Severe Mental Disorders (SMD):
As discussed in Chapter 1, Severe Mental Disorders (SMDs) are those disorders that are
commonly identified and recognized as "mental illnesses". People suffering from these
disorders show gross disturbance in thought, behavior, and awareness. The treatment is
often done in hospitals and requires medication. Since those who suffer from these disorders
face difficulties in carrying out social and occupational functioning, the burden on the
caregivers is also high. More so if, the mentally ill person is the breadwinner or the
homemaker of the family. In some cases of SMD the treatment may take a very long time
and the expenditure incurred also adds to the burden. We list below some of the commonly
seen Severe Mental Disorders.
Schizophrenia: This illness usually starts at an early age (15-30 years) and the person
loses his/her ability to think, show emotions and process information from the environment
correctly. Behavior and talk becomes strange. The person may also hold some unusual,
false, firm ideas or beliefs (which are not shared by others), neglects taking food and ignores
personal hygiene. Sleep is usually disturbed. He or she is often found walking aimlessly
and may at times become violent towards others or harm herself/himself. At times the
person may appear dull and withdrawn too (not talking or mixing with others, preferring
to be alone). This disorder, unless treated, can carry on for a very long time. Imbalance of
certain chemicals (neuro transmitters) in the brain is seen in this disorder and is thought
to be cause. Treatment is mainly through medication and the medications commonly given
for Schizophrenia are called anti-psychotics (e.g., Chlopromazine, Haloperidol, and
Resperidone). Injections like Fluphenazine, Thepenthixol, and Haloperidol are also given.
24
Identification of Common Mental Disorders and Counseling Skills
Electro Convulsive Therapy (ECT) may be prescribed in certain cases. Since this disorder
causes a high degree of disability, psychosocial methods of treatment, such as supportive
counseling, cognitive behavioral counseling, social skills training and vocational
rehabilitation have been found to be very effective, especially in the rehabilitation of these
patients.
Bipolar Affective Disorder (BPAD): This disorder is called Bipolar, because it alternates
between two extremes of mood states - Mania (excitement) and Depression (sadness).
Those affected seem unusually and excessively happy without any reason or for a very
small reason. They may talk too much, believe that they are very big and important people,
have special powers and special talents. They may become irritable and pick up arguments
with Other people and at times also become aggressive and violent. They neglect basic
needs (like food, hygiene and sleep) and social norms (may take off their clothes, or behave
in a sexually inappropriate manner). The cycle of excitement usually lasts for about two
weeks and reoccurrence is common. Excessive secretion of certain chemicals in the brain
is usually seen in this disorder. A manic episode is sometimes followed by a depressive
episode. In this episode symptoms are very much like the ones seen in a Mild/Moderate/
Severe Depressive Episode (see Depression under CMD). The medications commonly
prescribed for BPAD are anti-psychotics and mood stabilizers (e.g.. Lithium,
Carbamazapine and Sodium Valproate). The treatment of this illness may be long term.
Acute and Transient Psychotic Disorder: Also known as Brief Psychotic Disorder, this
disorder can last from 1 day to 1 month and the symptoms resemble those for Schizophrenia
(e.g., abnormalities in behavior, thought and perception). It usually arises as a response to
a stressor or a group of stressors. The treatment for this disorder is very much like the one
used for Schizophrenia, but the duration is shorter, and long term disability is usually not
seen.
Common Mental Disorders (CMD):
These disorders are most commonly found in the community. They often go unreported
as the symptoms are difficult to recognize. The level of social and occupational functioning
of the client might drop but not significantly, i.e., the person will continue to carry out
his/her daily routine but the efficiency will come down. The symptoms are not visible
physically, hence the person does not go to a doctor, until such time that the disorder
starts affecting the daily functioning routine (e.g., not able to carry on his/her work or
re
identification of Mental Disorders
25
unable to sleep at all or not able to attend office). Some adult CMDs are discussed in the
following paragraphs.
Depression: In this disorder the individual suffers from sadness of mood, loss of interest
or enjoyment, and drop in energy level leading to feeling tired after doing even little work.
Other common symptoms include reduced attention and concentration, ideas of guilt and
shame, and thoughts or acts of suicide and harming oneself deliberately. Sleep and appetite
are also disturbed. For this illness to be diagnosed as clinically significant the symptoms
should be present for at least 2 weeks continuously. Depression can be caused by biological
factors and psychosocial stressors (e.g., loss of a family member, failure, divorce, financial
losses, etc.). It is found more commonly among women than among men. The
recommended treatment for depression is a combination of anti-depressant medicines
(e.g.. Fluoxetine, Sertaline and Amitryptiline) and cognitive behavioral counseling. An
episode of Mild or Moderate Depression may at times remit on its own with counseling.
Medication is however necessary in the case of a severe episode. The categories of
Depression as per the ICD-10 are described in Appendix B, Tables 1,2 & 3.
Mild Depression: In the case of Mild Depression the symptoms of Depression are the
same as those described in the preceding paragraph. Individuals might have difficulty in
carrying on with day-to-day functioning
but they nevertheless carry on and
usually do not cease to function
completely (Appendix B, Table 1). A
group of physical complaints associated
with it at times is given in Appendix B,
Table 2.
Moderate Depression: In case of
Moderate Depression the symptoms are
the same as those described for a
____
Depressive Episode but they are present
I
to a higher degree. The person
experiences considerable difficulty in
carrying out day-to-day functioning both at work or household (Appendix B, Table 1).
Moderate Depression may include a group of physical and bodily symptoms in addition
to the symptoms of Depression (Appendix B, Table 2).
26
Identification of Common Mental Disorders and Counseling Skills
Severe Depression: In Severe Depression, the client usually shows distress and at times
agitation. Loss of self-esteem and feelings of worthlessness and guilt are prominent. I he
probability of suicide is also high. The group of physical complaints is almost always
present in this disorder. During an episode of Severe Depression a person may not be able
to carry on with social/work/domestic activities, except to a very limited extent (Appendix
B, Table 1 and 2). Sometimes in an episode of Severe Depression certain psychotic symptoms
may also be present (like those seen in Schizophrenia - delusions, hallucinations, etc.).
Dysthymia: The word Dysthymia means "ill-humored", implying a person who is irritable,
angry and complains all the time. This disorder is characterized by a continuous sadness
of mood (or low mood) for a period of at least 2 years. Unlike Mild, Moderate or Severe
Episodes of Depression the sadness of mood here is continuous. The individuals might
worry and complain of symptoms like lack
of sleep and how everything is an effort.
They are able to carry on with their dayto-day activities though efficiency drops.
The other typical symptoms include
feelings of znot being good enough', shame
and guilt, irritability and anger, loss of
interest in activities that the person used
to enjoy, poor concentration, and sleep
disturbance. (Appendix B, Table 3).
Identification of Mental Disorders
27
Women's Mental Health: Certain types of depressive disorders are found only in women.
Women usually experience some physical, emotional and behavioral changes associated
with phases of their menstrual cycle. These changes include depression, irritability, and
other physical and emotional changes. Since a lot of these changes cause sadness of mood
we will discuss these changes under Depression.
Premenstrual Dysphoric Disorder: Premenstrual Dysphoric Disorder refers to the physical
and mental symptoms associated with the changing hormone levels that accompany the
menstrual cycle. It occurs about one week before the beginning of menses and the following
symptoms are commonly seen:
□ depressed mood.
□ feelings of inadequacy ("people are better than me/there is something lacking in me
as compared to others").
□ feeling of hopelessness ("nothing good is going to happen to me in the future").
□ worthlessness ("I am no good").
□ anxiety.
□ tension.
□ having difficulty in concentration.
□ mood swings (sometimes happy, sometimes sad on the same day and crying spells).
□ prone to tears very easily.
□ extra sensitivity to angry or rude statements by others (to which they may not have
reacted to at all on any other day).
□ anger.
□ irritability.
□ increased personal conflicts (getting into arguments and fights with close people very
quickly on any small reason).
□ lack of energy and exhaustion.
□ headache.
□ sleep disturbance.
The physical symptoms include edema (body retains a lot of water and therefore feet or
hands swell up), weight gain (due to body retaining water), breast pain, headache, and
vague/non-specific body pains. The symptoms start receding at the beginning of the
28
Identification of Common Mental Disorders and Counseling Skills
menses in some cases and definitely finish before the end of menses in other cases. Women
who experience Premenstrual Dysphoric Disorder are more likely to suffer from depressive
disorders and Postpartum Depression (discussed next).
The treatment for Premenstrual Dysphoric Disorder include well balanced diets, calcium
and vitamin B6 supplements, exercise, relaxation techniques, yoga, anti-depressant
medication and cognitive behavior counseling to handle the negative thoughts that are
predominant during this phase.
Postpartum Depression: About 50% of women report feeling moody, sad and tearful in
the period immediately after childbirth / delivery. This phenomenon is called "Postpartum
Blues" and usually goes away by itself within a period of 1-12 weeks. About 10% women
develop Postpartum Depression. This is characterized by:
□ sadness of mood.
□ excessive anxiety.
□ sleeplessness.
□ occasional thoughts of death or suicide.
□ easy tearfulness.
□ excessive dependency (on people close to them).
□ clinging behavior.
□ feelings of guilt or inadequacy.
□ no interest in child care and in some cases thoughts of harming the baby.
Postpartum Depression is attributed to rapid changes in women's hormonal levels, stress
of childbirth and the increased responsibility that motherhood brings. It has been discussed
here because it is commonly found after childbirth. If the symptoms of this disorder do
not go away in 12 weeks, it is advisable to consult a psychiatrist for medication and
counseling. Women who experience Postpartum Depression are at a higher risk for an
episode of Depression later in their lives. Postpartum Depression following the next
delivery is also likely.
Depression in Menopause: Menopause is a period of time when women stop having
their monthly periods and experience symptoms related to a lack of the hormone estrogen.
This usually occurs in the late 40s and 50s and is a normal process of aging. Menopause
.....
Identification of Mental Disorders
29
marks the end of the reproductive age. The lack of hormone produces certain physical
and emotional changes.
The physical changes include:
□ sleep difficulties.
□ urinary problems (burning sensation during passing urine).
□ hair thinning or loss.
□ weight gain.'
□ flashes of heat spreading through the body associated with sweating and a sense of
unease (hot-flushes).
•
The emotional problems include:
□ irritability.
□ mood swings.
□ nervousness.
□ stress.
□ depression.
Women who have had a previous depressive episode are more likely to experience a
recurrence during menopause. To reduce the severity of the symptoms certain medicines
can be taken to bring back the balance of the hormones. Medication will also help reduce
the feeling of sadness. Anti depressants are also prescribed for women who are moderately
to severely depressed. Cognitive behavior counseling has been found to be very useful for
handling negative thoughts and behaviors that worsen the sadness of mood.
We will now move on to a symptom commonly present in mood disorders.
Suicide: Suicide is not a disorder but a symptom of mood disorders and other mental
illnesses. The majority of people who attempt suicide have an associated mental disorder
like Depression. Suicide is an attempt by the person to end his/her own life. Psychologically
it is seen as a "cry for help" from the person who is feeling unbearably sad, and is stuck in
a situation from which she/he sees no escape. It can also be a consequence of stressful life
events like unexpected failure, financial loss, chronic poverty, or divorce. It is essential to
talk about the factors leading to suicide, since the early signs are often ignored. If they are
30
Identification of Common Mental Disorders and Counseling Skills
recognized in time help can be sought. To clarify suicidal attempts one should assess
these factors: were there any previous attempts of suicide? If yes, then how serious was
the previous attempt? How determined was the person to end his/her life? How much
time and effort had gone into the planning of the suicide? If the individual has made a
previous attempt to commit suicide the chances are that the person will make another
attempt. Therefore these factors should be carefully assessed and if the risk of suicide is
high, steps should be immediately taken to make sure that the person does not make
another attempt. Counseling with the family members and the client are helpful in these
cases.
Let us turn to a category of disorders related to anxiety and tension.
Anxiety: Anxiety is a non-specific, unpleasant, vague sense of apprehension or nervousness
often accompanied by the following physical symptoms:
□ headache.
□ sweating.
□ palpitation (increased heart rate which seems loud).
□ tightness in the chest (as if there is a band around the chest).
□ mild stomach discomfort and restlessness which is seen in an inability to sit or stand
still (without fidgeting) for long.
□ muscle tension (stiffness of body).
The other symptoms include:
□ getting tired easily.
□ difficulty in concentrating or mind going blank.
□ irritability.
□ sleep disturbance (insufficient amount of sleep, difficulty in falling asleep, restless
unsatisfied sleep).
Anxiety can be distinguished from Fear, which is a response to a real, known, external,
definite threat. Anxiety is a response to a threat that is unknown (or unacknowledged),
internal and causing some unease in the mind of the person. It is also an alerting signal to
warn of impending danger, which may or may not be present. Thus to some extent all of
us feel anxious at times but when this anxiety occurs without any reason, is much more
Identification of Mental Disorders
than what is expected as a reaction to a situation and interferes
with the day-to-day functioning (social, occupational and
domestic) of an individual, it is seen as a mental disorder.
Symptoms of Anxiety may at times be mixed with symptoms
of Depression and vice versa. In such cases the category of the
disorder that has a higher number of symptoms should be
accepted. In case symptoms from both categories are equally
present, then a diagnosis of Mixed Depression with Anxiety
can be given. The treatment for Anxiety Disorder includes anti
anxiety (anxiolytics) medicines, counseling and relaxation
exercises.
Generalized Anxiety Disorder (GAD): This disorder is characterized by symptoms of
anxiety, which are not specific and not related to any situation, person or circumstance.
The person complains of continuous feelings of nervousness, trembling, bodily stiffness,
tension; sweating, palpitations and stomach discomfort. These complaints have no specified
pattern. This disorder tends to occur more in women. The complaints must be present for
at least 6 months before this disorder can be diagnosed. Care should be taken to rule out
any physical cause of anxiety like drug withdrawal, side effects of medicines or
hyperthyroidism before a diagnosis of GAD is made (Appendix B, Table 4). Relaxation
and cognitive behavioral counseling in addition to anti-anxiety medicines have been found
to be effective in this disorder.
Panic Disorder: Panic Disorder is characterized by sudden frequent attacks of severe
anxiety. These attacks are not related to any particular situation or circumstance, and
therefore are unpredictable. In Panic Disorder the person experiences sudden attacks of
palpitations, chest pain, choking sensation, dizziness and breathlessness. The person feels
that she/he is going to die, is going mad and has no control over himself/herself and the
situation. These attacks usually last for a few minutes. The number of times they might
occur changes from person to person. A person with panic attacks often fears having the
attack. This affects the day-to-day functioning. The person may stop going out of the house
or to public places fearing such an attack. The symptoms in a panic attack are very similar
to a heart attack and thus very scary for the family and observers. It is advisable to rule
J
Identification of Common Mental Disorders and Counseling Skills
out any medical reason for the symptoms before diagnosing Panic
Disorder. The following four points should be kept in mind before
making a diagnosis of Panic Disorder:
recurrent, unexpected panic attacks.
persistent concern about having additional attacks.
‘
worry about the implications of the attacks and its consequences.
significant change in behavior following the attacks.
