Background Information

Rose, mother to five year old daughter, appears to be well spoken and articulate. No details in regards to Rose’s marital status, work or family apart from her daughter were readily apparent from the session. No information is provided as to whether Rose has other children, or family living and work arrangements. Unfortunately, there is also no information in regards to any previous health issues.

Description of the Presenting Problem

The presenting issue was the five-year old daughter not sleeping in her own bed for the entire night. When Rose’s daughter would wake up in the middle of the night crying, Rose would take her daughter from her own room to her bed, the reasoning that if Rose just put her back in her own bed she would be awake crying again in a few minutes. It was decided (presumably a joint decision between Rose and her partner) that this should be stopped, as it was causing problems for Rose in that she herself was not able to sleep as her daughter would take over the bed, and Rose was unable to get sufficient meaningful sleep. The joint decision was that the child would allowed to cry, and not moved from her own bed.

Progress had been made in getting her daughter to sleep in her own bed for the full night, but this changed two weeks ago, and Rose feels they are back to square one. No information has been provided as to whether there was a precipitating incident that caused the change in behaviour and reversed the progress that had been made. Rose has had discussions with her daughter’s teachers, however no records are available in regards to any action taken.

Diagnosis

It is concerning that Dr Berenson as counsellor does not seem to have sufficient background information on the problem that Rose is dealing with to form any diagnosis or action plan for helping Rose. The difficulty being faced by Rose is dealt with as an emotional and relationship issue by Dr Berenson.

Intervention

During the session, Dr Berenson, a therapist using a humanistic approach, attempts to help Rose deal with this problem. The person-centred counselling approach used, also known as client-centered, places much of the responsibility for the treatment process on the client, with the therapist taking a nondirective role (Egan, 2007).

The person-centred approach considers the client as the authority on their own experience, and that the client is competent to reach their own potential for change and development. Rogers believed people are intrinsically good and trustworthy, having the potential to understand themselves and resolve their own problems without undue intrusion from a counsellor (Geldard & Geldard, 2005).

Person-centred theory does not require that the client be diagnosed in order to seek and realise improvement.Counsellors avoid being directive, as the client is responsible for the direction (Egan, 2007).

Evaluation

The session itself seemed quite short at only thirty minutes long. The setting of the session as a training tool may also have influenced both the counsellor Dr Berenson and Rose as the client, making them very self aware, and not providing a comfortable and safe environment conducive to meaningful communication. Dr Berenson makes note during the session about whether they are “messing up the interview or not”, and it does seem that his attention is divided.

It also appeared a bit strange in the light of the change and progression in person-centered counselling theory in the decades since Rose and Dr Berenson recorded this session. It was actually quite difficult to separate an analysis of techniques and skills used by Dr Berenson, from the attitudes and styles of the time. One could be quite revisionist, and look at the session only through the lens of current mind-set of the role of women in the home and the seemingly paternalistic manner of the male doctor towards a female client. Dr Berenson is not an inexperienced or untrained counsellor, and has developed counselling theory research in regards to interpersonal skills and organisational models.

However, in regards to communication skills and counselling techniques modeled by Dr Berenson, there are some aspects that could be improved upon, and perhaps such a short training tape was not the best example of an array of person-centered techniques. In such a short, artificial setting, it would be difficult to demonstrate every single counselling technique possible, and much more difficult to develop a therapeutic counselling relationship, and very much of challenge to set the core conditions for therapeutic change.

Roger’s core conditions

The three main core conditions that Carl Rogers considered essential for effective counselling are unconditional positive regard, empathy and congruence (Myers, 1986). In addition to these three basic requirements, Roger theorised that there were six conditions in total, and if these were all fulfilled, the client would improve over time. These six conditions are that:

Unconditional positive regard, empathy and congruence are required to assist change and improvement. Without these conditions being present a therapeutic relationship will not emerge. The client has to be engaged. Emotional contact is needed. If the client does not want to be there they are free to withdraw and the counselling process cannot continue. Achieving any objective requires encouraging conditions – in unfavourable conditions, individuals may well not develop in as much as otherwise possible (Kottler, 2004).

Unconditional positive regard is defined as when a counsellor accepts the client unconditionally and unreservedly. The client is free to explore their feelings and beliefs without fear of censure or disapproval. The client is free to explore without having to meet any standards of behaviour or to anything to earn positive regard. The client can just accept it as fact (Egan, 2007).

