Case study: The initial consultation
The initial consultation begins from the very first time you have contact with a client, from either the initial contact or the first time an enquiry is made via an email. It is important to appear professional at all times. As soon as you set up your appointment with the client, send off a letter and a brochure, providing there is time to do this, it will also remind them of the appointment (Banyan & Klein, 2001 p49).
The purpose of the consultation is many faceted. It is the time for a therapist to explain what hypnosis is to the client and answer any questions that may arise. It gives the therapist an opportunity to establish a rapport with the subject, gain their confidence, and assist the client perform several simple exercises to put them at ease. The establishment of rapport is amongst the most important objectives of the consultation and many believe that the success of the therapy depends upon it. In order to build the all important relationship, the client needs to feel respected, heard, understood and liked by the therapist. (Hewitt, William W, 2003 p19).
Goals need to be clarified during the initial consultation and are based upon the information elicited from the client during the compilation of the working model. They are not final but temporary and flexible, always amenable to modification and they are always specific to the client. They are goals that are attainable, realistic and appropriate to the client’s emotional state. Goals that are too ambitious or introduced prematurely can increase anxiety and may even threaten the client. (Hewitt, William W, 2003 p20).
The initial consultation is the time to explain to the client working methods and techniques. It is the time to dispel misunderstandings about therapy in general and hypnotherapy in particular. It is the opportunity for the client to ask questions about the therapy and the therapist. (Hewitt, William W, 2003 p20).
The initial consultation is an opportunity for the therapist to decide whether they could work with a client and whether the client would like to work with the therapist. It is an opportunity to get to know the client and then to decide if what the therapist has to offer is appropriate for their needs. It is also the time to discuss the treatment schedule and to gather sufficient information and a time, if appropriate, for an initial session of hypnosis to prepare them for what it is like and also to give the client some relaxation after completion of the administrative part of the initial consultation.
Establish from the client what brought them to the office; explore their motivation for them seeking out a hypnotherapist and what their expectations and hopes are. Build a rapport with the client, discuss what they have tried before and what goals they have.
General conversation can often get a client to consider things that they may not have considered previously. The presenting condition is often not the real issue, and it may take time for the client to realise and put into words other issues they may have. The actual process of talking in confidence to an empathetic person may release many emotions, and it should be borne in mind that the client may take time to begin to trust and be able to divulge historical events that they find difficult.
A therapist should obtain a history of the problem or issue and explore with the client what they think may be causing the issues.
An Intake form should be completed for each client, as a minimum it should include the following: (Banyan & Klein, 2001 p49).
Telephone numbers and whether or not you can call
Issue they want you to work on, the presenting condition may not necessarily be the real issue but a cover for issues that may be more difficult for a client.
Whether or not they have attempted hypnosis before
If they have, whether or not they thought they were hypnotised
Who the practitioner was
Any illnesses that they are being treated for
Any medication being taken
Details of doctors
Family details to include relationships with parents, siblings and significant others
Any events that have occurred and the clients views and thoughts of any such events
The clients objective in seeking help including any reservations they may have
It is important to the client that she has the opportunity to express what she thinks the problem is. It is even more important for you to not automatically believe it. While you are listening to the client you are building up rapport (Banyan & Klein, 2001 p49).
Explain the code of ethics and confidentiality (Brookhouse and Biddle)
Therapists engaged in the practice of Hypno-Pyschotherapy and allied disciplines shall, at all times, conduct their professional lives with the propriety and dignity becoming a servant of the public, and pledge that they will not under any circumstances, infringe the code of morality becoming their profession, and will not commit any breach of conduct that will adversely reflect upon themselves, the NCHP and the NRHP, or upon their practitioners.
Therapists shall confine their services to the recognised spheres of their profession, and shall neither offer nor promise cures for specific conditions, nor engage in any activity likely to bring the profession into disrepute.
Therapists are required to disclose their qualifications when requested and not claim, or imply, qualifications that they do not have. Physical evidence of such qualifications should be made available for inspection by any legitimate enquirer.
Therapists are required to disclose their terms, conditions and, where appropriate, methods of practice at the outset of therapy. Failure to act thus may be seen as morally repugnant as well as counter-productive in therapeutic terms.