Both medication (anti-anxiety) and cognitive behavioral
counseling are useful in these disorders (Appendix B, Table 5).
Phobia: In this disorder, the anxiety arises as a response to certain well-defined situations
or objects. These situations and objects are themselves not dangerous (e.g., fear of darkness,
red objects, black cats, blood, heights, open spaces, etc.). The person tries to avoid these
situations or objects as far as possible. If the person faces these situations she/he experiences
reactions ranging from uneasiness to terror and fear. Often even thinking about these
situations and objects causes similar reactions. Explaining or providing information that
other people do not regard these situations as dangerous or threatening does not in any
way put the anxiety to rest. People who have this disorder often recognize that this fear is
excessive (more than normal or more than what other people experience) and irrational
(has no logical or reality basis). Phobic anxiety often coexists with Depression. Phobias
except for social phobia are more common in women. Panic attacks can also occur in a
phobic situation. Both medication (anti-anxiety) and cognitive behavioral counseling are
useful in these disorders (Appendix B, Table 6). The two most common types of phobias
seen in the community are Agoraphobia and Social Phobia.
Agoraphobia: In this disorder there is a fear and avoidance of crowds, public places,
traveling alone or traveling away from home. Essentially, these are considered as places
from which escape to a safe place (usually home) might not be possible. The person fears
that she/he will collapse and be left helpless in a crowd. This is one of the most unbearable
phobias and some people become totally home bound in order to avoid such a situation.
It usually starts in early adulthood (18-24 years) and is more common among women
(Appendix B, Table 6). Cognitive behavioral counseling has been found to be useful in the
treatment of Agoraphobia.
Identification of Mental Disorders
33
Social Phobia: This is a disorder characterized by fear and avoidance of social situations.
The individual fears that others might pass judgment, comment or look too closely at
him/her in small group situations such as eating out, attending marriages and parties,
waiting at bus stop, etc. It is a fear of behaving in a way that will be embarrassing or
socially inappropriate (like spilling food items, vomiting, appearing ill dressed) in front
of others. Such unsuitable behavior,the individual feels, will surely cause others to pass
remarks that will be humiliating, shameful and embarrassing. So the individual tries
his/her best to avoid such situations. In case that is not possible the person will show
symptoms like blushing, trembling, not maintaining eye-to-eye contact, feeling the need
to urinate urgently. Other symptoms of Anxiety will also be seen. This disorder is equally
common among men and women and usually starts in adolescence (Appendix B, Table
6.1). The treatment of this disorder is done through cognitive behavioral counseling.
1
'_____
e
34
Identification of Common Mental Disorders and Counseling Skills
Stress related disorders are as follows:
Somatoform Disorders: This disorder is characterized by two years or more continuous
complaints of multiple and different types of physical symptoms (pain, weakness, tiredness,
vomiting, diarrhea, constipation, inability to carry out normal sexual activity, blindness,
deafness, irregular menstrual periods, unusual/excessive vaginal discharge, sleep
disturbance, etc.). There is no physical cause for this disorder. The people who suffer from
this disorder keep talking, thinking or worrying about the symptoms. They go to several
doctors (at least three consultations)
including faith healers and multiple
investigations are usually done. They
refuse to accept that there is no physical
explanation for their symptoms in spite
of the negative test results and constant
reassurances from the doctor. They may
take medicines on their own, without the
advice of the doctor to get relief from the
multiple aches and pains. The symptoms
do not allow them to carry out their social
or familial responsibilities.
This disorder is an indication that the person has some psychological stress, problem or
conflict in his/her mind. The inability of the person to express and handle the problem
causes stress, which gets converted and expressed through a physical symptom. In a sense
Somatoform Disorders can be seen as a "cry for help" and attention from a person who
may feel unloved, neglected, unwanted or marginalized. This disorder can be very
frustrating for both the doctor and the client and the family. Symptoms for Anxiety and
Depression must be checked since they might also be present along with the symptoms of
Somatoform Disorders. Counseling through the process of teaching coping skills is seen
as an effective way of dealing with stress (Appendix B, Table 7).
Obsessive Compulsive Disorder (OCD): OCD is ci disorder characterized by an idea or
impulse, which interferes all the time with the person's thinking process or awareness.
There is a feeling of anxiety and fear and this leads the person to take some action against
the idea or impulse. The person usually recognizes that this idea or impulse is irrational
and unwanted (by the person). Obsessions are repeated and continuous thoughts, impulses
Identification of Mental Disorders
35
or images in the mind. They are interfering, not under the person's control and cause the
person a lot of anxiety and distress. These thoughts and worries are not simply about reallife problems. The person tries to ignore them, or suppress them but without much success.
The person also recognizes that these thoughts or images are his own and have not been
put into his mind by another person.
Compulsions are repeated actions or acts (behaviors) - hand-washing, touching, checking,
counting, praying, repeating words or numbers silently, etc. The person feels compelled
to do these in response to a repeated thought (obsession). These actions are carried out to
reduce or prevent the distress/anxiety the person experiences due to the repeated thoughts.
These actions are sometimes done because the person fears that if he/she does not do
these acts repeatedly, then something terrible will happen, either to him/her or to the
family/loved ones. The anxiety may or may not reduce following the compulsion, but
resisting the compulsion creates further anxiety in the client. These obsessions and
compulsions are time consuming, cause a high level of distress and interfere with the
person's day-to-day functioning (at work, home, social relations, etc). Both medication
and cognitive behavioral counseling are effective for OCD, especially when used together
(Appendix B, Table 8).
<
/ , 2. , i
.
36
Identification of Common Mental Disorders and Counseling Skills
We will now discuss a disorder, which usually occurs after a traumatic event has taken
place. The disorder presents itself in the form of physical problems, which arise out of
severe psychological distress.
Dissociative Disorders: Dissociative Disorders arise as a consequence of severe, excessive
stress. The onset and ending of the disorders is often sudden. This stress can be sudden or
a continuous or ongoing one. Dissociative Disorders can produce complete or partial loss
of memories of the past, complete or partial loss of awareness of identity and unusual
sensations. Lastly it can also produce complete and partial loss of control over those bodily
movements, which are usually under a person's control (e.g., walking, turning of head,
speech).
Dissociative Disorders are usually associated with traumatic events (e.g., accidents, sudden
financial loss, rape, etc.), intolerable and continuing problems, or relationship problems
and difficulties. The stress of these events and the situation is seen as unbearable by the
person and is "converted" (without the person being aware of it) into a bodily symptom.
Another reason for conversion could be that the person does not have effective ways of
coping with the severity or suddenness of the problem. The disorder is an outlet to the
anxiety and pain and at times also gets the person attention and help, which she/he might
otherwise not get.
These disorders stop once the stress goes down but might come back in times of acute
stress again. The person suffering from Dissociative Disorder often shows a complete
denial of the problem, even though at times the stressor might be obvious to others. Women
suffer more from this disorder than men. A reason for this could be attributed to the
marginalized status of women in our society. Women do not have the "voice" or means to
express their pain and demands. Also there is often no one to listen to their problems.
That is why there is a tendency to convert their psychological distress into a more obvious
' physical symptom. In that sense this disorder is a cry for help.. Counseling of a supportive
nature, with emphasis on problem solving and assertiveness, is seen as an effective form
of intervention with these clients.
I
Identification of Mental Disorders
37
A few types of Dissociative Disorders are as follows:
Dissociative Motor Disorder: A diagnosis of Dissociative Motor Disorder should only be
made when one has carefully ruled out the presence of any physical reason that may be
causing the symptoms. The most common symptom of Dissociative Motor Disorder is a
complete or partial loss of ability to move the limbs. Complete or partial paralysis, weakness
or lack of coordination of the limbs, which results in clumsiness and problems in walking,
may be seen. There might also be severe trembling or shaking of the hands, legs or the
whole body. Look closely for stressors in the person's life, especially close to the onset of
the illness (Appendix B, Table 9)
Trance and Possession Disorder: In these disorders there is a temporary loss of both the
personal identity of the person and an awareness of the surroundings. The person talks
and behaves like a different person - like god, goddess, holy person, spirit of dead person,
etc. This gives the person a convenient way to express conflicts, demands and problems
and also gets him/her attention from others who are concerned.
There may be short episodes of
abnormal behavior during which
time it might look as if the person has
gone mad. She/he might talk
nonsense, abuse or assault others,
walk naked or half naked, fail to
recognize the place, people or time
and
remain
confused.
After
recovering from the episode the
person will claim to have no memory
of that specific period. In certain
societies they might attribute such
behavior to evil spirits, ghosts and
witches (Appendix B, Table 9.1).
38
Identification of Common Mental Disorders and Counseling Skills
Dissociative Convulsions: Tn this
disorder the symptoms resemble those
for an Epileptic Fit. Jerky movements,
tongue biting, falling down, rolling
up of the eyeballs, etc., are usually
seen. The difference between an
Epileptic
Fit
and
Dissociative
Convulsions is that the person will not
seriously hurt himself/herself in a
\ Dissociative Convulsion. There is no
passing of urine or stools while having
a dissociative convulsion, and the person does not become unconscious. It usually occurs
i
when there are people or help nearby (Appendix A, Table 9.2).
At the end of this chapter yon should have learnt:
1. Some of the Severe Mental Disorders.
2. The different types of Common Mental Disorders
3. To identify the signs and symptoms of CMDs with the
help of Appendix B
4. To identify when a disorder is at the clinical or sub-clinical
level.
CHAPTER 4
Overview of Counseling
What is Counseling?
Counseling is a process in which one person (counselor) helps another person (client) to
better understand and solve some problems he/she may be facing. Help is defined as
providing resources and skills that enable people to help themselves. In counseling,
conditions are created in such a manner that clients get an opportunity to fulfill their
needs for security, love, respect and self-esteem. Clients are encouraged to think and plan
rationally, do problem solving, look for alternative solutions and make decisions. The
counselor provides-the support to clients to handle the pressures arising from their
problematic situations.
Counseling is a change
process ' (growth
and
healing). One looks for the
strengths within the client.
Clients learn new ways of
thinking, behaving and
feeling (growth). It is also a
process where clients who
have experienced traumatic
or painful events are better
able come to terms with them. The counseling process is a partnership between the client
and the counselor, where the counselor brings his/her skills to help the client in solving
the problems, but does not take an authoritarian position (one-up position). Counseling is
a relationship in which both partners are equal.
The counselor can learn and benefit as much from the experiences of clients, as can clients
from the counselor's skills. In the counseling process, the counselor helps clients to
express their feelings in a safe, supportive, collaborative and non-judgmental environment
Identification of Common Mental Disorders and Counseling Skills
42
and to identify and clarify their problems. Clients are also encouraged to talk about how
they have dealt with the difficulties on their own and identify coping methods that have
been both helpful and not helpful. In the counseling process, the counselor enables clients
to learn effective and appropriate coping skills and achieve goals that are important to
them.
Aim of Counseling
The aim of counseling is to help individuals empower themselves in such a manner that
they are-able to recognize and strengthen their inner resources as well as adapt and cope
with stressful life situations. Counseling is an empowering experience because the
counselor helps clients to become self-reliant and find solutions, which they would be
most comfortable with. Counseling is time limited to a specific problematic situation or
problem. There is no guarantee, however, that clients will never face problems in the
future after having gone through counseling once. But, clients can always come back to
counseling whenever there is a crisis, stress or problem in the future.
Skills and Qualities of an Effective Counselor
Counseling to a large extent is influenced by who the counselor is and what skills he or
she has. For counseling to be beneficial, a counselor must possess the following qualities:
1. Good listening skills - An effective counselor is someone who is interested in listening
to the concerns of the clients. Listening is different from hearing. A counselor not only
listens to what clients are saying but also listens to how they are saying it. Listening is
an active attending process with little or no verbalization. Good listening skill is a
technique that must be learned. Listening also means being able to tolerate silence.
Listening without criticizing, passing judgment, interrupting or getting impatient is
an important quality of an effective counselor. A counselor must take the problems of
clients seriously and should be willing to openly discuss anything the clients wish to.
2. Knowledge base and skills - A counselor must have a knowledge base of the types of
emotional and behavioral problems that are likely to occur. A competent counselor
should have the necessary skills (practical knowledge) and the ability to help clients
with their problems. A counselor should be trained adequately in all aspects of
counseling techniques and in the process of counseling. A counselor, lhei clot e, should
be trained in understanding various types of emotional and behavioral problems and
Overview of Counseling
43
the factors that influence mental health. A counselor should be willing to work with
clients, but not make decisions for them or tell them what to do. Remember, counselors
have no magical poiuers, skills or knowledge to solve the problems of the clients. As
9
counselor, you help clients to solve their problems, not solve the problems for them.
3. Empathy - This is a very important quality in a counselor. The counselor tries to put
himself/herself in the client's place and understand the problem. If the counselor has
the capacity to feel yet not get emotionally involved in the experiences of clients, and
communicates it sensitively, then clients are more likely to feel relaxed and accepted
by the counselor. Being empathic means that the counselor is able to understand what
the client is feeling and going through and is able to relate to the client's problems and
circumstances. IHs important to understand the difference between sympathy and
empathy. Sympathy is when a person is able to understand the other person's problems
but pities him/her, whereas empathy is when one is able to put oneself in another
person's place and understand and relate to the other person's distress and problems.
4. Unconditional positive regard - A counselor should be able to accept clients as they
are and not show bias, disregard or disrespect because of the problem or the nature of
the client. For example, a victim of domestic violence may seek the help of a counselor,
but if the counselor believes that she is a weak woman because she is being beaten up
by her husband, then the counselor shows disregard and disrespect for her problem.
5. Objectivity - A counselor, on the one hand, should be empathic and be able to
understand the problems and feelings of clients from their perspective. On the other
hand, it is equally important to be objective. Being objective means that the counselor
should not get emotionally involved with the problems of clients and should be able to
view them as a third party. Objectivity is essential in a counselor, because it helps
him/her to be able to help clients explore alternative solutions to their problems. If a
counselor loses objectivity and becomes emotionally involved in the problems of clients
then he/she starts experiencing the same reactions of the clients and will be unable to
show clients a way out of the problem.
6. Encouragement - A counselor should always encourage clients by stressing on their
strengths and capabilities to boost their self-esteem and prevent demoralization. Often
clients come to a counselor because they have lost confidence in their ability to think
for themselves, or recognize their strengths. They feel helpless, as if they have no control
over what is happening to them or their situation. At such times, a counselor should
encourage clients to believe in themselves and make the effort to find solutions to their
problems.
44
Identification of Common Mental Disorders and Counseling Skills
7. Effective communication - A counselor should be able to effectively communicate
his/her thoughts, feelings and understanding of the problem to the clients. A counselor
should use common words from everyday language. Sometimes a counselor might
have to point out a maladaptive pattern of behavior, thinking or feeling. Care should
be taken to put the message across in such a manner that clients do not feel as if they
are being ridiculed, scolded or blamed for the problem.
8. Trust - An effective counselor inspires trust and gives confidence to clients to discuss
their innermost problems without fear, shame or guilt. Trust and confidence is a function
of confidentiality - a reassurance that the information that clients share with the
counselor will be kept in confidence, will not be misused or revealed without their
consent. A counselor's ability to communicate honestly and truthfully forms the basis
of trust on which the client-counselor relationship rests.