Empathic understanding is characterised by the counsellor accurately perceiving the client’s feelings and views from the other’s perspective. When the counsellor understands what the world looks like from the client’s point of view, it shows that that view has value, and that the client being accepted for themselves (Corey, 2009).

Congruence is defined as the counsellor being genuine and real. The counsellor does not present as a distant expert, but is right there in the session, present and transparent to the client (Corey, 2009.

The three core conditions are to help the client to grow and develop in their own way – to build up and develop their own self and to become a better person free from outside pressures to act or think in specific ways (Corey, 2009). During the session with Rose and Dr Berenson, these basic conditions were not always evident. There are is basic connection there, and Rose does thank Dr Berenson at the end for the opportunity, but throughout the session, Rose does not seem to have the opportunity to tell her story without interruption or in her own words. Rose is really being listened to, or her input valued. The session comes across as more a psychology lecture than a therapeutic relationship; more science than helping.

Communication

The session does start well, with minimal encourages, such as “Mmm”, and “Umm” were used in the beginning, with Dr Berenson prompting Rose to tell her story. It does not always progress well. Some of the language used by Dr Berenson does not seem appropriate, telling Rose to “resolve the conflict inside” and “censor some of that”. This is very stilted and academic phrasing to be used in talking to a housewife.

Advising a mother of a five-year old that the child is a “partner in the effort”, and to give “that understanding to her” does not appear helpful at all. Perhaps in a longer session, Rose would have been able to talk more with Dr Berenson, and go into problem solving models in more depth.

Interrupting is generally not a good communication style for counselling, yet Dr Berenson does interrupt Rose several times during the session. Dr Berenson also asks many closed questions, not giving Rose the opportunity to tell her story, and ending up with a series of questions where the only reply from Rose is “Yes”. There where few probing questions asked; a more effective use of questioning may have helped Rose challenge and explore her options.

The short session did not appear to show a genuine congruent relationship – communication did not always work both ways. Dr Berenson seems to be asking leading question – providing an answer for Rose, rather than allowing her to respond, and telling Rose what she feels “partly you feel some guilt” “you are torn” “one feeling compounds another”. This does not come across a mirroring back to Rose what the counsellor is hearing, and possibly more sensitivity could be shown in naming emotions. Making assumption with insufficient information should also be avoided.

Empathy

In general, this session seemed to be more about the counsellor, that the client. Again, this could be the result of the artificiality of the session, rather than a failing of the counsellor. Still, there is no evidence that Dr Berenson is able to put himself in another’s shoes, and show an understanding of what Rose is feeling.

Perhaps some discussion about childhood norms might have been appropriate. It may be helpful for a first time parent to know that this situation is not unusual. Perhaps some focused self-disclosure, if Dr Berenson is a parent who has been in similar situations, could be helpful for Rose to make the situation less about conflict and guilt, and focus more on doing what is best for herself and her family (Egan, 2007).

Dr Berenson also tells Rose directly what the goal is; “to resolve the conflict, inside of you, not get your daughter back in bed” – rather than being an understanding listener, he is the one doing most of the talking at the end, and Rose is the one reduced to one word answers.

Problem Solving

To be able to solve a problem, the first thing needed is information about the current situation, and also willingness on the part of Rose to change and move forward. Dr Berenson talked about guilt and tears, but seemed a bit short looking at the source of any problems or difficulties, or on practical and substantial assistance in helping Rose to deal with her problem.

It would also be of a concern if there were other factors or issues impacting on Rose and her daughter. Dr Berenson, with a more in-depth dialogue, could have looked at a deeper reason for the night time interruption, such as night terrors or a similar sleep disorder, which would impact on any intervention or action taken by Rose. There might be a more serious underlying cause for her daughter’s waking at night, such as school bullying or relationship problems, and a dialogue with the school teachers and if possible, the daughter, may be helpful. Providing problem solving techniques for the daughter, rather than just to Rose, in helping to establish bed time routines, making sure that the bedroom is comfortable and inviting, or it could be something as simple as providing a good night light for the room.