Therapists are required to preserve confidentiality and to disclose, if requested, the limits of confidentiality and circumstances under which it might be broken to specific third parties. It should be noted that therapists have a responsibility to the community at large as well as to individual clients.
Therapists should consider the clients best interest when making appropriate contact with the clients General Practitioner, relevant psychiatric services, or other relevant professionals and with the clients knowledge and consent. In seeking advice, as appropriate and perhaps declining to treat and/or referring, therapists show an awareness of their own limitations whilst acting in the best interest of those seeking their help.
Therapists are required to maintain appropriate boundaries with their clients and to take care not to exploit their clients, current or past, in any way, financially, sexually or emotionally.
Therapists are required to maintain their ability to perform competently by undergoing personal therapy, if required, and engaging in Continuing Professional Development (CPD), including a commitment to ongoing supervision/peer supervision and other, verifiable, CPD activities.
Therapists are required to clarify with clients the nature, purpose and conditions of any research in which the clients are involved and to ensure that informed and verification consent is given before commencement. Such consent should allow for a ‘cooling off ‘period, and may be withdrawn at any time thereafter should any such clients so choose.
Therapists are required to safeguard the welfare and anonymity of clients when any form of publication of clinical material is being considered and to obtain their permission whenever possible.
The principles underlying the two previous paragraphs shall also be applied should therapist be engaged in the public media of whatever description.
A therapist who is convicted in a court of law of any notification criminal offence, or who is the subject of any successful civil action by a client, shall immediately report the facts in writing to the NRHP’s Board of Directors. In any such instance, the individual concerned shall consider him or herself suspended from membership of the NRHP and/or student body of the NCHP pending decision concerning such membership by the NRHP’s Board of Directors.
Therapists are required to ensure that their professional work is adequately covered by appropriate indemnity insurance. All members of the NRHP are required to be so insured. Prior to eligibility for membership of the NRHP, persons on premises used by the NCHP for purposes of training, and under the supervision of the NCHP Tutor, are required to be covered through NCHP insurance.
A complaints procedure exists, to receive any complaint against a therapist, to consider the therapists response and to arrive at a decision based on all the presented facts.
Appeals are allowed against any decisions made. The Complaints Procedure is detailed in the NRHP’s ‘A Guide to NRHP’, and will be made available to any person on request, and to all therapists applying to join the NRHP . In the event of a complaint against the institution, ie. The NCHP or NRHP, a Complaints Procedure has been published and is available upon request.
Therapists are required to take appropriate action to make a complaint which will be dealt with in accordance with the Complaints Procedure, with regard to the behaviour of a colleague which may be detrimental to the profession, to colleagues or other members.
Therapists shall not give any performance, lecture or display which presents hypnosis or psychotherapy or allied disciplines as a means of entertainment.
The professional notices of therapists shall be kept to a dignified wording and confined to approved publications only, and/or otherwise be brought to public notice in a dignified manner. (The NRHP’s board of Directors may, at its discretion declare an advertisement or publication or method of publicising services to be unacceptable).
Any therapist breaking this code of Ethics and Clinical Practise shall at the discretion of the NRHP’s Board of directors, be liable for forfeiture of membership or other sanction(s) as directed by the Board of Directors.
The NRHP’s Board of Directors shall have the power to interpret and enforce compliance with the Code of Ethics and Clinical Practice by all therapists, and to impose such sanctions as it sees fit for breaches of the Code. Where dual membership exists, details of therapists who are suspended by, or expelled from, the NRHP, are automatically deleted from the UK Council for Psychotherapy’s National Register of Psychotherapists.
Every client should be disclosed information as to why their therapist is qualified to carry out the work with them, this may help to alleviate any insecurities and to enhance confidence in the therapist.
Cancellation policy - A therapist should always advise clients of their cancellation policy and it should be included in the written agreement for the client to take away from the session with them.
Remove fears and misconceptions – tell the client that hypnosis is a normal and spontaneous state of mind that all human beings have experienced thousands of times. If the client comes to the office filled with fears and misconceptions regarding hypnosis, he or she will inhibit the response. Take some time to explain what you mean by the conscious, subconscious and unconscious levels of the mind. This will promote understanding when you use the terms and help de-mystify them (Banyan & Klein, 2001 p49).