9.
Courage - Being a counselor demands a special kind of courage - courage to put
one's personal needs in the background and let clients become self-reliant and
ultimately empowered. A counselor should keep the information confidential and
build the confidence of clients. A counselor should have the courage to objectively
view the problems of clients without letting it affect himself/herself.
10. Socio-culturally sensitive solutions - A counselor's understanding of the problem,
advice, suggestions and problem solving should be based in reality. The counselor
should keep the socio-cultural backgrounds of clients in mind while doing counseling.
Solutions should be based on the familial and social context of the clients. If a counselor
gives solutions, which are not practical, reasonable or applicable, clients will never be
able to put them to use in their real-life situations.
11. Supportive - A supportive counselor inspires trust in clients. A counselor is supportive
if he/she accepts clients, is warm towards them and gives them a secure and supportive
environment in counseling. A supportive counselor will gradually make clients believe
that she/he is making maximum effort to understand and solve their problems.
12. Non-judgmental Attitude - An effective counselor is free from bias and expectations.
For instance, bias can be seen in issues of morality - wrong or right judgments. A
counselor should not make judgments on the behavior of the clients, whether wrong
or right, good or bad. Being non-judgmental also means that the counselor should not
force his or her ideas on clients. For example, if the counselor tells the client that she
or he is in a bad marriage, then the counselor may implicitly convey to the client not
to stay in the marriage or postpone having children. A counselor should not have any
€
Overview of Counseling
45
expectations concerning the outcome of the sessions or how clients should respond to
what he/she says or does. Often expectations arise when a counselor has been working
with a client over a period of time. The counselor may think that he/she has put in a
lot of effort, hard work and time and therefore feels that some positive results must
be seen. If clients are unable to show positive results, sometimes the counselor may
become unhappy or angry with them.
13. Strength to withstand pressure - An effective counselor should have the strength to
withstand pressure from clients to solve the problems in a quick and painless manner.
The counselor should also be able to withstand pressure from within himself/herself
to solve the problems for clients and to give answers and solutions. It is often tough to
hold oneself back from setting the pace to solve the problem and follow it through.
This pressure puts the frustration tolerance (ability to withstand pressure) of the
counselor to test^which has to be sufficiently strong, as often clients and their concerned
families will really put it to test.
14. _ Qeal with Failure - All counselors have to deal with failure at some point. An effective
counselor is one who is aware that he/she is not omnipotent, does not have all the
answers all the time, and is likely to get stuck now and then in the problem of the
clients. When such situations arise, it is best that the counselor talks with his/her
peers and discusses the problems in counseling a particular client. At times, despite
the counselor's best efforts clients may not improve at all, or may not improve to the
expected level. Failure may be seen in the form of clients dropping out - clients may
not perceive counseling as an option.
15. Know your Limitations - An effective counselor is one who knows his/her limitations
and realizes when he/she is getting stuck in the sessions. Sometimes, a counselor
may find that she or he is not able to help clients anymore, or feel that clients need to
go to an expert for further counseling. In such situations, it is important for the
counselor to realize his/her limitations.
16. Emotionally stable - An effective counselor should be comfortable with himself/
herself and the interpersonal relationships with family, friends and colleagues. He/
she should enjoy a wide social support network and seek help whenever necessary. If
a counselor has personal difficulties he/she must attend to them before helping clients.
Personal difficulties can cause bias or interfere with the counseling process. Effective
counselors usually have a variety of interests and hobbies. They find ways of relaxing ’
or relieving their own stress through relaxation methods.
46
□
□
□
□
□
□
□
□
Identification of Common Mental Disorders and Counseling Skills
Good listening skills
Knowledge base and skills
Empathy
Unconditional positive regard
Objectivity
Encouragement
Effective communication
Trust
I
□ Courage
□ Socio-culturally sensitive
solutions
□ Supportive
□ NIon-judgmental Attitude
□ Strength to withstand pressure
□ Deal with Failure
□ Know your Limitations
□ Emotionally stable
The Counselor - Client Relationship
The relationship between the counselor and the client is of utmost importance in the
counseling process. A strong bond between the two determines how successful the
counseling process will be and how much change the client will bring to himself/herself.
In order to be a good counselor, a person must have certain qualities (described in the
previous section), which will help him/her to develop a strong bond with the client.
Each client-counselor relationship is a unique
and fresh challenge to the counselor. This
relationship is unlike the ones the client has
with friends, family members, spouses. The
relationship between the counselor and the
client is structured and carefully planned.
The counselor is both objective and
emotionally involved with the client. Even/
counselor should maintain a balance between
objectivity and emotional involvement. Being
objective means that the counselor respects
the views of clients, does not force his or her
ideas on them, and looks at their problems
rationally and analytically.
Overview of Counseling
47
Emotional involvement indicates that the counselor is warm and caring towards clients,
is interested in their problems and gives the clients a feeling of being understood. If the
counselor gets too emotionally involved with clients it will be difficult to be objective.
Objectivity is necessary to understand the nature of the problems of clients and emotional
involvement is necessary to build a safe and secure environment in which clients can
express their feelings without hesitation, shame or fear. An effective counselor needs to
maintain this balance well.
When clients come for counseling, they will not be able to clearly understand the
relationship between the counselor and them. Sometimes this relationship appears to be
vague to clients. It is the counselor's responsibility to define and structure their roles in
the beginning of the counseling process. Clients must be given a clear idea of the
relationship, the kind of work that will be done by the counselor, and the counseling
process. Clients should also be told that the relationship is an equal partnership between
the two. In this equal partnership, the responsibility of the counseling being a successful
process lies with both the client and the counselor. This process of defining the relationship
in clear terms is called structuring.
Accepting clients as they are is an important aspect of the client-counselor relationship.
Acceptance is a positive, active attitude. It means, "I accept you, even if I may not necessarily
agree personally with what you think or feel". For clients, being accepted means that the
counselor understands them, is concerned and cares for them and respects them for what
they are. Acceptance by the counselor indicates that clients are worthy, have the right to
make their own decisions, have the capacity to choose wisely and are responsible for their
own life. Clients should feel that the counselor really cares about what they think, wants
to help them and will not judge them. Acceptance does not mean approval. Accepting
means, neither approving nor disapproving what clients say or feel. It simply means, that
clients as people have the right to feel and think differently from the way the counselor
thinks and feels. If clients feel accepted by the counselor, they will become more involved
and the counseling process will become more meaningful.
Besides being understanding, accepting, caring and being concerned, the warmth that the
counselor shows towards clients is yet another important aspect of this relationship. Being
warm to clients means showing consideration. Consideration is shown through a keen
interest in the problems and difficulties of clients. Warmth is also expressed through small
gestures like smiling at clients when they come into the room, offering a seat, etc.
48
Identification ofCormron Mental Disorders and Counseling Skills
The counselor must come across to clients as a genuine, honest person with a sincere
attitude. Being honest in this relationship means being straightforward. If the counselor
tries to put up a "front" or pretends to be interested in clients when not really feeling so,
clients will immediately make out that the counselor is not being genuine.
The views of clients regarding their problem are more important than the counselor's
opinions. When clients come for counseling, the counselor must help them to set the goal
of counseling - what is it that they want to do, what behavior do they want to change, etc.
The counselor must communicate to the client "I am here to help you" and not "I will
solve your problems for you". The counselor must always remember that solving the
problems for clients will harm them more, as it weakens their internal resources in the
process and makes them more dependent on the counselor for every answer.
The counseling relationship is an equal relationship. Clients must solve their own problems
and becomes empowered through the process. This process is facilitated by the skills and
the personality of the counselor, and the environment of the relationship (safe and
confidential client-counselor relationship) provided by the counselor. The counselor often
faces pressure from within to solve the problems of the clients, hasten the pace of counseling
or even tell clients how to lead their lives. It is important to recognize this pressure as the
counselor's need and not the client's expectation. Expression of ideas that would help
clients is important to counseling - these ideas must not be forced on or sold to clients.
One of the principle functions of the client-counselor relationship is to provide support
for clients, especially in a crisis. Acceptance, warmth, understanding and other such
qualities of the counselor help clients to feel secure and supported in the relationship. A
supportive relationship has four important values. One, it helps in reducing anxiety that
clients feel (because of their problems, or difficulties) and thereby develops a sense of
security and comfort in them. Two, it gives assurance to clients that they can be helped, no
matter how difficult the problem is. Three, it makes clients realize that they have the
freedom and the ability to choose and change their behavior and ways of thinking or
feeling. Four, it prevents clients from taking hasty or impulsive decisions that might harm
them in the long run. For example, a suicidal person may think that there is no other
option for him/her than to commit suicide. A supportive relationship with the counselor
will encourage this person to look for alternative solutions to suicide.
Overview of Counseling
49
1 low effective counseling will be depends to a large extent on the quality of the relationship
between the counselor and the client. Therefore the basic qualities expected of a counselor
(described earlier) are very important to this relationship. The attitude of the counselor
has a considerable influence on the counseling environment. Giving support in a safe and
secure environment creates the right kind of atmosphere for counseling. All this will
determine to a large extent whether clients will continue counseling, how useful it will be
to them and how successful the outcome of counseling will be.
Counseling Setting
The setting in which the counseling is done is very important. It determines how
comfortable clients will be with counseling. It is recommended that counseling to be in a
neutral setting, for example, the center of the organization. The room should be well lit
and ventilated, with minimum noise level. The setting should provide privacy to clients
to talk comfortably. While in session, make sure you are not interrupted by other colleagues
working at the center. Make sure no
one comes into the room. Avoid
having a telephone in the room. The
counselor and the client should sit
A 1
face to face either across the table or
on the ground. This facilitates good
eye-to-eye contact. The seating
should be comfortable for the client
(whether on the ground or across the
table). If clients are facing a window,
draw the curtains so that they are not
distracted by what is going on
outside. Besides it is best that outside
people avoid seeing the clients.
If the counselor goes to the homes of the clients for counseling (which may be the case in
NGOs), then he/she has to find a room in the house where the counselor and the client
can talk in privacy without interruptions from other family members or outsiders. After
such initial sessions at home clients may feel comfortable about coming to the center.
50
Identification of Common Mental Disorders and Counseling Skills
At the end of this chapter you should have learnt:
1. What is counseling?
2. The skills a counselor should learn.
3.
The qualities of an effective counselor.
4. The importance of a counselor-client relationship and how
it can be established.
5. The nature and type of setting in which counseling can be
done.
I
J
I
!
I
CHAPTER 5
Techniques of Counseling
There are several types of counseling techniques that are used by counselors. We have
chosen those commonly used techniques, which are easy to understand and practice, and
are relevant for community-based counseling. The descriptions of the techniques are given
for individual sessions; they can, however, be used for group counseling. Although we
have described the techniques separately for ease of understanding, in practice, a counselor
usually uses a combination of techniques.
I. Supportive Counseling
Supportive counseling draws on the supportive aspects of the counselor-client relationship.
It helps clients through a time in their life when they feel stuck, helpless or troubled. The
counselor helps and supports clients to cope with their distress. The counselor attempts to
handle the distress rather than treat the cause of the problems. The counselor also provides
acceptance, security and dependence for the client during a crisis.
In supportive counseling clients are encouraged to talk about their problem situation and
the distress associated with it, e.g., guilt, anger, sadness, frustrations, etc. Being supportive
towards clients is central in this form of counseling. Support given to clients can be viewed
in different ways. A counselor is supportive to clients when he/she:
□ accepts them.
□ is warm.
□ provides a secure and supportive environment
□ is reassuring.
□ encourages clients to explore different feelings.
□ finds alternative ways of solving the problems.
□ respects the thoughts and feelings of clients.
Being supportive towards clients has several benefits. First of all it helps reduce excessive
anxiety and makes clients feel secure and comfortable. When clients believe that the
Tm- ii o
I
,
•,e V-'lawii jiMn.
52
Identification of Common Mental Disorders and Counseling Skills
counselor is emotionally supportive of them, they feel worthy, loved and respected. Second,
it gives assurance to clients that they can be helped. When clients feel hopeless or helpless
about their feelings, the counselor's calm, accepting and reassuring manner is a powerful
support, which helps them feel hopeful and confident about the future. It helps clients
explore options, look at alternatives realistically and not choose self-defeating options.
Active Listening
The actual approach of supportive counseling is one of active listening and helping clients
see alternatives to their situations and problems. Clients are helped to understand the
changes that have occurred in their lives (traumatic events, stressful events), accept the
situation and move on with their lives. However, before this can be accomplished, clients
needs to be given room to express sorrow, anger and hopelessness over the situation, and
give vent to feelings that they may not have had the opportunity to express earlier. Clients
need reassurance that a supportive counselor can handle their distress and hold out hope
for their recovery.
The counselor helps clients understand the difference between recovering and gaining
back what was lost. Sometimes clients come with problems that are caused by very real
situations. For example, a client may have lost his/her family and home in communal
riots. The reassurance that there is no point in crying over what has been lost seems useless
and very frustrating to clients. Instead, the counselor should help the client in
acknowledging that the loss and pain cannot be forgotten or compensated, and at the
■
•-•rr-’ w—'■ -
Techniques of Counseling
53
same time, take care to point out ways in which life can become meaningful once again.
Often, re-establishing old ways of living may not be possible and the client has to come to
terms with the changes that have happened. The supportive counselor introduces these
changes in a gentle, but firm manner.
Ventilation
People often try to suppress their emotions. They might want to forget an individual or a
situation, which may have caused them stress, distress or anxiety. Or perhaps the
environment of the person does not provide an outlet for these issues to be discussed or
shared, e.g., talking about child sexual abuse or sexual feelings is not encouraged in our
society. These problems and the associated emotions get "bottled up" inside the individual.
To explain how it feels people often use terms like 'heavy heart", and "weight on my
chest".
When the counselor encourages clients to focus on their "feelings" and talk about their
reactions to the problems they are facing, it is called ventilation. An individual who is
allowed to talk about these bottled up emotions, situations or people will feel a sense of
relief. The suppressed or bottled up feelings are brought out. After a process of ventilation
clients feels as if a load has been lifted off their chest.
If the counselor is able to
encourage and handle ventilation
w
then clients feel supported and
understood. The counselor's nonjudgmental and supportive
attitude also helps this process.
Being empathic, asking openended questions and active
listening are also important in this
process.
fit
Identification of Common Mental Disorders and Counseling Skills
54
CASE EXAMPLE:
Client: I feel that this is the last time that I am going to listen to all these accusations about my
character from my mother-in-law.
Counselor: How do you feel when she makes all these accusations? (Open-ended question,
facilitating client to talk more)
Client: She just goes on and on. Does not even care if others are listening.
. Counselor: What does she say that upsets you so much?
Client: I really think she does... [Starts crying]
The counselor lets her cry for a while, till her weeping comes down and then offers her a
glass of water. Allowing clients to cry is also a form of ventilation.
Counselor: you were telling me that your mother-in-law's accusations make you upset. Would
you like to tell me more about it?