Egan’s Helping Model

This is a three-stage approach to counselling and helping clients theorised by Egan as a tool to help people manage problems and work out opportunities. The aim of this model is to help people “to become better at helping themselves in their everyday lives” (Egan 2007). The clients’ empowerment is stressed, as is the clients (not the counsellors) agenda. This model tries to move the person towards action that leads to positive outcomes that have been chosen by the client, and therefore more valued by the client.

This model is a framework for conceptualising the helping process, and is very useful for working on current issues (Egan, 2007). The model works best if when used with Rogers’ core conditions, and the counsellors approach is based on genuineness, respect, and empathy, and if good communication and active listening techniques are used.

The Egan model aims to move the client through three stages:

• The Current Picture – where am I now?
• The Preferred Picture – where do I want to be?
• The Way Forward – how do I get there?

Not every client will need to pass through all three stages, and some may need to move through previous stages as, moving back and forward, as different strategies are tested and tried (Egan, 2007). With more time, and multiple sessions, Dr Berenson could have used this model to allow Rose to find her own path, and to test out options and alternatives, giving her ownership of any decision, and not just accepting advice from a counsellor.

Improvements and Changes

More empathy could be shown by the counsellor – enough to promote a healthy counsellor/client relationship, but not so much that it overwhelms the therapeutic relationship, would have improved the communication between client and counsellor: “We sometimes identify so closely with clients that we lose our own sense of identity and assume their identity. Empathy becomes distorted and militates against a therapeutic intervention” (Corey 2001).

Both counsellor and client seemed distracted by the recording process; it can be difficult to promote real communication when the physical environment is distracting or uncomfortable. It is not just the setting in regards to posture, eye contact, or sitting position; if everyone is inattentive due to outside sounds, too loud street noises or if the area is too open (or closed), can negatively impact on the therapeutic process (Egan, 2007).

Shorter responses from Dr Berenson, with a greater use of open questions, could have allowed Rose more opportunity to tell her story, evaluate her options, and to choose actions to accomplish her goal of getting her daughter to stay in her own bed during the night (Geldard & Geldard, 2005).

The session may be improved by the addition of Rose’s partner – the actions and choices of the co-parent will impact on the success of Rose’s chosen path. Counsellors can help clients to consider options and alternatives, to look at motivations and obstacles, set goals, and form action plans. The client needs to take on the responsibility for action to achieve improvement in their life. This session was about more than Rose, it involved her daughter, and potentially her partner. A group session might be considered as an option (Kottler, 2004).

Because of its emphasis on unconditional positive regard and its basic assumption that humans are fundamentally good, this therapeutic approach is less able to deal with genuinely destructive behaviours – if it surfaced that problems faced where arising from severe disturbances, a referral to a psychiatrist or general practitioner would be an alternative. However, where the client has been upset by disturbing events (if these problems where arising from a critical incident at school or at home), unconditional positive regard is a valuable to set up a safe and secure place for the client to deal with problems (Kottler, 2004).

Clients who have a desire to explore their feelings and find out more about themselves as a person may be attracted to the person-centred approach. Clients who would prefer a counsellor who gives a lot of advice and analysis may find the person-centred approach less useful. Clients who want to tackle specific habits or patterns of thinking may benefit from the addition of something like Cognitive Behavioural Therapy (Kottler, 2004).

It is very important that counsellors recognise that each client is unique and different, with unique needs, and plan intervention accordingly. The counsellor must settle on an individual approach that will allow for openness with the client, provide better reactions and response, and lead to more productive outcomes (Egan, 2007).

Recognising the value of each individual is part of the process of developing client confidence and self-assurance, as is providing a safe and supportive environment throughout the counselling process (Geldard & Geldard, 2005). It is just not always easy.

References

• Corey, G. (2009). Theory and Practice of Counselling and Psychotherapy. Belmont: Thomson/Brooks Cole.
• Egan, G. (2007). The Skilled Helper: A Problem-Management and Opportunity-Development Approach to Helping 8th ed. Pacific Grove: Brooks/Cole.
• Geldard, D. & Geldard, K. (2005). Basic Personal Counselling 5th ed. Frenchs Forest: Pearson Education Australia.
• Kottler, J.A. (2004). Introduction to Therapeutic Counselling 5th ed. Frenchs Forest: Pearson Education Australia.
• Myers, D. (1986). Psychology. New York: Worth Publishers Inc.