If time allows it is a good idea to give a brief demonstration of what hypnosis may feel like. Some clients feel that if they come for hypnosis then that is what they should receive and it also prepares the client for future hypnosis. It is easier for a person on a second or subsequent session of hypnosis to go into a deeper trance in a shorter period of time. If a convincer is also performed the outcome is more likely to be a positive one.
It is always a good idea to give the client the opportunity to answer questions about the session.
Structured Approaches –v- Unstructured Approaches
The main advantage of using a structured approach is that you get all the information that you require, however, initially the forms and/or questionnaires may not be complete and it is through experience that a good questionnaire is formed. The disadvantage is that there may be information that is not volunteered through the questionnaire process which may be missed out.
The unstructured approach involves general discussion with a client which enables them to take the lead role in the discussion. The main benefit to this approach is the client is more likely to disclose more things but it will only be the things they want and usually in a way that they want to tell the story.
Provision of a contract
All therapy is undertaken as a result of a contract between the client and the therapist. It is preferable that this should be a written contract rather than a verbal contract. Such a contract should include:
a statement of cost per session or whole course of therapy
a statement of confidentiality
the clients right of access to the complaints procedure a copy can provided to any client who asks for it from NCH
the fact that there can be guarantee of a success. (Banyan & Klein, 2001 p49).
The initial consultation is also the time when the therapist decides the treatment plan and decides on the most appropriate approach for the client. There is no single agreed approach to how a therapist establishes his or her treatment schedule; often the approaches vary between clients and also the problems that are being dealt with. The following are the main approaches that can be chosen by a therapist
Stages of an interview
Receiving, Responding, Reassuring
It is most important that the person seeking help is on arrival immediately the focus of attention. All other concerns of the therapist and his/her staff are secondary to this. Sensitive and efficient service is what is required from the outset. The therapist should immediately respond to the clients’ needs, apprehensions. The client should be aware that they are able to talk in confidence to the therapist but also make the client aware that they have a social responsibility. (Brookhouse and Biddle)
Listening and Observing
A client should be allowed to tell his/her story and any interruption at this stage is likely to be intrusive and counter-productive. When the client finishes the therapist should paraphrase the story and seek the clients’ approval that the essential points are accurate. The client should be asked how they feel and given positive regard about how well they have done (Brookhouse and Biddle).
During the spotlighting stage the client is invited to select the parts of the story that seem to be most significant and carry the most emotional weight. The client is controlling the spotlight and the therapist is waiting to see what is revealed. The therapist chooses to respond to the clients’ communication, Rogers identified five different categories of response, the probing response, the evaluative response, the interpretative responses, the reassuring response and the reflective response. Whichever of these responses the therapist choose to adopt, he/she should be aware of the consequences of the chosen approach. At the conclusion of this part of the interview, the therapist will have collected valuable information about the client and words of encouragement should be given (Brookhouse and Biddle).
Recording, Relaxing and Explaining
This stage of the interview is the most appropriate time for recording essential details about the client, details can be written down and the client can be asked to sign their accuracy. This can be followed by the client being asked to close their eyes and quietly remove any tension that remains as a result of the interview. The client should be encouraged to ask any questions. (Brookhouse and Biddle).
The therapist brings the session to a close and at this stage it should be suggested that a 48 hour period should elapse before any final commitment to therapy is made. Both the therapist and client have a period in which to consider whether or not a working alliance is possible or desirable. If it is decided that therapy is to go ahead then a consent form will need to be signed at the next meeting (Brookhouse and Biddle).
During the 48 hour period, the therapist has time to reflect on whether or not he/she can help the potential client. The therapist must feel that they possess the necessary expertise and should there be any doubt about this the decision must be to refer the client to the correct area of competence. (Brookhouse and Biddle).
If the therapist feels that they are able to work with the client then the 48 hours is a good time to plan the intervention with the client, and plan the work that is to be achieved along with consideration to the most appropriate theoretical approach for the client and their issue(s).
Different Theoretical Approaches
Classical psychoanalysis (Freud) – Pays attention to unconscious factors related to infantile sexuality in the development of neurosis. Psychoanalysis, emphasizes working through transference, in which clients perceive their therapists as reincarnations of important figures from their childhoods, and interpretations of dreams. (Nelson-Jones, Richard 2006 p4).