[Through out the entire session the client talks to the counselor about her problems and
the distress she feels and the counselor listens patiently].
Acceptance
Acceptance is a technique of responding with short phrases such as "hmm-hmm", "Yes,
go on", which imply that the counselor is listening, attending to what the client is saying
and accepting it. It is usually employed in the beginning phase of counseling, when clients
narrate the situation or the problem, which is causing them distress. The counselor tries to
convey to clients that it is safe to talk about anything, and that they need not be ashamed
or scared of expressing how they really feel. There are several ways in which the counselor
conveys his/her acceptance of clients. One is to maintain eye-to-eye contact with clients.
Another is neutral facial expressions or nodding of the head. The counselor conveys genuine
interest through these expressions. Third is the tone of the voice and fourth is the distance
and posture the counselor maintains. If the counselor leans forward and sits comfortably
close to clients, clients will be assured that the counselor has a friendly attitude. This
posture also conveys qualities of openness and sincerity in the counselor. Yawning, crossing
and re-crossing of legs, grasping the arms of the chair tightly, shifting constantly are some
of the negative cues that can make clients feel uncomfortable in the counselor's presence.
Techniques of Counseling
.55
CASE EXAMPLE:
Counselor: You appear to be worried about something. Is there anything that you would like to
talk to me about?
Client: sometimes I really wonder if life is worth living.
Counselor: Would you like to talk to me about it? Talking and sharing a problem is usually
helpful.
Client: I don't feel like waking up in the morning. After all there is nothing to look forward to. I
just lie in bed most of the time, or say that I am ill. This way I don't have to go out and meet
people or work.
Counselor: I can understand what you must be feeling and how every little thing must seem like
an effort.
Client: I feel very bad at times and other may think that 1 am lying but what else do I do?
Counselor: I realize that you must be feeling upset about how others may react to your behavior.
Reassurance
A key technique of supportive counseling is giving reassurance to clients who are in
distress. Reassurance involves focusing on the strengths of clients and helping and
reassuring them on the decisions and steps they have taken in dealing with the problems
in their life. Showing a realistic goal is a crucial part of this process. This involves
encouraging clients to look for alternative ways of solving or handling a problem.
Reassurance by the counselor conveys an optimistic and hopeful feeling to clients.
Reassurance encourages clients to explore new ways of behaving, thinking, feeling, and
trying out different behaviors.
It helps reduce anxiety and
insecurity in clients. It has the
effect of positively encourag
ing new patterns of behavior.
It provides the hope that
change is possible. It shows
the concern and supportive
stance of the counselor.
56
Identification of Common Mental Disorders and Counseling Skills
CASE EXAMPLE:
A woman comes to the counselor at the domestic violence support center.
Client: I really don't know if I have done the right thing in leaving home.
Counselor: You did what you thought was the best option in the given situation.
Client: 1 feel so scared. What is going to happen now?
Counselor: It is all right to feel scared. Leaving home is not at all an easy decision for am/ one.
Client: What will happen now?
Counselor: You have been brave to come here for help. Let us see together what are the options
available and work out the best plan for you.
Guidance
In supportive counseling, giving the client guidance and advice is an essential component.
By guidance we mean that clients are helped to move in the direction of finding solutions
to the problems they face. Guidance involves re-phrasing or re-stating the problem in
different words - this reassures clients that in their situation others also may have reacted
in the same manner. The counselor attempts to build a link between the difficult situation
that clients face and the distress that is being caused by it. This explanation helps clients
understand their problems, feelings and reactions and also brings about a sense of relief
and hope. Understanding the problem is the first step towards finding a solution to the
problem. Explanation helps in giving a direction to clients. When clients are able to
understand the nature of the problem and why it is happening, they will be better prepared
to look for solutions.
The counselor may at times also give advice to clients. Advice is usually given in the form
of a suggestion, where clients are given alternatives to handle the problem. However,
direct advice is avoided, because if, on the one hand, it is important to guide clients in the
right direction, on the other, it is equally important to help clients think for themselves.
Sometimes clients facing a high level of distress feel they have exhausted all methods to
deal with the situation. They may also express helplessness to look or plan for alternatives
to deal with the difficult situation. In such cases the counselor might think it necessary to
give advice and guidance. This helps support clients and restores their faith in the resolution
of the problem.
The counselor, while giving suggestions and advice, should lake care not to force a
particular decision or strategy on clients. The advantages and disadvantages of each
Techniques of Counseling
57
suggestion should be discussed and clients should be allowed to choose the option they
think best. It helps clients gain confidence and a sense of control that they can do something
about their problems. The counselor should make sure that the suggestions are practical,
realistic and acceptable to clients. Secondly, all suggestions should be made keeping the
religious-cultural-social-economic milieu of clients in mind.
CASE EXAMPLE:
A woman talks to the counselor at the health camp that has been organized at her village. The
counselor is told that she is a regular patient at all clinics and health camps. Her complaints are of
physical aches and pains, which have not shown any response to medicines.
Client: This pain is making my life very miserable. 1 am not able to take care of my home and
family.
Counselor: Have you noticed any worsening in the pain when you are feeling miserable and sad?
Client: Yes, the days that the pain is more my mood is also very bad.
Counselor: Sometimes our body reacts to how wefeel. If we are happy our bodyfeels light and free,
if we are tense our body muscles feel stiff and painful, if we are troubled it seems as if there is
no energy in the body, there are headaches and sleep is troubled. Do you think this is also true
in your case?
Client: Could be, why?
Counselor: Because if they are related, then improvement in one can lead to improvement in the
other.
Client: Is that possible?
Counselor: It usually is. Shall we look at ways in which we can improve the sad mood and see if
your pain also improves? Is that ok with you? Can we try?
Client: if you think that will help me then why not.
Reflection
Reflection of feeling is an attempt by the counselor to re-phrase in fresh words the feelings
expressed by clients. The counselor mirrors the feelings of clients for their better
understanding. The counselor also tries to convey to clients that he/she is able to
understand and share their feelings.
Emotional problems often arise when there is either denial or non-acceptance of certain
feelings. It is important to reflect feelings in words different from the ones that clients
58
Identification of Common Mental Disorders and Counseling Skills
have used. All statements made for this purpose are put before the client in the form of a
hypothesis or a tentative suggestion. For example, "It seems to me that you are feeling
angry because you husband is unable to express his affection for you in the manner that
you would like"? Rephrasing validates the experiences of clients and helps them think
about aspects that they had not thought about before. It also leads to ventilation or
expression of feelings.
Strengthening coping skills
Strengthening coping skills is another technique of supportive counseling. Every individual
uses different methods of coping with situations. By coping we mean the ways in which
we handle/manage different types of situations and our feelings for those situations. For
example, an individual going through a financial loss (a stressful situation) turns to drinking
large amounts of alcohol (negative distraction which is a coping method) to deal with the
stress. Alternatively, another person with the same situation may do problem solving and
seek help and support from family or friends. In counseling an attempt is made to help
clients strengthen existing adaptive coping skills and learn alternative coping skills as
well. This leads to clients feeling hopeful and reassured.
An attempt is made to first strengthen the existing coping methods of clients. This gives
encouragement to clients who feel that they have been doing something, which is effective
and has helped them so far. It also gives them hope that since they have been able to
handle the problem in some way then in future too they will be able to deal with their
Techniques of Counseling
59
problems. There are several coping strategies that people adopt: Distraction, praying to
God, acceptance, denial, support seeking, problem solving, etc. are some of the strategies
of coping.
No one coping method is good or bad, ineffective or effective. The method an individual
adopts to handle the problem or distress will depend on the situation and the context.
Moreover, at any given point in time, people may use more than one method of coping
with their distress. For example, if an individual has lost a loved one, in the initial phase
there may be denial that the loved one has not actually died. But as time goes by the
person begins to accept the loss of the loved one. In the process of grieving over the loss
the individual may seek support from family and friends. A point to keep in mind is that
a coping method may be useful in a particular situation but not in another. To take the
preceding example further, if the individual continues to live in denial over a long period
of time, then that method of coping becomes ineffective.
The individual is also encouraged to think and try out new and alternative ways of coping.
In this process some risk taking is also encouraged. Every alternative coping method that
the client thinks of is evaluated in terms of merits and demerits and the possible difficulties
in carrying it out. The counselor then gently and consistently helps the client put into
practice these new coping skills.
II. Cognitive Behavioral Counseling
Cognitive behavioral counseling is a time limited structured approach used to treat a
variety of common mental disorders - Depression, Anxiety, Phobia, etc. The word cognitive
means thoughts or thinking process. The thinking process means how an individual
interprets or assesses situations (whether harmful, threatening, painful, happy or positive).
The way individuals interpret or assess a situation is based on their past experiences and
influences how they think or act subsequently. The word behavior means that which is
observable in a person's actions. Thought, feeling and behavior are linked in a circular
manner. An individual's thoughts influence the way she/he feels, which in turn influences
the way he/she behaves. Therefore, sometimes this becomes a vicious cycle. In cognitive
behavioral counseling an attempt is made to break this vicious cycle by changing behavior
or thought which results in change of mood or feelings.
... _.J
60
Identification of Common Mental Disorders and Counseling Skills
Depressed people mostly have negative thoughts about themselves, their world and their
future. These thoughts may result in feelings of worthlessness, guilt, incompetence, defeat,
loneliness and hopelessness. Clients with Anxiety Disorder often have thoughts about
some danger they believe they are likely to fall into. These types of thoughts (or images)
are called automatic thoughts. These thoughts come to mind automatically, and most of
the time clients do not recognize these thoughts because they are not paying attention to
what they are thinking. These automatic thoughts reflect how clients perceived the situation
rather than the actual situation. In other words, the actual situations maybe quite different
from the way clients perceive them.
For ease of understanding we will first describe some of the common behavioral techniques
and then the cognitive techniques. However, in counseling, the behavioral and cognitive
techniques are used in combination since cognitive behavioral counseling attempts change
in thoughts, behavior and feelings.
Relaxation
One of the common techniques used is relaxation. Everybody faces problems or stress
during their lifetime (physical, social, financial, etc J. The body responds to stress by getting
ready to either fight/face the problem, or escape the situation. In such cases the body is
said to be under "stress". Stress to some extent is healthy as it prepares the individual to
face the problem. Bodily changes like increase in blood pressure, increased heartbeat,
faster breathing and muscles becoming tense are all indicators that the body is under
stress. Once the stress passes or is dealt with, the body comes back to a state of relaxation.
When an individual faces problems day after day or if the stressors have been going on
for too long (e.g., financial difficulties, bad marriage, disability, illness of family member
who needs care giving), the body remains in a state of constant tension/stress. If this
stress carries on over a period of time it causes physical problems like blood pressure,
heart disease, stroke, migraine, lowered ability to fight diseases and chronic aches and
pains. Psychologically, the individual becomes irritable, short-tempered, depressed and
anxious. The coping and problem solving abilities of such an individual also become limited
and stereotyped (repetitive). Often people do not realize that they are tense till their body
breaks down (collapses) under constant stress by developing the previously mentioned
physical disorders.
Techniques of Counseling
61
The physiological (bodily) changes that take place during relaxation are the opposite of
those that occur when an individual is under stress. A disturbed mind cannot exist in a
calm body and neither can the body be stressed when the mind is calm. Based on this
principle certain relaxation exercises can be taught and practiced by individuals who show
symptoms of stress like irritability, anger, depression and physical symptoms.
The first step in teaching relaxation strategies is to recognize when the body is under
stress. Relaxation exercise also has a preventive function. Relaxation exercises are very
simple, like taking deep long breaths originating from the stomach (not the chest). Often
visualizing alongside that the breath coming from the stomach is useful. Or imagine that
the breath is carrying out all the tension through the nose. While breathing deeply one can
also repeal a calm word or phrase like 'calm down', 'relax' or a religious word like 'Om'.
One such method of relaxation is Guided Imagery.
Guided Imagery
It is a way to achieve relaxation by means of visualizing or creating a relaxed and pleasant
experience in the mind. These are the steps to be followed:
1.
Make the client lie down or sit in a reclining and comfortable position.
2.
The room should be quiet, preferably with dim lights.
3.
Make sure that you are not interrupted or disturbed during this period (approximately
20 minutes).
4.
Give these instructions: "Close your eyes. Breathe comfortably and normally. Let your
body be loose, light and free. Arms should be relaxed lying loosely by your side or on
your lap. Fists should not be clenched and palms should be open, facing upwards.
Check that your eyes are relaxed. Forehead is relaxed. Lips and tongue are relaxed.
Jaws are loose and relaxed. Neck and shoulders are relaxed. Back is relaxed. Stomach
and chest are relaxed and breathe normally. Thighs and legs are loose. Feet are
comfortable without any tension, loose, and relaxed".
5.
Leave the client in this state for a few minutes to allow him/her to relax all parts of
the body.
6.
Speak to the client again: "Now make a picture in your mind of a place where you
would like to go. This picture could be of any place (garden, seaside, hill station, your
own bed room, etc.) In the place you have pictured, imagine the colors in that place,
the sounds of that place, the smells of that place. Visualize as many details as you
62
Identification of Common Mental Disorders and Counseling Skills
want there. However, keep in mind that you should be alone and not talking with
people. Do not crowd this place. Be alone".
7.
"Now go into that place alone. You may like to sit or lie down. Do whatever that you
enjoy. Stay there for a while. If any thoughts come to your mind, do not force them
out. Let them come and go. Gradually as you learn to relax these thoughts will go
away". (Let the person be in this state for at least 7-10 minutes).
8.
"Now please leave the scene and come back to the room. Remember that this is your
place and you can go back to it whenever you want to relax".
9.
"Slowly count 1-10 and open your eyes".
10. "Now you may get up".
11. "How do you feel?"
Practice this with clients until they are comfortable doing it on their own.
Modeling and Behavioral Rehearsal
There are certain types of behavioral techniques, which are helpful when the client has to
learn a new behavior. For example, the counselor may want to teach a client how to handle
an abusive spouse without getting angry or being abusive herself. The counselor will
usually take a situation described by the client herself, in which the husband turns
aggressive or abusive towards her. The counselor will then rehearse this scene using
behavior or statements that the client can use to prevent herself from getting abused or
beaten. The whole sequence is rehearsed step by step with the client. The counselor attempts
to show how alternative ways of behaving can bring a difference to the situation, e.g., the
client preventing the husband from being abusive or aggressive.
In the above example the counselor has used the behavioral techniques of modeling with
behavioral rehearsal. "Modeling" means to perform or act and show what exactly has to
be learnt by the client. Modeling is used to teach new behavior by breaking it down into
smaller parts so that gradually a whole new behavior is learnt. It is an effective way to
teach new behavior. In counseling the model can be the counselor. The counselor will
model a new behavior and with the help of behavioral rehearsal the client and counselor
will enact the new behavior, so that the client is able to learn it in a safe and secure
environment. Behavioral rehearsal is a role-play. It helps to strengthen the client's new
behavior before the client goes and applies it in a real-life situation. Behavioral rehearsal
can be done again and again until the client feels confident of using the behavior in a real-
r
Techniques of Connseling
63
life situation. After each rehearsal, the counselor gives feedback to the client, modifications
are made, and then practiced again.
Reinforcement
With each of these behavioral techniques, reinforcement is given to the client. Reinforcement
is a basic principle of learning, a way of encouraging the client to adopt and try new
behaviors or ways of thinking. Reinforcement is usually making a positive statement - for
example, praising the client or smiling. Therefore, each time clients learn a new behavior
or attempt to change their way of thinking, the counselor will encourage or reinforce the
behavior by saying, "very good", "yes, I am happy that you made the effort", "that's very
nice", etc.
Distraction
Another technique often used in cognitive behavioral counseling is called distraction. It is
usually used when clients find it difficult to take their mind off certain problem situations
or their distress. For example, when clients are feeling very sad or distressed, they may
have negative thoughts about themselves, the future and the world in general. In
distraction, the counselor will help clients to divert their mind off the issues that are
distressing them. One way of doing this is by identifying a list of things that the clients
enjoyed doing. From this list of activities, clients select those that they feel they will be
able to do with minimum effort. Examples of such activities are reading, going for a walk,
sitting with a neighbor and talking, doing some embroidery work, praying, attending a
mandal meeting of an organization or religious gathering, etc.
64
Identification of Common Mental Disorders and Counseling Skills
Distraction can also be done in the thinking process. For example, as soon as clients start
feeling anxious, or have negative thoughts, they are asked to think about some pleasant
neutral thought or are asked to activate an image of a pleasant past event or natural
surrounding. They have to make sure that it is not related to the anxiety provoking situation
or the difficult situation. Distraction has been found to be useful with common mental
disorders like Depression, Anxiety, and Somatoform Disorders, where clients are so
preoccupied with their bodily symptoms that is it often difficult to engage them in
counseling which involves talking. Therefore, a good way to start counseling with these
clients is to use distraction.
Ignoring
Ignoring is a technique related to distraction. It is a technique based on the learning principle
that an individual will gradually stop any behavior that is not paid attention to. The
rationale behind it is that people often indulge in disruptive, harmful, dramatic or extreme
behaviors as a means of getting attention. When such behavior is ignored, eventually it
will be abandoned. This technique has been found to be useful with children, but it has
also been used effectively with adults. For example, a client comes to you with complaints
that her mother-in-law often makes derogatory comments about her cooking and this
distresses her a lot. The client can be taught to ignore the mother-in-law's comments.
Initially, when the client uses this method, the mother-in-law's abusive behavior may
increase. However, if the client is consistent in ignoring these comments over a period of
time, she will notice that it has gradually come down.
Activity Scheduling
In cognitive behavioral counseling, one of the techniques that has been found to be effective
and useful is called as Activity Scheduling. This technique involves planning some part of
the daily activities of clients (with their cooperation) in such a way, that clients derive
pleasure out of them or are able to do routine activities (in case of clients whose functional
level has dropped significantly because of the distress). Activity scheduling helps those
clients who spend a lot of time brooding over problems and distress. Care is taken to see
that the activity schedule has both pleasurable and routine daily activities. This technique
is helpful with people who have lost interest in doing things that they enjoy and who find
doing basic necessary activities also difficult.
’if! ■vt '
Techniqne< of Counseling
65
In activity scheduling clients are asked to first write down all those activities they do
through the day and the amount of time spent in doing each of those activities. Then they
are asked to make a list of things that they do well. Next thev are asked to make a list of
those activities that would give them pleasure or enjoyment. Thev can also be asked to
write a list of things that they would like to do or those they have stopped doing, either
due to lack of time or because they don't feel like doing them anymore on account of the
distress they are feeling.
Once these lists are ready then the counselor helps clients in drawing a daily schedule,
which attempts to structure their activities. The aim is not to fill each hour with some
activity. The counselor introduces one or two activities that are pleasurable in the schedule
given to the clients. Clients are asked to keep a chart of the things that they did each day
and rate the activities on a five point scale: how much pleasure it gave them, and how
much of a sense of success they had after it (mastery). Attempt is made to achieve a balance
between activities that give pleasure and routine activities that have to be done.
The counselor can also introduce a Star Chart with the activity schedule. This chart is be
kept by the counselor and she/he gives a star against each activity that the client has been
able to do and derive pleasure from. The star chart acts like a positive reinforcement. It
gives clients a sense of achievement and confidence that they will be able to do routine
work as well as pleasurable activities that give them enjoyment. Each time clients come
back for a session, the counselor also verbally reinforces and encourages them on their
success. The counselor should remember that this is a relatively long process and it may
take some time. Therefore it is important that the counselor motivates and encourages clients
to keep at it, until clients feels that they have achieved mastery over their daily routine.
66
Identification of Common Mental Disorders and Counseling Skills
CASE EXAMPLE:
A 40-year-old man has been feeling sad and dull for most of the days for the last 2 years. He has
gradually stopped going to the fields to do farming, feels tired easily and does not derive pleasure
from any activity. He has also been found to be sitting alone at home arid not talking to the family
members. The client has been identified as having Dysthymia and referred to psychiatrist. Apart
from the medication given, the counselor is also doing counseling with the client. Speaking about
his activities, the counselor finds that he takes care of his basic needs, but after food sits around
aimlessly or lies on the bed all day. The family is upset at this behavior and it is causing problems
at home.
The counselor asks him to list the things that used to give him pleasure and the routine activities he
is supposed to do. In the process of discussion, the client reports that going to the chaupal and
meeting people, going to the market, smoking beedis, etc., are some of the activities that he enjoyed.
Then he is asked to make a list of things that he did well prior to the distress that he has been feeling
for the past two years. The client says farming, milking the cows, going to the market place to sell
the agricultural products, etc.
The counselor outlines an activity schedule for the client, which includes one or two pleasurable
activities and one or two routine activities. As the client starts doing these activities, gradually
more activities are added to the schedule until the client achieves the level offunctioning prior to
the disorder.
Problem Solving
Problem solving is a vital part of cognitive behavioral counseling. Often frustration arises
when people feel stuck in a difficult situation and are so distressed or upset by it that they
are not able to find a solution to either reduce the problem or distress.
In problem solving the counselor actively encourages clients to seek alternative ways of
solving their problems by:
1. Analyzing the situation that.is making clients feel stuck in it.
2. Explaining this process to clients.
3. Encouraging different ways of looking at problem situations.
Techniques of Counseling
67
The counselor acts as a facilitator in problem solving for clients and does not find the
solutions for them. The steps involved in problem solving are:
1. The first step in problem solving is asking the client to think specifically about the
problem in terms of " How is the situation that I am in a problem for me?" and " How
does it affect me"?
2. In the next step, the client is encouraged to think on the lines of: "What is it that I am
doing, thinking, feeling because of this problem"? "What is it that I am not doing, not
feeling, not thinking, which is contributing to the continuing of the problem situation
or distress"? The focus is on the client's actions, behavior or feelings and not on what
others are doing to contribute to the problem. The rationale behind this is that, often in
counseling, one may not be able to change the situation or the behavior of others because
they may not be in.the client's control. However, the client's own behavior and feelings
are under his/her control.
3. The next step in this process is called brainstorming. In brainstorming, clients are
asked to generate alternative solutions to the problem. They are asked to list down all
possible solutions to the problem without evaluating if they are right or wrong. They
are encouraged to be creative. All the solutions generated by clients are put into a
priority list, in terms of feasibility (which solutions will be more practical and
applicable). Clients are encouraged to think of the benefits and drawbacks for each
choice that is generated (preferably written down). This process also emphasizes that
there are no "perfect" or absolute solutions.
4. Clients are then asked to re-prioritize the alternatives on the basis of the solution they
are most comfortable with and are confident of implementing. Clients are asked to
adopt the alternative that is highest on the priority list and apply that solution to their
real-life situation.
The counselor discusses how clients will implement the solution and the problems they
might encounter in adopting it. The counselor also prepares clients for the possibility that
the solution might not work. If it doesn't work, clients qre asked to review why the solution
did not work and also go over the other alternatives that have been generated by them.
The alternatives clients have generated can be rehearsed in the counseling session so that
clients have the opportunity to practice them in a safe and secure environment before
applying them in real life. This also has the advantage of making modifications to
alternatives before clients actually apply them.
Identification of Common Mental Disorders and Counseling Skills
In the subsequent session, if clients have been successful in implementing an alternative
solution to their problem, then the counselor discusses the impact of the solution and how
it made clients feel. The positive impact of the solution is used as a means of reassuring
and encouraging clients. It also serves to build the confidence of clients in their ability to
handle their distress and problems more effectively. On the other hand, if clients have not
been successful in implementing the solution or if it has had a further negative effect, then
the solution is once again discussed in terms of what could be the possible reasons for it not
working. Clients are also encouraged to explore other alternatives from the list prepared earlier.
J}
CASE EXAMPLE:
A wonidii comes to the counselor saying that she is having a lot of difficulty in handling her 10 year
old boy. He is stubborn, gets angry quickly, and does not listen to her. This also causes tension in
the house and often the husband gets angry with herfor not handling the children well. The counselor
use's a problem solving approach with the client. She asks the client to first clearly identify what the
problem is in handling her son and the distress she is feeling because of it.
. The client is then asked to think about the problem in terms of what it is that she is doing or not
doing that is contributing to the problem. The emphasis is on what the client is doing or not doing
rather than on what the son does. Following this brainstorming is carried out, wheie the client is
asked Io list nil the possible solutions to this problem. The client comes up with the tollowing
sik<osI?ohs:
• ... t
-
....
>
Techniques of Counseling
69
□ / can shout at and slap my son when he speaks rudely to me.
□ I can ignore him when he starts shouting and behaving badly.
□ I can lock him up in the bathroom and tell him that I will not let him out until he stops shouting.
□ I can hug him tightly and make him sit in my lap until he stops shouting.
□ I can try and distract him by giving him something to eat or give a toy to play with.
□ I can calmly ask him what it is that is making him angry and try to understand his reasons.
□ / can threaten him that I will complain to his father when he comes home and then he will get a
beating.
□ I can ask my husband to talk to him.
□ / can invite an elder from the family and ask him/her to explain to the child.
The client is then asked to rate the benefits and the drawbacks for each solution that she has generated.
After carrying out a similar exercise for all the options the client prioritizes the solutions on the
basis of which solution she is most comfortable with and how confident she is of implementing it.
The counselor then helps the client to plan out the first option in the priority list. For example, if
the client's first option is to have a talk with her son to find out why he is getting angry, she is asked
to practice with the counselor by means of role-play, modeling and actual training in implementing
the solution. When she feels confident of these skills she is asked to talk with her son. On the basis
of the feedback that the client gets the plan is modified (if needed) with the help of the counselor. If
this solution is not working, then the client is encouraged to try out the other alternatives that she
has generated in her list.
Assertiveness Training
A part of the problem solving technique is assertiveness, which must be learnt.
Assertiveness training is a technique employed when clients are not able to express what
they feel in an appropriate manner. They feel that they don't have the words to express, or
that what they might say will bring trouble upon them, or that the other person might
take it either as a complaint or as being disrespectful, etc. Hence clients are not able to
express their feelings and ideas appropriately, and it all remains in their minds causing
them sadness, anxiety or anger.
Assertive behavior helps clients say what they are feeling in an honest, open manner
without hurting or disregarding the feelings of others. This involves changing the manner
(tone, attitude and facial expression) with which a statement is being said, choosing an
70
Identification of Common Mental Disorders and Counseling Skills
appropriate place to express what they feel and being careful about the language employed.
Assertiveness training includes teaching clients how to make statemenls beginning with
"1 feel/think" rather than "you are". For example, instead of" You are always shouting at
me and trying to put me down in front of others" one can say, " I feel very upset when you
shout at me in front of others. Can we do something about it"? In such statements clients
are taking responsibility for what they are feeling. When clients take responsibility for
what they are feeling they will also make the attempt to feel better rather than put that
responsibility on others. If the significant other (significant others are those who are
important in our lives, e.g., parents, siblings, husband, wife, children, friends) is not able
to fulfill that responsibility, then they are likely to get more upset and the blaming will go
on. It is a cycle that clients get caught in, where they feel helpless, sad and angry.
Assertiveness training is practiced effectively
with clients with the help of modeling and role
play (Behavioral Rehearsal). The counselor
explains to clients the difference between
assertiveness and aggressiveness. Often when
clients are asked to be assertive, they confuse
it with being aggressive. In aggression there is
an abuse of the rights or feelings of others and
the intention is to hurt or negatively affect the
other person. In assertiveness the welfare and
feelings of the other person are also kept in
mind.
CASE EXAMPLE:
A client has communication problems with his wife. Whenever he objects to her spending too much
money or the house being untidy, she gets offended and starts shouting at him. He constantly
worries that he should not say or do anything to make her angry or upset, because it causes a lot of
tension in the house. Yet, at the same time, hefeels that he is not able make her understand his point
of view. In this case the counselor first discuses with the client the possible statements that he can
put across to her in such a manner that she does not get angry. The counselor uses modeling to
demonstrate the possible ways in which he can say those statements. The client then practices these
statements as part of various role-plays with the counselor in situations where assertiveness is
required. The counselor gives the client feedback regarding his attempts. When the client is
---.
Techniques of Counseling
71
comfortable using these statements, the counselor goes on to the next step: to generalize this assertive
behavior in situations beyond the house and wife.
The counselor must point out during the feedback session that initially the client might receive
negative comments and feedback. Any change in his behavior would also require others to change
their behavior, which they might resent. Thus the important thing is to be preparedfor such behavior
from significant others in the beginning, but to continue with the assertive behavior consistently
and firmly.
Some of the cognitive behavioral counseling techniques focus more on the cognitive
component. Many people are not aware of the automatic thoughts they think, because
they do not pay attention to what they are thinking until they actually start monitoring
them and paying attention to them. Clients are encouraged to pay attention to the kind of
thoughts that come to their minds and to make links with the situation in which they
occur. Diary keeping is one such method. The diary has to be filled in daily by the clients.
It is based on the A-B-C model. A - refers to activating events; B - refers to beliefs or
reactions to events; and C - refers to the emotional consequences. The aim of the counseling
is to teach clients to modify their beliefs (B) about an event (A) in order to change their
emotional reactions (C). Clients are taught to "challenge" their negative thoughts and
substitute those with more rational beliefs. The emphasis is also on consistently solving
problems and initiating behavioral change.
Diary keeping is a task that requires practice and the counselor has to explain how each .
step needs to be done. As one carries out such type of monitoring, the counselor and
clients gather more information, which helps clients in deciding what their priorities are
for changing ways of thinking. The counselor can ask questions like "What sort of situations
make you feel more distressed"? "What sort of thoughts, feelings and behavior patterns
would you like to change"? This technique can only be used with literate clients. However,
the A-B-C model can be used for both literate and illiterate clients to help them understand
the circular nature of thoughts, feelings and behavior. In other words, it can be used as an
explanatory model by counselors.
72
Identification of Common Mental Disorders and Counseling Skills
CASE EXAMPLE:
Situation
Any event that leads to
unpleasant emotion, or any
thought or image leading to
unpleasant emotion
E.g. While boiling milk in
the morning, the milk boils
over
Emotions
Automatic
thoughts
Specifically name the The thought that
emotion - angry, sad, immediately and
anxious etc.
invol u n tarily follows
the event
Anxious, nervous
I should have been
jumpy
more careful.