Analytical therapy (Jung) – Divides the unconscious into the personal unconscious and the collective unconscious, the letter being storehouse of universal archetypes and primordial images. Therapy includes analysis of the transference, active imagination and dream analysis. Jung was particularly interested in working with clients in the second half of life. (Nelson-Jones, Richard 2006 p4).
Person-centred therapy (Rogers) – Lays great stress on the primacy of subjective experience and how clients can become out of touch with their organismic experiencing through introjecting others’ evaluations and treating them as if their own. Therapy emphazises a relationship characterized by accurate empathy, respect and non-possessive warmth. (Nelson-Jones, Richard 2006 p4).
Gestalt Therapy (Perls) – Individuals become neurotic by losing touch with their senses and interfering with their capacity to make strong contact with their environments. Therapy emphasizes increasing clients’ awareness techniques, experiments, sympathy and frustration, and dream work (Nelson-Jones, Richard 2006 p4).
Transactional analysis (Berne) – Transactions between people take place between their Parent, Adult and Child ego states. Therapy includes structural analysis of ego states, analysis of specific transactions, analysis of ego states, analysis of specific transactions, analysis of games - series of transactions having ulterior motivations – and analysis of clients’ life scripts. (Nelson-Jones, Richard 2006 p4).
Reality therapy (Glasser) – Clients choose to maintain their misery through choosing inappropriate ways to control the world to satisfy their needs. Therapy includes identifying clients’ wants and needs, teaching choice theory, planning and, where appropriate, training clients in the behaviours they needed to succeed. (Nelson-Jones, Richard 2006 p4).
Existential Therapy (Yalom and May) – Draws on the work of existential philosophers and focuses on helping clients deal with anxieties connected with four main ultimate concerns of human existence: death, freedom, isolation and meaninglessness. Therapy focuses on clients’ current situations, with different interventions used according to the nature of developing fears. (Nelson-Jones, Richard 2006 p5).
Logotherapy (Franki) – Clients can become neurotic because they face an existential vacuum in which they are unable to find meaning in their lives. Logotherapists use methods such as teaching the importance of assuming responsibility for finding meaning, Socratic questioning, offering meanings and analysing dreams. (Nelson-Jones, Richard 2006 p5).
Psychotherapeutic School (Sullivan) – The therapist is an active participant in the therapeutic process. He viewed the process as communication between two people, he was not only concerned with what is said but also how it is said. The client’s expressive behaviour is a rich source of information for the therapist but Sullivan also pointed out that the therapist’s behaviour in the relationship will also have an effect on the data received from the client. (Nelson-Jones, Richard 2006 p5).
Behaviour therapy (Pavlov, Skinner & Wolpe) – Emphasizes the learning of behaviour through classical conditioning, operant conditioning and modelling. Therapy consists of learning adaptive behaviours by methods such as systematic desensitization, reinforcement programmes and behaviour rehearsal. (Nelson-Jones, Richard 2006 p5).
Rational emotive behaviour therapy (Ellis) – Emphasizes clients reindoctrinating themselves with irrational beliefs that contribute to unwanted feelings and self-defeating actions. Therapy involves disputing clients’ irrational beliefs and replacing them with more rational beliefs. Elegant or profound therapy entails changing clients’ philosophies of life. (Nelson-Jones, Richard 2006 p5).
Cognitive therapy (Beck) – Clients become distressed because they are a faculty processors of information with a tendency to jump to unwarranted conclusions. Therapy consists of educating clients in how to test the reality of their thinking by interventions such as Socratic questioning and conducting real-life experiments. (Nelson-Jones, Richard 2006 p5).
Multimodal therapy (Lazarus) – Clients respond to situations to their predominant modalities: behaviour, affect, sensation, imagery, cognition, interpersonal and drugs/biology. Based on a multimodal assessment, therapists are technically eclectric, using a range of techniques selected on the basis of empirical evidence and client need. (Nelson-Jones, Richard 2006 p5).
Areas that need to be considered, for what is the most important meeting you ever have with a client. I have included the ethics and also the different theoretical approaches which have to be considered when working with a client. The importance of keeping records cannot be stressed enough.
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