Rate belief in
the thought
Ona scale of 1-10,
rate how much you
believe this thought
to be true
I am always careless.
9
I can't do anything, well
7
Once a diary has been kept for a period of time then clients can be helped to challenge
their beliefs through the following type of questioning:
1. What is the evidence for and against my belief?
2. What are the alternative explanations for an event or situation?
3. What are the real implications if my belief is correct?
4. Are there any alternative ways of looking at the situation?
5. Where is this way of thinking getting me?
6. What is the effect of thinking this way?
7. Am I jumping to conclusions?
8. Am 1 taking things personally, which have little or nothing to do with me?
Cognitive Restructuring
Another technique often used in cognitive behavioral counseling is called Cognitive
Restructuring. It is based on the principle that if people can consciously change (re
structure) their way of thinking, they can be more productive (behavior) and positive
(feeling) about themselves. Cognitive restructuring is a way of giving oneself more control
over one's thoughts, feelings and behaviors.
The counselor helps clients in this process by telling them how as humans we are all
inclined to errors in thinking and exaggeration of faults. The counselor helps clients
substitute these negative thoughts with more rational and positive thoughts. This is a
process of re-structuring, where clients discover different patterns of thought, feeling and
behavior that they would like to experience more often. It is important to point out to
- ■' ilM’'If
Techniques of Counseling
73
clients that change is not something that a person does once and then forgets about it. In
order to bring about lasting change, it is important to practice this change in their real
lives again and again. Therefore, practice must be emphasized, and for that counselors
can give homework to clients. Homework helps clients practice in their real lives what
was taught in the session.
Practice in the counseling session is done through Behavioral Rehearsal. One of the ways
to ensure that the change process continues is to positively reinforce clients each time they
have been able to restructure their way of thinking in the present. The counselor should
praise every attempt clients make in their ways of thinking. However, it is equally important
to teach clients self-praise. They should be encouraged to praise themselves whenever
they have turned an unrealistic thought into a realistic one, or have been able to utilize the
technique of questioning irrational thoughts as mentioned earlier, in order to understand
and deal with a stressful situation.
The two most powerful keys of constructive change are: altering ways of thinking - a
person's thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and ways of
directing attention - for the better. This is the cognitive aspect of counseling. Helping
clients meet the challenges and opportunities in their lives with a clear mind and then
taking actions that are likely to have positive results is the behavioral aspect of counseling.
Cognitive aspects are used to change ways of thinking and behavioral aspects are used to
change the behavior. For example, techniques like diary keeping (cognitive) with problem
solving and coping skills (behavioral) are used in combination for this type of counseling.
Identification of Common Mental Disorders and Counseling Skills
74
In brief, these are the following steps of cognitive restructuring:
□ Explain the A-I3-C model to clients.
□ Identify negative automatic thoughts - negative automatic thoughts occur automatically
in response to a situation or event.
□ Test these negative automatic thoughts by assessing evidence for and against - it is
useful to ask clients to monitor their thoughts in relation to certain situations in which
they occur (diary keeping).
□ Challenge these thoughts.
□ Generate more rational and realistic counter thoughts or comments (cognitive
restructuring and problem solving).
Thus, cognitive behavioral counseling is a collaborative effort of both the client and the
counselor. The emphasis is on an open relationship where the client can ask the counselor
all his/her doubts without feeling a sense of shame. Cognitive behavioral counseling is
usually done for a shorter period of time. The counselor and the client work towards
specific, time-limited, achievable and realistic goals.
Spacing of Sessions
Although counseling is a time-limited activity, the number of sessions for counselors
working in a community setting is not specified. The number of sessions will depend on
the client's availability of time. The counselor can choose to have one or two sessions, or
as many as 10 sessions. The time duration of a single session may vary from 20 minutes to
an hour. Avoid having a session longer than an hour. Longer sessions tend to exhaust
both the counselor and the client. The optimum period for a regular counseling session is
45 minutes. However, if the counseling has to be done in a single session, the counselor
may choose to have a session longer than an hour. Do not start exploring a new problem
if you don't have the time for it in the session.
Initially, when counseling starts, the counselor may choose to have frequent sessions (two
or three times a week). As counseling progresses, it is. preferable to have one session per
week. Towards the termination of counseling, the time period between sessions is gradually
increased from a week to 15 days, then a month, and finally a follow-up once in three
months. The spacing and number of sessions are kept flexible, keeping in mind the target
population that the organization is working with. Time may be a constraint for clients, or
T'eclmiqties of Counseling
75
they may liiul it cliflicult to travel to the organization's center frequently. Therefore these
logistics should be worked out initially so that the counselor can plan the counseling
sessions.
Sometimes, you may have successfully completed counseling with a client, and after a
period of time, the client comes back again with symptoms and a high level of distress. Do
not be discouraged. Counseling is not a one-time activity. Having been through counseling
once does not necessarily mean that clients will never again have problems or that they
will never again need counseling. In fact, if clients come back for counseling at another
point in time, it is a good sign. It means that clients recognize that a problem of this nature
can be handled through counseling and is actively seeking help.
At the end of this chapter you should have learnt:
1. The different types of techniques of supportive counseling.
2. The different types of techniques of cognitive behavioral
counseling.
3. That techniques are usually used in combination.
4. How to space sessions for counseling.
CHAPTER 6
Counseling Process
The counseling process is defined as the steps and changes that take place in counseling.
It is a process in which the counselor helps clients either through a difficult period (by
being supportive) or a problem solving process involving decisions and actions.
Broadly, the counseling process can be divided into 7 steps.
Step 1: Stating Concerns and Establishing the Need for Counseling
The first step is to do the in-take interview (described in Section I, chapter 2). Here the
counselor will take the entire history of the problems of clients and the distress they are
facing because of it. Information about the family background and other related factors
are also sought. This first step enables clients to state their concerns, problems, distress
and reasons for seeking counseling. Often when clients come for counseling they do not
recognize the need for help. They may blame others or think that they are victims of fate.
They do not have a sense of "ownership" of their problems, nor do they recognize that
they may be able to do something to solve the problem or reduce the distress. Therefore,
it becomes important to help clients recognize the need for help and "ready" them for
doing something actively to change their condition.
It is important for the counselor to realize that clients may initially hesitate to make a
commitment to counseling. The process of change is difficult and frightening for clients.
Change would mean giving up old habits of behaving, thinking, or confronting painful
feelings. The counselor needs to be sensitive to signs of distress or resistance to change
that clients may show in the initial process of change.
Step 2: Establishing the Working Relationship
The counselor must establish a working relationship with clients. This is a relationship of
trust based on openness and honesty. It is important for the counselor to establish credibility
as a trustworthy person. Establishing a working relationship is the responsibility of the
Identification of Common Mental Disorders and Counseling Skills
78
counselor. The success of counseling will largely depend on how effectively the counselor
applies his/her skills (described in section II, chapter 1).
Step 3: Determining the Goals of Counseling
Here the counselor discusses with clients what they would like to do in counseling and
what their expectations are from counseling. Sometimes clients come for counseling
believing that the counselor has extraordinary powers to change their behavior or problem
situation. It is important for the counselor to clarify that the counseling process will involve
the efforts of both the client and the counselor. The counselor does not have any magical
powers to solve the problems of clients. The counselor can help clients to reduce their
distress and help them find solutions to their problems. In that sense, the counselor is like
a facilitator. Agenda and goal setting should be done with the consent and agreement of
the clients.
At times, clients will come with a number of problems, and some of them may not have an
immediate or long-term solution. It helps, therefore, if the counselor can make a priority
list in discussion with the client and handle first those problems which may have a tentative
solution. At other times, the counselor may find that there is no immediate solution to the
problem situation. In such a case, counseling should focus on reducing the distress in
such a manner that clients are able to deal with the situation more effectively or come to
terms with it.
Step 4: Working on Problems and Goals
It is from this step onwards that the change process begins. The process involves:
1. Clarification of the nature of the problem and choosing techniques, which would help
clients reduce distress and/or solve the problem (problem solving process).
2. Exploration of feelings.
Once the counselor has an understanding of the problems, it becomes important to
determine the sort of techniques that can be used for a particular client. Usually, a
combination of supportive and cognitive behavioral techniques is used in counseling.
However, in certain cases the counselor may choose to use more of supportive techniques
than cognitive behavioral ones. This depends on the kind of problem the client has. For
example, if on assessment, it is felt that the client may benefit from modifying his/her
Counseling Process
79
way of thinking, then the counselor may choose to use cognitive behavioral techniques
predominantly. If, in another case, it is felt that the client needs support through a difficult
phase in his/her life, then the counselor may use supportive techniques predominantly.
The problem solving process has the following steps:
1. Developing a clear statement of the client's problems.
2. Describing the problem solving process.
3. Developing a plan for the counseling process.
4. Trying the plan in a real-life setting.
5. Evaluating the outcome and making modifications in the problem solving plan.
The counselor should try to make sure that clients have an understanding of the process
and are also willing to apply the process for change.
Along with problem solving process it is also important to explore the feelings of clients.
When clients experience distress because of the problem situation, feelings are explored
in detail in order to achieve clarity about the distress as well as help clients take
responsibility for them. Observation and alertness are two skills that help the counselor to
be aware of the feelings of clients in the counseling sessions. Initially, clients may feel
threatened when they come for counseling. They may show resistance to the counselor's
explanation of their problems and distress, in accepting responsibility for change and to
the actual process of change. Gradually as the working relationship is established and
counseling proceeds, clients begin to trust the counselor and feel more comfortable with
the counseling situation. They begin to assume greater responsibility for their feelings
and have a greater clarity of the problem situation.
Step 5: Facilitating the Change Process
Facilitating the change process involves awareness or understanding of the problem
situation and the distress that clients experience. As counseling proceeds clients begin to
understand the nature of the problem and the distress they face. Sometimes, during this
phase, clients may become uncomfortable with counseling because they come to realize
that certain patterns of their own behavior or thinking may be causing or maintaining
their distress. Clients often have difficulty in accepting these patterns about themselves.
Sometimes clients may feel worse before getting better. It is important that the counselor
is alert to these signs and is supportive and reassuring of clients.
80
Identification of Common Mental Disorders and Counseling Skills
Step 6: Planning a Course of Action
Sometimes counseling can result in understanding and comfort. Clients are able to either
accept their problem situations (in case a change cannot be brought in to that sphere), or
are able deal with it in a more effective manner. A wide range of cognitive behavioral
counseling techniques, (described in section II, chapter 2) are used to urge clients from
merely being aware of their problems and distress to doing something about them.
In this phase of counseling, clients are encouraged to put into practice some of the
techniques that they have learnt (for example, problem solving, cognitive restructuring,
relaxation exercises, etc). When clients are able to practice their newly learnt skills in reallife situations, they will be able to judge whether these skills really reduce their distress or
solve their problem. Often this is a gradual process. Clients will not see the impact of the
change immediately, but it will be evident over a period of time. When clients practice
these skills consistently, they will be able to see a change in their way of behaving or
thinking. Because this process is often slow, it is also painful and frustrating for clients.
They may think of giving up the new way of behaving because it does not seem to give
immediate results. At times like this the counselor should encourage and reassure the
clients. Each new change (however small) should be positively encouraged. This will
motivate clients to continue with the change process.
Step 7: Evaluating Outcome of Counseling and Termination
A key indicator of successful counseling is the degree to which clients have achieved the
goals that were set when counseling began. The decision to terminate (complete and stop
counseling) is a joint one, taken by the counselor and the client. We list some of the questions
that the counselor should ask himself/herself to decide whether counseling has been
successful and should be terminated:
1. Did the working relationship between the counselor and client help the client?
2. In what way did it help the client?
3. If it did not help the client, why not?
4. If the goals that the client had set at the beginning of counseling were not entirely
achieved, what progress was made?
5. Does the client feel somewhat confident in handling his/her problems?
6. Does the client feel that the distress he/she facing has come down in any way? If yes,
then in what way?
Counseling Process
81
7. How has counseling helped the client? Ask the client to enumerate.
8. How does the client feel at the end of counseling?
If the above answers are mostly positive and the client reports a significant decrease in the
level of distress, then the counselor can start preparing the client for termination.
Termination means ending the counseling contact. As much as it is important to initiate
clients into counseling, it is equally important to prepare clients that they do not need
regular counseling anymore. An abrupt ending to counseling can lead to clients feeling
abandoned and confused, which in turn may lead to feelings of anxiety. They may not feel
prepared to face real-life situations without the safety net of counseling. Therefore, the
counselor should gradually prepare clients for termination. One of the ways of preparing
clients for termination of counseling is to space out the number of sessions. The focus of
the session turns towards getting feedback about how clients are using the skills learnt in
counseling. The counselor now uses more supportive techniques and clients are encouraged
to talk about the positive aspects of the results that the changes have brought about.
However, it is equally important to do follow-ups with clients, even after regular sessions
of counseling have been stopped. Follow-up is important because it gives clients the
assurance of continued contact whenever they feel the need for it. It also gives the counselor
an opportunity to see how effectively clients are using the skills learnt in counseling.
Certain conditions should be kept in mind while doing counseling with clients. These are
as follows:
1. The nature and severity of the client's symptoms. For example, a client coming with
severe depression may have difficulty in expressing his/her feelings. In which case, it
is important that the client be first referred for treatment to a mental health professional.
Only when the depressive symptoms have reduced significantly can counseling be
attempted.
2.
The length and persistence of symptoms. For example, if a client has been drinking
for a long period of time and has difficulty in functioning because of that, then it may
be difficult to do counseling with such a client. It is best that he/she is referred to a
mental health professional first.
3. What sort of stressful experiences has the client had in the past? If the client has an
ongoing long-term difficulty (for example, economic difficulties) or a series of traumatic
events (communal riots, loss of property, loss of job, death of family members in the
riots, etc.) then he/she may require more time to come to terms with the distress and
Identification of Common Mental Disorders and Counseling Skills
82
the problems. The counselor needs to be more supportive and patient with the client.
Options may be more oriented towards social work. For example, helping him/her
find a place to stay (like a shelter), look for income generating avenues, etc.
4. Coping mechanisms in the past. This relates to how the client faced the problems in
the past, how he/she dealt with it. The client's strengths should be used as a motivating
factor to bring about a change.
5. Readiness for counseling. How ready is the client for counseling? Does he/she think
it is important for him/her? Has he/she been forced into counseling by another person?
How does that person think it will benefit the client? These are all important questions.
Counseling will not be effective unless the client is ready for it.
6. Extent of counselor's training. The counselor's training will to a large extent determine
how effectively he/she will be able to handle the problems of the client. The lay
counselor will come across certain types of problems, which he/she may not be able to
handle. If so, the counselor should recognize his/her limitation and refer the client to a
mental health professional.
7* The amount of time available. Exploration of feelings and distress should be done
depending on the amount of time the client can spare for counseling. If the client does
not have time to attend regular counseling sessions, the counselor may decide to use
techniques that the client can practice at home.
Essentials of Counseling:
1.
Maintain a clear and specific focus in counseling.
2.
Through a collaborative effort define goals in counseling. These goals are flexible and
can be reviewed and revised as counseling proceeds. Defining goals helps both the
counselor and the client maintain a structure and focus in the sessions.
3.
Emphasize the "feeling" component in counseling.
4.
Recognize and understand the emotional dependency of the client. Encouraging
emotional dependency to some extent is necessary to help the client gain trust in the
working relationship and counseling. However, excessive emotional dependency will
hamper the progress of counseling.
5.
Be flexible.
6.
Give time to generalize from the counseling session to the real-life of the client. Do
not be impatient for a quick change.
It
WW 1 -.1 <
Counseling Process
83
7.
Clarify when you don't understand something that the client has said and give time
for him/her to explain.
8.
Help and encourage the client to assume responsibility for success and setback in
counseling.
9.
Sometimes the client will go back unhappy from the session. Do not feel pressured to
make the client "happy" at the end of each session.
10. At times, during counseling the counselor may notice a worsening in the client's level
of distress. Do not feel worried and anxious about it. Sometimes, clients will feel worse
before they start feeling better. This is because, in the course of counseling, they may
have confronted certain patterns of their behavior or thoughts that are painful to accept.
Clients need time to come to terms with these painful revelations, and during this
period the counselor may see a worsening of distress. However, a supportive and
reassuring counselor will eventually be able to help clients get better.
At the end of this chapter you should have learnt:
1. The seven steps of the counseling process.
2. The conditions that should be kept in mind while
counseling.
3. The essentials of counseling.
------------------
. ■
.............. V.V - -
85
CHAPTER 7
Ethics in Counseling
Ethics in counseling are a set of dos and don'ts that are prescribed for counselors. Ethics
also serve as guidelines that assist the counselor to give the best help to clients.
Here are some ethical guidelines that a lay counselor should keep in mind:
1)
The counselor should maintain confidentiality of all the information clients have
shared. No information should be shared with the families of clients or others without
the consent of clients. Even if the problems of clients are discussed as an example in
the organization or in training, care should be taken to ensure that no personal names,
names of place of residence, village, and town, etc., are used and no identifying
information should be shared. It is the counselor's responsibility to see that the
information is not misused in any respect.
2)
The agenda of the counseling session and the goal of counseling should be set by
clients in collaboration with the counselor. The counselor should not try to force on
clients what she/he thinks is important for clients or the way they ought to lead their
lives. What clients want should be the focus of counseling.
3)
The counselor's behavior should be such that clients are able to trust him/her. The
Counselor should be open and honest when he/she communicates and should never
give false assurances.
4)
The counselor should be non-judgmental. This means that the counselor should be
free from bias and expectations. He/she should not make judgments like right or
wrong, good or bad, etc., on the behavior/thinking/feelings of clients. Being nonjudgmental also means that the counselor will not discriminate (in the quality of
counseling services offered) on the basis of gender/age/caste/religion/socioeconomic status of clients.
5)
The counselor should not make assumptions. Making assumptions is a common
process that everyone uses to understand another person. Assumptions are often
formed automatically without our being very aware of them. In the counseling session.
Identification of Common Mental Disorders and Counseling Skills
86
therefore, it becomes essential that any assumptions that the counselor makes should
be clarified first with the clients. These assumptions or preconceived notions can be
about factors related to the symptoms, the personality, the thinking process, the
behavior, the problem situation, the socio-cultural background of clients
6)
The counselor should maintain boundaries in a counseling relationship. This means
that the counselor should not reveal any personal information that is more than
necessary for establishing a rapport (e.g., marital status, place of residence, personal
interests or choices) with clients. Disclosing such information will affect the
impartiality of the counseling process.
7)
There might be times during counseling when some reaction or behavior of clients
might upset the counselor. In such cases it is important that the counselor not show
that he/she is angry or upset. The counselor should not shout at clients or belittle
(show clients as being unworthy, or look down upon them) them in any situation.
There might be times in the counseling session when clients get abusive or take out
their anger by throwing things around. The counselor should not threaten clients but
should use techniques like limit setting. Limit setting can involve asking clients to go
out of the counseling situation and come back when they are feeling calmer. Limit
setting can also involve the counselor leaving the counseling situation for a specified
period of time or terminating the session for that particular day. It is important that
the counselor recognizes that clients are not upset with the counselor per se, but that
the emotional outbursts are reactions to the problems that clients are facing.
8)
The counselor should always give importance to the problems of clients over any
personal interest. The counselor must not gratify his/her own needs in the counseling
relationship.
9)
The counselor should not carry his/her personal issues and needs to counseling.
They can be emotional, sexual or monetary needs.
10) If the counselor has personal issues, he/she should seek counseling for that first before
counseling others. Otherwise he/she is likely to be biased or it may interfere with the
counseling process.
11)
The counselor should not form any personal relationship with clients (e.g., that of a
friend) during or after counseling. If clients bring gifts or make attempts to make the
counseling relationship personal, the counselor should gently but firmly dissuade
them from doing so. Do not accept personal gifts or favors from clients or their families.
Ethics in Counseling
87
12) The counselor must maintain neutrality in the counseling relationship. Neutrality
implies impartiality and objectivity, which are very important in any counseling
relationship.
13) The lay counselor is only given limited training in the identification of common mental
disorders and in counseling skills. He/she must, therefore, acknowledge this limitation
and work within the said limits.
14) The lay counselor should take support by discussing with the peer group.
15) The lay counselor must refer clients to mental health professionals when:
a.
A problem is severe or is identified as a disorder at a clinical level.
b.
Despite a series of counseling sessions, clients do not show any improvement
and their distress does not seem to have come down.
If the counselor carefully follows these ethical guidelines, he/she will be able to offer the
best service to clients.
__
• • ——i
Appendix A
PROFORMA FOR HISTORY TAKING
Name
Age
Sex
:
Male / Male
:
Urban / Semi-Urban / Slum / Rural
Address
Region
Occupation
Marital Status
Single / Married / Divorced / Separated / Widowed
Family Structure
Joint / Nuclear
Annual Income
Religion
Family Details
Spouse / Father's Name
No. of Children
No. of Siblings
Illnesses in the family
Physical
Mental
:
Hindu / Muslim / Christian / Others
i
a
in - Take Interview
1. Chief complaints
2. Duration of the problem
3. Onset
4. Course
5. Precipitating factors
6. History of present illness
Biological
7. Level of Functioning
Social
Occupation
8. Family Functioning (Use genogram)
-- Wr ’
FAMILY GENOGRAM
Male
Female
Married
Married within blood relations (Consanginous)
Children
Age
o
Age
Age
Age
Divorced
Death
or
Affected Individual(s)
or
BP (Problem)
Diabetes (Problem)
Index Patient
/
Twins
Death in Infancy/Abortion
_T
o
I
! 15^5
I_______________
Remarriage
Please note: Mention age of each individual
or
“I
b
I
i
J
Impression
Referral
Plan of Action for the client
r,
-------
Appendix B
Note: For each symptom multiple questions can be asked to find out whether the symptom is
present or not.
Table 1: Depression
Mild Depressive Episode: To diagnose this disorder two of the first 3 symptoms and at least 2 of
the symptoms from number 4 to 11 given in Table 1 must be present for a period of two weeks
continuously to be diagnosed as Mild Depressive Episode. Therefore the total number of symptoms
should be not more than 4.
Moderate Depressive Episode: Two of the first 3 symptoms and at least 3 or more symptoms
from number 4 to 11 given in Table 1 must be present for a period of two weeks continuously to
be diagnosed as Moderate Depressive Episode
Severe Depressive Episode: All three symptoms from 1-3 must be present. Additionally, at least
4 or more symptoms from number 4 to 11 given in Table 1 must be present for a period of two
weeks continuously to be diagnosed as Severe Depressive Episode.
Note: If these symptoms arc not present continuously for a period of two weeks then the disorder
is at a sub-clinical level.
SI. No. Signs/symptoms
1.
Sad mood, present every day
and for most of the day
2.
Lack of energy and getting
tired easily
3.
Not interested or not
experiencing pleasure in
activities that usually give
pleasure
4.
Loss of confidence or
self-esteem
5.
Unreasonable and
inappropriate guilt or
self-blame.
6.
Repeated thoughts of death
or suicide, or making plans/
attempts to commit suicide
7.
Increased or decreased sleep
Questions to ask
1. Do you feel sad or depressed most of the day?
2. Do you feel sad all the time, every day?
1. Do you feel that you tire easily?
2. Do you feel that you have no energy to do any of the usual
activities that you do through the day?
3. Do you feel that even the smallest tasks make you easily tired?
1. Do you find that the activities that gave you pleasure
earlier (e.g., meeting people, going out, watching T.V. etc.)
now don't interest you at all?
2. Do you find that you have stopped doing all those activities
that gave you pleasure earlier?
3. Do you find it difficult to enjoy yourself?
1. Do you feel that you are not a good enough person?
2. Do you feel that you lack confidence in yourself in the past
few weeks/months?
3. Do you feel worthless?
4. Do you feel you are good for nothing?
5. Do you feel that you cannot do anything well?
1. Do you feel guilty all the time about things that you might
not have done?
2. Do you feel guilty for things that you are not responsible for?
3. Do you blame yourself for things that go wrong in your
life/family/house?
4. Do you blame yourself often, even for things that you
might not be responsible for?
5. Do you feel guilty thinking that you could have done
things better?_____________________________________
1. Do you get repeated thoughts of killing yourself or ending
your life?
2. Do you feel that you don't deserve to live and therefore
should end your life?
3. Do you feel that you should end your life because it is not
worth living, because there is no hope?
4. Do you feel so helpless that you feel that ending your life
may be the best way?
5. Have you ever made plans for taking your life?
6. Have you ever made an attempt to take your life? If yes,
in what ways?
7. What plans have you made?____________
1. For how many hours do you normally sleep?
2. Have you been sleeping much more than your normal hours?
3. Do you find that you are sleepy throughout the day and
want to go back to sleeping?
4. Have you found it difficult to wake up in the mornings?
5. Have you found it difficult to go to sleep?
6. Have you found that you wake up often in the night and
find it difficult to go to sleep?
7. Have you found that you wake up at least 2/3 hours
before your normal time to wake up?
SI. No. Signs/symploms
Questions to ask
8.
Increased or decreased
appetite
1. Do you feel hungry?
2. Do you feel that you have been eating more than your normal
diet?
3. Do you find that you eat all the time?
4. Do you feel that you don't feel hungry at all?
5. Do you feel that you have to force yourself to eat?
9.
Complaints of decreased
ability to concentrate or think
10.
Increased or decreased
motor activity
1. Do you find it hard to think or concentrate on your work?
2. Do you find your attention getting distracted by things other
than your task?
3. Do you find it so difficult to concentrate that you are not able
to finish a task?
4. Do you find that you are not able to think or plan anything?
1. Do you feel so restless that you are not able to sit or stand in
one place for more than a few minutes at a time?
2. Do you find that you are not able to sit still for more than a
few minutes at a time?
3. Do you feel that you have to move about all the time?
4. Do you feel that you aren't able to move from one place to
another?
5. Do you find that it takes a lot of effort to move around from
one place to another?
6. Do you find that you are sitting in the same spot for more
than a couple of hours without moving and do not have the
energy to move?
11.
Sad and pessimistic views
of the future
1.. Do you feel that there is nothing to look forward to in the
future?
2. Does the future seem hopeless and depressing?
3. Do you worry that nothing good is going to happen in the
future?
Table 2: Somatic Symptoms in Depression
The following are the somatic symptoms often present in Depression. In order to diagnose
Depression (Mild, Moderate, or Severe) with somatic symptoms, 4 of the 8 symptoms must be
present for a period of two weeks in addition to the criteria for Mild, Moderate and Severe Episode.
SI. No. Signs/symptoms________
Significant loss of appetite
1.
2.
Significant weight loss
(5% or more in one month,
about 2.5 — 4kgs loss)
3.
Lack of sexual desire/
interest in sexual activity
4.
5.
6.
7.
8.
Questions
_______________________________
1. Do you feel that you don't want to eat food?
2. You don't feel like eating at all.
3. You are not feeling as hungry as you used to?
4. Do you feel hungry at all or do you have to force yourself to
eat?___________________
1. Have you lost weight in the last one month?
2. If yes, how much?
3. Do you feel that the weight loss is because you are not eating
well?
4. Have other people noticed the weight loss?
1. Do you feel that you have no interest in sexual acts?
2. Do you feel that you have no sexual desire?
3. You don't feel like having sex with your husband/wife/
partner?
_ __________________________
1.
Do
you
feel
that
when
you wake up in the morning you feel
Mood is more sad in the
very
sad
and
depressed,
and as the day goes by the mood
mornings
begins to improve?
2. Do you feel that you are sadder in the mornings than in the
daytime or the evening?
1. How many hours of sleep do you get normally?
Consistently waking up
2. Have you been sleeping well?
2 hours or more earlier than
3. Do you wake up at least 2 hours before your normal time of
the usual time
waking?__________________________
4. Do you find that the activities that gave you pleasure earlier
Not interested in activities
(e.g., meeting people, going out, watching T.V. etc.) now don't
that gave pleasure earlier
interest you at all?
5. Do you find that you have stopped doing all those activities
that gave you pleasure earlier?
6. Do you find it difficult to enjoy yourself?
1. Do you feel that your functioning has slowed down a lot?
Significant decrease in
response and motor slowness 2. Do you find yourself taking more time doing activities than
you used to earlier?
- walking, speech etc.
3. Do you feel you have begun walking, talking and moving
slowly?
4. Do all activities take a long time?__________________
1. If there is a happy occasion in the family/social circle, do
Lack of emotional responses
you find it hard to enjoy yourself?
to events or activities that
2. If somebody cracks a joke, do you find it humorous and
normally produce emotional
laugh?
reactions
3. If somebody is rude to you, or abuses you, or says hurtful
things, does it affect you in the same manner as it used to
earlier?
-
i
Table 3: Dysthymia
At least 3 of the following symptoms should be present for a period of 2 years or more.
SI. No. Signs/symptoms
Questions to ask
1.
Decreased energy and/or
activity
2.
Inability to fall asleep
3.
Loss of self-confidence or
feelings of inadequacy
Do you get tired quickly?
Do you feel that you are not as active as you used to be?
Do you feel it takes a lot of energy to do even small things?
Do you find it difficult to fall asleep?
Do you toss and turn in your bed for a long time before you
fall asleep?
3. Do you find that you lie awake in your bed for 2 - 3 hours
before you fall asleep?
1. Do you feel that you are not good enough?
2. Do you feel that you lack confidence in yourself?
3. Do you feel that you are worth 1 ess?
4.
Problems in concentration
1. Do you find it difficult to concentrate on most of the things?
2. Do you find that you get distracted by small things around
you quickly?
3. Do you feel that you are making more mistakes in your work
than you used to earlier?
5.
Frequent crying spells
1. Do you feel like crying often?
2. Do you feel like crying about small things?
3. Do you feel like crying for no reason at all?
6.
Loss of interest in
pleasurable activities
7.
Feelings of hopelessness and
despair
8.
Feelings of inability to cope
with the routine of daily life
9.
Pessimism about the future
or brooding about the past
10.
Social withdrawal
1. Do you feel that you have lost interest in things that used to
give you pleasure earlier?
2. Do you find it difficult to enjoy activities which gave you
pleasure earlier (e.g., watching T.V., movie, chatting with
family, neighbors, going out) ___________
1. Do you feel that there is no hope in the future for you?
2. Do you feel that things cannot change for the better in your
life?
3. Do you worry a lot that things will not improve in the future?
1. Do you find it difficult to take care of your routine daily work?
2. Do you feel that you cannot do your routine daily work as
well as you used to?
3. Do you find that it takes a lot of energy in doing routine daily
work?
1. Do you worry about the bad things happening to you or your
family in the future?
2. Do you keep on thinking about all the bad things that have
happened in the past?
3. Do you worry that nothing good will happen in the future?
1. Do you feel like meeting with people?
2. Do you find that you are not able to enjoy meeting people as
much as you did earlier?
3. Do you avoid going out or meeting people because
you don't enjoy it any more?
4. Do you find that more and more you are spending time away
from people in your family, friends or neighbors?
1.
2.
3.
1.
2.
SI. No. Signs/symptoms
Decreased talkativeness
11.
Questions to ask____________________________________
1. Do you feel that you don't like talking as much as you did
earlier?
2. Do you or others around you feel that you have become very
quiet?
3. Do you find that you are mostly quiet when you are with
people?
4. Have others pointed out that you don't speak as much as
you used to?
I
Table 4: Anxiety
Ask these general questions before you go to the criteria for specific disorders.
General Questions:
1. How long have you been feeling worried or anxious?
2. Is this anxiety related to a particular situation or context?
3. Is the anxiety a reaction to some situation, person, event or context?
4. Is this worry, anxiety or apprehension controllable or uncontrollable?
5. What are the situations under which you are able to control the anxiety?
6. How does the anxiety start?
7. Do you feel worried and anxious all the time, even though there is no reason for being so?
Generalized Anxiety Disorder (GAD):
The following criteria must be fulfilled for a period of at least 6 months. At least one symptom
from 1 - 4 and any other 3 or more symptoms must be present from 5-22 for diagnosing GAD.
Tick against all those symptoms that are present.
SI. no Signs/symptoms
_!____ Palpitations or pounding heart or increased heart rate
2 ___ Sweating
3 ____ Trembling or shaking
4 ____ Dry mouth not due to any medical condition or medication
5 ____ Difficulty in breathing____________________________________
6 ____ Feeling of choking
7 ____ Chest pain or discomfort
8 ___ Feeling like vomiting or experiencing churning in the stomach
9 ____ Feeling dizzy, unsteady, light headed or faint
Feelings that objects are unreal and that they are not really there
10
11___ Fear of losing control, "going mad", or falling down on fainting
12
Fear of dying
Hot flushes or cold chills
13
14
Numbness or tingling sensations
15
Muscle tension or aches and pains
16
Restlessness and inability to relax
17
Feeling mentally tense
~18~ Feeling of difficulty in swallowing, as if there is a lump in the throat
19
Getting startled easily
20
Difficulty in concentration
21
Persistent irritability__________________
22
Difficulty in falling asleep because of worry
Present / absent
Table 5: Panic Disorder
For Panic Disorder to be diagnosed the person must have at least 4 attacks in four weeks to be
diagnosed as a moderate panic attack. For severe panic attacks, the person must have 4 attacks
per week for over a month. If the symptoms described in Table 5 are not present for the specified
time period, the disorder is at a sub-clinical level.
Remember that the person must develop these attacks suddenly and abruptly and reach a peak
within a few minutes. At least 4 of the following symptoms given in Table 5 must be present to
diagnose a Panic Disorder, out of which one symptom should be present from 1 - 4.
The following general questions should be first asked:
1. Have you ever felt intense fear of something going wrong with you?
2. At such times have you felt that you are going crazy or are going to die?
3. Do you have choking sensations at these times?
4. How does it start?
5. Does it start suddenly/abruptly or slowly/gradually?
6. How often does it happen?
7. How long does it last?
8. What do you feel when it happens?
Tick against all those symptoms that are present.
SI. no
L___
2. ___
3. ___
4. ___
_5.___
6. ___
7. ___
8. ___
2^__
10.
11.
12. __
13.
14.
.1 ——
S i gns/sy m ptoms_____________________________ _
Palpitation, pounding of the heart, increased heart rate
Sweating______________________
Trembling or shaking__________________________
Dryness of mouth_____________________________
Sensation of shortness of breath__________________
Feeling of choking_____________________________
Chest pain or discomfort________________
Nausea or vomiting sensation __________________
Feeling dizzy, unsteady, faint, lightheaded_________
Fear of loosing control or going crazy_____________
Fear of dying_________________________________
Chills or hot flushe____________________________
Numbness or hot flushes______________
Feeling that things are not real and 'not really here'
Present / absent
Table 6: Phobia - Agoraphobia
Marked and consistent fear and avoidance of two of the following, associated with anxiety
symptoms:
1. Crowds
2. Public places
3. Traveling alone
4. Traveling away from home
General Questions:
1. Do you feel extremely scared or fearful in crowded places, or open public places, or of some
specific object, person or animal?
2. Does this happen every time you are in that situation?
3. Do you feel scared or fearful even thinking about these situations?
4. Please describe the way you feel in situations that you fear a lot?
5. Do you feel that this is a normal or excessive reaction?
6. Do you think it is an unreasonable reaction?
7. Do you avoid these situations/persons/objects completely?
8. If you avoid or escape the fearful situation/object/person, does the fear go away completely?
9. Has this affected your social and occupational functioning? If yes, in what way, please describe.
Tick all those symptoms that are present from the onset of the disorder. These symptoms must be
present when the person is in the situation or thinking about the situation and not in general. At
least 1 from symptom 1 to 4 should be present. Altogether there should be at least 3-4 symptoms
present for it to be diagnosed as Agoraphobia; otherwise the disorder is at a sub-clinical level.
SI. no
Signs/symptoms
Palpitations, pounding heart, or increased heart rate
Sweating__________________________________
Trembling or shaking________________________
Dryness of mouth
5____ Difficulty in breathing
6. ___ Choking sensation___________________________
7. ___ Chest pain or discomfort
8. ___ Nausea or vomiting sensation__________________
9. ___ Dizzy feeling, lightheadedness, faint____________
10. __ Feeling that things are not real and 'not really here7
11. __ Fear of going crazy, fainting, losing control_______
T___
2. ___
3. ___
4. ___
13.
Fear of dying_______________________________
Hot flushes or cold chills
14.
Numbness or tingling sensation
12. __
Present / absent
—— -w at. -F-wRj
Table 6.1: Social Phobia
1. Marked or excessive fear of being the focus of attention. Fear of behaving in a way that will be
embarrassing or humiliating.
2. Active avoidance of being the focus of attention.
Note: In addition to the 2 symptoms mentioned above, two of the symptoms from 1 to 13, and 2
from number 14 to 16 must be present to be diagnosed as Social Phobia. All together there should
be 4 symptoms present. If the symptoms are less than the number mentioned, then the disorder is
a sub-clinical level. General questions as given for Agoraphobia can be asked for Social Phobia as
well.
SI. no
L___
2. ___
3. ___
4. ___
5___
6. ___
7. ___
8. ___
9. ___
10. __
11. __
12. __
13. __
14. __
15.
16.
Signs/symptoms
_________________________
Palpitations, pounding heart, or increased heart rate
Sweating________ _________________________
Trembling or shaking_______________________ _
Dryness of mouth___________________________
Difficulty in breathing________________________
Choking sensation___________________________
Chest pain or discomfort______________________
Nausea or vomiting sensation_________________
Dizzy feeling, lightheadedness, faint____________
Fear of going crazy, fainting, loosing control______
Fear of dying_______________________________
Hot flushes or cold chills_____________________
Numbness or tingling sensation
Blushing or shaking__________ *______________
Fear of vomiting____________________________
Urgency or fear or urination or defecation (potty)
Present/absent
Table 7: Somatoform Disorders
General Questions:
1. Do you suffer from multiple aches and pains?
2. Have you been investigated for these aches and pains?
3. How many doctors have you seen for these aches and pains?
4. Have any of the doctors that you have seen been able to explain why these symptoms occur?
5. Do you believe when the doctors tell you that there is nothing wrong with you physically?
6. Do you think that they are right — that there is no physical cause for your aches and pains?
7. How long have you been having these symptoms?
8. Do you find that you are thinking about these physical complaints all the time?
9. Do you think these aches and pains have affected your day-day routine work?
10. Do you feel that you are not able to carry out your daily routine work because these symptoms
trouble you a lot?
Note: There should be a history of at least 2 years of complaints of multiple and different physical
symptoms that cannot be explained by any physical disorder. A total of 6 or more symptoms from
at least two separate groups (e.g., cardiovascular and gastrointestinal) or any other combination
from the list should be present to make the diagnosis. If the symptoms are less in number, then the
disorder is at a sub-clinical level.
Category
Gastrointestinal
Cardiovascular
Genitourinary
Skin & Pain Symptoms
Signs/Symptoms_______
Abdominal pain
Nausea
Feeling bloated or full of gas
Bad taste in the mouth or excessive coating of the k)ngue
Complaints of vomiting________
Frequent loose motions or fluid discharge from the anus
Breathlessness without exertion
Chest pain
Frequent urination or difficulty in urination________
Unpleasant sensation in and around the genital area
Excessive vaginal discharge____
Patchy or discolored skin
Pain in the limbs, feet, hands or joints
Unpleasant tingling or numbness
Present/Absent
Table 8: Obsessive Compulsive Disorder (OCD)
General Questions:
Note: (i) Either obsessions or compulsions or both should be present on most days for a period of
two weeks, (ii) Some of these questions require you to note down the answers and others require
you to tick against "yes" or "no", (iii) First ask these questions for obsessions (which are repeated
thoughts). Then ask the same set of questions for compulsions (which are repeated actions of one
kind).
1. Are these thoughts/images/urges coming from within your mind or is someone forcing you
to think about them?
2. Can you control them?
3. How do you control them?
4. For how long are you able to control them?
5. What is the content of these thoughts/images/urges?
6. How do you feel when these thoughts come to you?
7. How do you decrease/lessen your distress when these thoughts come to you?
8. Does it work? If yes, for how long does the relief last? Then what do you do?
9. Have you had to make changes in your daily routine because of this problem?
10. When these thoughts/images/urges come to your mind, do you try to resist them?
11. Are these thoughts interfering with your daily routine or any task/work that you are doing?
12. Do they come again and again? Are these thoughts unpleasant?
13. Do these thoughts make you feel distressed?
14. Do you try to stop them?
15. Have you been successful in stopping these thoughts at any time?
16. Are you upset with the nature of the thoughts/images/urges?
17. Even though this thought comes again and again, do you carry out the action repeatedly, is it
a pleasurable experience or not?
Table 9: Dissociative Disorder
Remember these two criteria must be present: (i) There is no evidence of a physical disorder to
explain the symptoms that a person is showing, (ii) There is a significant relationship between the
onset of the symptoms and the time of the stressful event.
Dissociative Motor Disorder:
One of the two criteria given below must be present.
A. Complete or partial (partly or some part of it) loss of ability to perform those movements,
which are under voluntary control (talking, moving the limbs, working with the hands, stiffening
of the neck, being able to stand without support, rolling of the eye-balls in an upward direction).
B. No coordination in balance or gait while walking, or inability to stand without support.
Note: Questions should be mainly asked to the family members, as they will be able to give more
objective information on the symptoms. Before asking the questions, please ascertain what type of
motor disorder the person is having. Bear in mind while conducting the interview for diagnosing
the disorder that the answers to the questions should be noted in detail. The same is true for all
types of Dissociative Disorders mentioned subsequently.
Questions to be to Family:
1. When was the first time you noticed the client behaving in this manner? Was it related to a
stressful event? Or did these symptoms come up after a traumatic event?
2. How did the person behave when the attack took place?
3. What did the person do?
4. How long did the episode last?
5. Were you able to talk to this person during the episode?
6. Have you noticed these attacks happening at a particular time or place? Is there a pattern that
you have noticed?
7. What difficulties has the client been facing after this problem has begun?
8. What effort does the client make to overcome this problem?
Questions to be asked to the Client?
1. What difficulties do you face after this problem has begun?
2. How do you mange your daily routine after this problem started?
3. What do you think may be the reason/cause of this problem?
4. Do you think these symptoms are under your control?
..
Table 9.1: Trance And Possession Disorder
In Trance there is a temporary alteration of the state of consciousness shown by two of the three
of the following criteria:
1. Loss of sense of personal identity.
2. Narrowing of awareness of surround ings or selective focusing on one particular environmental
stimulus.
3. Restricted or limited movement, posture and speech.
In Possession the individual is convinced that he/she has been taken over by a spirit, power, god,
or another person. The individual has no control over his/her behavior. He/she behaves in a way
which is characteristic of the entity they believe has taken over him/her. The above-mentioned
first two criteria must be present. In addition, the patient must clearly state that these possessions
are unwanted and troublesome.
Questions to be asked to Family:
1. When the person is having this episode, does he/she recognize family members?
2. Does the person recognize the surroundings?
3. Does the person seem as if he/she is aware of what is happening to him/her?
4. Does the person do anything peculiar/new or different actions? For example, muttering, scream
loudly, £ing, speak in a different voice?
5. Later on, when the person has come back to the normal state, does he/she remember what
happened during the episode?
6. Does the person behave in such a manner that it appears to you as if some external person/
thing/animal is controlling his/her actions, behavior or speech?
7. Does the person behave as if his/her personality has been taken over by someone or something?
8. Does the person say who that person is?
Questions to be asked to Client:
1. Do you find these episodes troublesome?
2. What according to you is the reason that you are having these episodes?
3. Have there been negative consequences of these episodes (physical — being hurt; social —
people being scared of you, not wanting to talk with you, avoiding you; occupational — not
being able to perform your job)?
4. .Do you remember anything of what happened during the episode?
5. When you come out of the episode, how do you feel?
6. Have there been any events in the recent past, which might have upset or troubled you a lot?
If yes, please describe the event and how you felt about it?
.Mlh-
.
Table 9.2: Dissociative Convulsions
Persons suffering from this disorder have sudden and unexpected jerky movements, which appear
like fits but are not fits (epilepsy), as they are not followed by loss of consciousness. These jerky
movements are not accompanied by tongue biting, frothing at the mouth, seriously injuring oneself
due to falling or losing control over bladder, as can happen after an epileptic fit.
Questions to be asked to Family :
1. Does the person have sudden jerky movements of the body?
2. Do these jerky movements appear as if the person is having fits?
3. Has the person ever lost consciousness following these jerky movements?
4. Has the person ever got hurt during these fits (e.g., falling down, biting the tongue)?
5. Has there been frothing at the mouth after the fit?
6. During the episode, did the person roll his/her eyes upwards?
7. Has the person ever passed urine in his/her clothes during or after the fit?
8. When the fit is over, does the person have any memory of the episode?
- Media
16896.pdf
Position: 1405 (6 views)